ArticleLiterature Review

Gambling Disorder in the United Kingdom: key research priorities and the urgent need for independent research funding

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Abstract

Gambling in the modern era is pervasive due to the variety of gambling opportunities including use of technology (such as online applications on smartphones). While many people gamble recreationally without undue negative impact, a sizable subset of individuals develop disordered gambling, associated with marked functional impairment including other mental health problems, relationship problems, bankruptcy, suicidality and criminality. The National UK Research Network for Behavioural Addictions (NUK-BA) was established to promote understanding, research, and treatments for behavioural addictions including Gambling Disorder, which constitutes the only currently recognized formal ‘behavioural’ addiction. This statement from NUK-BA identifies the current status of research and treatment for disordered gambling in the UK (including funding issues), and key research that must be conducted in order to establish the magnitude of the problem, vulnerability and resilience factors, neurobiology, long-term consequences, and treatment opportunities. In particular, we highlight the need to: 1) Conduct independent longitudinal research on prevalence of disordered gambling (Gambling Disorder and at-risk gambling), and gambling harms, including in vulnerable and minority groups; 2) Select and refine the optimal pragmatic measurement tools; 3) Identify predictors (vulnerability and resilience markers) of disordered gambling in people who gamble recreationally, including in vulnerable and minority groups, longitudinally; 4) Conduct randomised controlled trials (RCTs) on psychological interventions and pharmacotherapy for gambling disorder; 5) Optimise our understanding of the neurobiological basis of Gambling Disorder, including genetics, impulsivity and compulsivity, and biomarkers; and 6) Develop clinical guidelines based upon the best possible contemporary research evidence to guide effective clinical interventions. We also highlight the need to consider what can be learnt from other countries’ approaches towards mitigating gambling-related harms.

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... Survey studies report that between 0.12 and 5.8% of adults worldwide have identified as having problem gambling in the past year (Calado & Griffiths, 2016). During recent years, the availability of gambling opportunities has increased due to the transition towards online gambling (Pallesen et al., 2021); individuals who previously might not have entered traditional gambling arenas, such as casinos or betting shops, now have easy access to gambling through online sites and smartphones (Bowden-Jones et al., 2022). ...
... In addition, individuals with GD are known as a heterogeneous population in terms of their developmental pathways (Blaszczynski & Nower, 2002) and clinical characteristics (Hodgins et al., 2011). Specific subgroups, such as women and socioeconomically marginalized individuals, may be more vulnerable to the harmful effects of GD (Abbott, 2020;Bowden-Jones et al., 2022), and work functioning may thus vary accordingly. This diversity needs to be considered, e.g. by applying statistical models that allow for richness and complexity in the data. ...
... The peak of work disability at the time of the incident GD diagnosis may reflect an accumulation of impairment and mental health problems until a tipping point. Previous research shows that individuals with GD can present in healthcare settings for other psychiatric problems, downplaying the role of their GD (Bijker, Booth, Merkouris, Dowling, & Rodda, 2022;Bowden-Jones et al., 2022). Financial and relationship problems often drive help-seeking due to GD, and seeking treatment can sometimes be the last resort after many years of gambling problems (Bijker et al., 2022;Medeiros, Redden, Chamberlain, & Grant, 2017). ...
Article
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Background This longitudinal register study aimed to investigate the association between gambling disorder (GD) and work disability and to map work disability in subgroups of individuals with GD, three years before and three years after diagnosis. Methods We included individuals aged 19–62 with GD between 2005 and 2018 ( n = 2830; 71.1% men, mean age: 35.1) and a matched comparison cohort ( n = 28 300). Work disability was operationalized as the aggregated net days of sickness absence and disability pension. Generalized estimating equation models were used to calculate adjusted odds ratios (AORs) and 95% confidence intervals (CIs) for the risk of long-term work disability (>90 days of work disability/year). Secondly, we conducted Group-based Trajectory Models on days of work disability. Results Individuals with GD showed a four-year increased risk of long-term work disability compared to the matched cohort, peaking at the time of diagnosis (AOR = 1.89; CI 1.67–2.13). Four trajectory groups of work disability days were identified: constant low (60.3%, 5.6–11.2 days), low and increasing (11.4%, 11.8–152.5 days), medium–high and decreasing (11.1%, 65.1–110 days), and constant high (17.1%, 264–331 days). Individuals who were females, older, with prior psychiatric diagnosis, and had been dispensed a psychotropic medication, particularly antidepressants, were more likely to be assigned to groups other than the constant low . Conclusion Individuals with GD have an increased risk of work disability which may add financial and social pressure and is an additional incentive for earlier detection and prevention of GD.
... Yet, the evidence that not only these brain regions but the dopamine neurotransmitter itself plays a role in the expectation of reward is compelling: dopaminergic neurons can code the probability of the reward in a primate model 5 . Moreover, a known side-effect of the treatment of Parkinson disease (known to impair dopamine production) is to dramatically increase impulsivity 6 . The dopamine receptor gene DRD4 fulfills many criteria as a good candidate gene: it is highly polymorphic 7,8 , expressed in the prefrontal cortex, it shows an unusually large variable repeat region (VNTR: variable number tandem repeat) coding for 16 amino acids in the third cytoplasmic loop, a region interacting with SH3 domain-binding proteins. ...
... www.nature.com/scientificreports/ The sample would satisfy conditions for a genetic adaptation to habitat 39,40 , with (1) limited migration -68% of grandparents of the risky area were born in the same village (Table S. 6), (2) strong economic benefit to live in risky area and (3) an heritable genetic trait which would help cope with risk, i.e. the 7R allele. However, we did not find evidence of genetic differentiation at the DRD4 locus relative to 29 unlinked microsatellites loci (Table S.8 and Figure S.2). ...
Article
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It has been shown that living in risky environments, as well as having a risky occupation, can moderate risk-tolerance. Despite the involvement of dopamine in the expectation of reward described by neurobiologists, a GWAS study was not able to demonstrate a genetic contribution of genes involved in the dopaminergic pathway in risk attitudes and gene candidate studies gave contrasting results. We test the possibility that a genetic effect of the DRD4-7R allele in risk-taking behavior could be modulated by environmental factors. We show that the increase in risk-tolerance due to the 7R allele is independent of the environmental risk in two populations in Northern Senegal, one of which is exposed to a very high risk due to dangerous fishing.
... Studies have revealed a 23% addiction rate among gamers, with ADHD identified as a potential risk factor [3]. According to the American Medical Association, approximately 90% of U.S. youth engage in computer gaming, with around 15% exhibiting addiction [4]. The problem is even more pronounced in South Korea and China, with addiction rates reaching as high as 29.4% [5]. ...
Article
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Background Internet gaming has gained widespread popularity in China, yet the classification of problematic gaming subtypes based on personality traits remains limited. This study aimed to employ latent profile analysis (LPA) to identify distinct groups of online gamers and compare key variables across these groups. Methods An online survey was conducted within 5593 internet gaming users, including a demographic questionnaire, queries on internet gaming usage, the Video Gaming Dependency Scale, and the Chinese Big Five Inventory-brief version. LPA was applied to identify distinct user groups, followed by an examination of associations between profile membership and auxiliary variables. Results LPA identified three gamer categories for problematic gaming: “high-risk” (64.78%), “medium-risk” (3.22%), and “low-risk” (32%). High-risk gamers allocated more time and financial resources to gaming for escapism and leisure purposes. The medium-risk group sought enjoyable experiences, exhibiting traits that were intermediate between the high- and low-risk groups. High-risk gamers demonstrated elevated levels of neuroticism, accompanied by lower scores in other Big Five personality traits. In contrast, medium-risk gamers scored low across all Big Five dimensions, while low-risk gamers achieved higher scores in all traits except neuroticism. Notably, the low-risk group reported forming the fewest new online friendships, despite sharing similar social motivations with the other groups. Conclusion Traits such as low neuroticism and high conscientiousness serve as protective factors against gaming addiction, while being unmarried or an only child provides additional safeguards. Conversely, increased time and financial investment in gaming activities are associated with a heightened risk of addiction. These findings are crucial for identifying high-risk gamers and informing the development of targeted interventions.
... Impulsivity and compulsivity are considered transdiagnostic features (18), with compulsivity having received less research attention regarding behavioral addictions (19). In possible transitions from impulsive to compulsive behavioral engagement, the precise roles of habits in drugtaking and addictive behaviors have been debated (20). ...
Article
Gambling disorder is the only behavioral addiction recognized as a clinical disorder in DSM-5, and Internet gaming disorder is included as a condition requiring further research. ICD-11 categorizes gambling and gaming disorders as disorders due to addictive behaviors. Additional behavioral addictions may include compulsive sexual behavior disorder, compulsive buying-shopping disorder, and problematic use of social media. This narrative review summarizes the current state of knowledge regarding these five (potential) disorders due to addictive behaviors. All five (potential) disorders are clinically relevant and prevalent. Behavioral addictions frequently co-occur with other mental and behavioral problems, such as depression, anxiety, and attention deficit hyperactivity disorder. Validated diagnostic instruments exist, with empirical support varying across conditions. No medications have approved indications from regulatory bodies for behavioral addictions, and cognitive-behavioral therapy has the most empirical support for efficacious treatment. Given that behavioral addictions are prevalent, frequently co-occur with psychiatric disorders, may often go undiagnosed and untreated, and have been linked to poorer treatment outcomes, active screening and treatment are indicated. Public health considerations should be expanded, and impacts of modern technologies should be investigated more intensively. Treatment optimization involving pharmacotherapy, psychotherapy, neuromodulation, and their combination warrants additional investigation.
... Impulsivity and compulsivity are considered transdiagnostic features (18), with compulsivity having received less research attention regarding behavioral addictions (19). In possible transitions from impulsive to compulsive behavioral engagement, the precise roles of habits in drugtaking and addictive behaviors have been debated (20). ...
Article
Gambling disorder is the only behavioral addiction recognized as a clinical disorder in DSM-5, and Internet gaming disorder is included as a condition requiring further research. ICD-11 categorizes gambling and gaming disorders as disorders due to addictive behaviors. Additional behavioral addictions may include compulsive sexual behavior disorder, compulsive buying-shopping disorder, and problematic use of social media. This narrative review summarizes the current state of knowledge regarding these five (potential) disorders due to addictive behaviors. All five (potential) disorders are clinically relevant and prevalent. Behavioral addictions frequently co-occur with other mental and behavioral problems, such as depression, anxiety, and attention deficit hyperactivity disorder. Validated diagnostic instruments exist, with empirical support varying across conditions. No medications have approved indications from regulatory bodies for behavioral addictions, and cognitive-behavioral therapy has the most empirical support for efficacious treatment. Given that behavioral addictions are prevalent, frequently co-occur with psychiatric disorders, may often go undiagnosed and untreated, and have been linked to poorer treatment outcomes, active screening and treatment are indicated. Public health considerations should be expanded, and impacts of modern technologies should be investigated more intensively. Treatment optimization involving pharmacotherapy, psychotherapy, neuromodulation, and their combination warrants additional investigation.
... Historically, in the United Kingdom, funding for gambling research has not been a priority for national research funding bodies [7]. As a result, many researchers have turned to alternative sources to fund their research, which includes the gambling industry [8][9][10]. ...
... However, recent reports indicate a growing trend in gambling [4]. The modern gambling landscape offers a wide range of opportunities, including online applications and smartphones [5]. The convenience and concealment of online gambling, along with its increasing accessibility due to the internet, have attracted a larger number of individuals to engage in gambling activities such as sports lottery or online poker [6]. ...
Article
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Impulsivity and emotion impairments have been noted in individuals with gambling disorder (GD). However, little research has investigated the influence of impulsivity and emotions on the severity of gambling in clinical populations. This study aimed to examine: (i) differences in emotions and impulsivity traits according to the severity of gambling in individuals with GD, (ii) the mediating effects of emotion in the relationship between impulsivity traits and gambling severity, and (iii) the predictive effects of emotion and impulsivity traits on GD severity. The study included 214 participants seeking treatment for GD who completed assessments for emotions (Patient Health Questionnaire-9 [PHQ-9], 7-item Generalized Anxiety [GAD-7]), impulsivity traits (Barratt Impulsiveness Scale [BIS], Self-control Scale [SCS]), and GD severity (DSM-5). Participants were categorized into mild (n = 78), moderate (n = 63), and severe (n = 73) gambling severity groups. Significant differences in emotions and impulsivity traits were observed across these groups. The severe GD group exhibited higher levels of depression, anxiety, and impulsivity traits, along with lower self-control, compared to the moderate and mild groups. Mediation analyses demonstrated that negative emotions mediated the association between impulsivity traits and the severity of gambling. More specifically, the indirect effects of impulsivity traits through PHQ-9 and GAD-7 were found to be significant, indicating a mediating role of emotions. Moreover, a predictive model incorporating emotion and impulsivity traits showed moderate accuracy in predicting the severity of gambling, with an area under the receiver operating characteristic curve of 0.714. This study highlights the distinct pathways through which impulsivity traits operate and emphasizes the need for prevention and treatment strategies that consider impulsivity traits and emotions for different levels of gambling severity.
... While certain countries, such as Singapore, have established guidelines over a decade ago (Ministry of Health of Singapore, 2011), recent efforts globally have emphasized the necessity for developing comprehensive guidelines. For instance, the UK National Research Network on Behavioral Addictions, under the leadership of H. Bowden-Jones, has underscored the importance of creating clinical guidelines for pathological gambling (Bowden-Jones et al., 2022). Additionally, the National Institute for Health and Care Excellence (NICE) is anticipated to publish guidance on the identification, assessment, and management of harmful gambling in July 2024 (NICE, 2024). ...
Article
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Online gamblers are more likely to experience gambling problems. The main objective was to compare the frequency of recovery one (middle-term) and two (long-term) years after treatment initiation, according to the gambling medium (Internet vs. land-based gambling). The secondary objectives were (i) to compare online and offline gamblers at inclusion and (ii) to investigate whether the gambling medium was a predictive factor of recovery. Outpatients beginning treatment for a GD (n = 237) were assessed at inclusion (treatment initiation) and after 1 and 2 years. Bivariate analyses were performed to compare online and offline gamblers at inclusion and on the frequency of recovery at one and two years. Two multivariate logistic regressions were then performed to identify factors associated with middle- and long-term recovery. The majority of patients achieved middle (74.2%) and long-term (78.9%) recovery, with no difference between online and offline gamblers. The gambling medium was not a predictive factor of recovery. Patients with a higher perceived self-efficacy (OR = 1.04 [1.01–1.07], p = .046) and having no history of mood disorders (OR = 11.18 [2.53–49.50], p < .001) at inclusion were more likely to achieve middle-term recovery, while long-term recovery was associated with a lower level of sensation seeking (OR = 0.67 [0.48–0.92], p = .015) at treatment initiation. Online gambling did not seem to influence middle- and long-term recovery compared to offline gambling. Enhancement of perceived self-efficacy and treatment of mood disorders, and treatment strategies focused on sensation-seeking may represent helpful care strategies for favouring achievement of middle-term recovery and maintenance of long-term recovery, respectively. ClinicalTrials.gov NCT01248767, date of first registration: November 25, 2010.
... To the best of our knowledge, it is one of the first times DUI for gambling disorder has ever been quantified; the disorder per se receives little research funding to date. 33,34 Now that it is apparent, it has a long typical DUI, practical steps could be taken to address and reduce this DUI. For other areas of mental health, there is evidence, from different countries and settings, that public educational campaigns are capable of reducing latency to treatment seeking over time. ...
Article
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Objective Gambling disorder is common, affects 0.5–2% of the population, and is under-treated. Duration of untreated illness (DUI) has emerged as a clinically important concept in the context of other mental disorders, but DUI in gambling disorder, has received little research scrutiny. Methods Data were aggregated from previous clinical trials in gambling disorder with people who had never previously received any treatment. DUI was quantified, and clinical characteristics were compared as a function of DUI status. Results A total of 298 individuals were included, and the mean DUI (standard deviation) was 8.9 (8.4) years, and the median DUI was 6 years. Longer DUI was significantly associated with male gender, older age, earlier age when the person first started to gamble, and family history of alcohol use disorder. Longer DUI was not significantly associated with racial-ethnic status, gambling symptom severity, current depressive or anxiety severity, comorbidities, or disability/functioning. The two groups did not differ in their propensity to drop out of the clinical trials, nor in overall symptom improvement associated with participation in those trials. Conclusions These data suggest that gambling disorder has a relatively long DUI and highlight the need to raise awareness and foster early intervention for affected and at-risk individuals. Because earlier age at first gambling in any form was strongly linked to longer DUI, this highlights the need for more rigorous legislation and education to reduce exposure of younger people to gambling.
... 3 In their 2021 evidence review, Public Health England reported that half of the UK population participates in gambling, with 0.5% of the population experiencing a high level of harm. 4 Gambling-related harm disproportionately affects disadvantaged and marginalized groups, exacerbates existing health and social inequalities 5 and intersects with challenges including suicide prevention, alcohol, smoking, interpersonal violence, criminality and homelessness. 6 Disordered gambling impacts physical and mental health in a range of ways and has significant community and societal costs. Recent estimates in the UK suggest the economic burden of harmful gambling is approximately £1.27 billion, including £342.2 million in mental and physical health harms and £79.5 million in employment and education harms. ...
Article
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Background: Disordered gambling is a public health problem with interconnections with health and social inequality, and adverse impacts on physical and mental health. Mapping technologies have been used to explore gambling in the UK, though most were based in urban locations. Methods: We used routine data sources and geospatial mapping software to predict where gambling related harm would be most prevalent within a large English county, host to urban, rural and coastal communities. Results: Licensed gambling premises were most concentrated in are as of deprivation, and in urban and coastal areas. The aggregate prevalence of disordered gambling associated characteristics was also greatest in these areas. Conclusions: This mapping study links the number of gambling premises, deprivation, and risk factors for disordered gambling, and highlights that coastal areas see particularly high density of gambling premises. Findings can be applied to target resources to where they are most needed.
... These include financial harms, poorer health and increased crime (Velleman and Orford, 2015). Gambling harms are a significant public health problem (Rogers, 2019;Wardle et al., 2019;Blank et al., 2021a) which may impact both the person gambling and those around them (affected others) (Salonen et al., 2015;Blake et al., 2019a,b;Bowden-Jones et al., 2022). ...
Article
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Gambling harms are disproportionately experienced among disadvantaged groups and as such, adult social care (ASC) practitioners are well-placed to identify and support affected individuals. There exists no evidence-based ‘introductory’ question for practitioners to identify those at risk of gambling harms, which includes family and friends (‘affected others’). To develop an ‘introductory’ question for use in English ASC, we conducted a scoping review that identified fifteen potential questions. Questions were refined through expert panel review groups (n = 13), cognitive interviewing (n = 18), test–retest reliability checks (n = 20) and validity testing (n = 2,100) against gold-standard measures of problem gambling behaviour. The question development process produced two questions suitable for testing in local authority (LA) ASC departments. These were (i) ‘Do you feel you are affected by any gambling, either your own or someone else’s?’ and (ii) ‘If you or someone close to you gambles, do you feel it is causing you any worries?’ Each had good face validity, strong test–retest reliability, correlated highly with well-being measures and performed reasonably against validated measures of problem gambling. These two questions are currently being piloted by ASC practitioners in three English LAs to assess their feasibility for adoption in practice.
... A study in Canada found that the prevalence rate of moderate-risk or problem gambling was 2.1% among adults in 2018 [10]. A study in the UK found that the prevalence rate of gambling disorder was 0.4% among adults in 2020 [11]. In Italy, in 2020, 9% of [14][15][16][17][18][19] year-olds have developed behaviors that fall within the scope of addiction, characterized by negative repercussions on the socio-emotional and relational sphere [12]. ...
Article
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This study aims to analyze the main and most recent forms of gambling and related psychopathological disorders, also proposing psychological clinical recommendations. From November 2022 to February 2023, we searched the databases of PubMed, Web of Science, Health & Medical Collection, Elsevier Journal, and Springer for relevant studies performing different searches through different search strings. New forms of gambling are mostly related to new technological tools, such as the Internet, smartphones, social media, or electronic machines. The prevalence of online gambling affects all demographic groups, although 35-44-year-olds appear to have the largest share. Online gambling can lead to addiction, financial hardship, and mental health problems. It has also been statistically significantly associated with high levels of Gambling disorder, high levels of depression and anxiety, poor overall mental health, and alcohol use. Furthermore, it has been noted that online gamblers are more likely to engage in high-risk gambling behaviors and have a higher prevalence of comorbid mental disorders. The review highlights the need for continued research on the impact of new forms of gambling and the development of effective prevention and treatment strategies. Further research is needed to better understand the complex relationship between new forms of gambling and the development of gambling disorders.
... Open questions about whether the "more severe" pattern represents a longerterm evolution or whether it constitutes different phenotypes, need to be addressed in especially designed studies. A recently published review about GD in the UK remarked on the key research priorities and the urgent need for funding ( Bowden-Jones et al., 2022 ). In this work, was pointed out the need to select and refine the most suitable pragmatic measurement tools, identify predictors of vulnerability, and improve understanding of the neurobiological basis of GD including impulsivity. ...
Article
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Patients with gambling disorder (GD) frequently present other mental disorders, such as substance use disorder (SUDs), attention deficit/hyperactivity disorder (ADHD), mood disorders, and impulse-control disorders. We propose that GD should not be conceptualized as a single nosological entity, but rather as a gambling dual disorder (GDD). This study aims to provide further evidence of the co-occurrence of GD and other mental disorders in routine clinical practice and to identify different clinical profiles of severity. This descriptive, cross-sectional, and observational study included 116 patients with GD who were undergoing treatment in a specialized center. The MULTICAGE-CAD 4 and South Oaks gambling screen questionnaires confirmed the presence of GD in 97.4% and 100% of the patients, respectively. Other addictive behaviors such as compulsive spending, Internet, video games, or SUD (59.5%, 27.6%, 11.2%, and 13.8%, European Neuropsychopharmacology 66 (2023) 78-91 respectively) were also identified. The most used substances were tobacco (42.2%) and alcohol (5.2%). Half of the patients suffered from ADHD, 30.2% showed moderate or severe depression, and 17.2% suffered from a social anxiety problem. The majority (76.7%) also presented a phenotype with high impulsiveness. The cluster analysis identified two different clinical profiles of severity in patients with GDD. One profile showed higher severity of other mental disorders (ADHD, depression, anxiety, SUD, or insomnia), impulsivity, general psychopathological burden, and disability. In conclusion, our study provides further evidence on the co-occurrence of GD and other mental disorders supporting the GDD existence, shows impulsiveness as a vulnerability factor for GD, and identifies two clinical severity profiles.
... Open questions about whether the "more severe" pattern represents a longerterm evolution or whether it constitutes different phenotypes, need to be addressed in especially designed studies. A recently published review about GD in the UK remarked on the key research priorities and the urgent need for funding ( Bowden-Jones et al., 2022 ). In this work, was pointed out the need to select and refine the most suitable pragmatic measurement tools, identify predictors of vulnerability, and improve understanding of the neurobiological basis of GD including impulsivity. ...
Article
Full-text available
Abstract Patients with gambling disorder (GD) frequently present other mental disorders, such as sub- stance use disorder (SUDs), attention deficit/hyperactivity disorder (ADHD), mood disorders, and impulse-control disorders. We propose that GD should not be conceptualized as a single nosological entity, but rather as a gambling dual disorder (GDD). This study aims to provide fur- ther evidence of the co-occurrence of GD and other mental disorders in routine clinical prac- tice and to identify different clinical profiles of severity. This descriptive, cross-sectional, and observational study included 116 patients with GD who were undergoing treatment in a special- ized center. The MULTICAGE-CAD 4 and South Oaks gambling screen questionnaires confirmed the presence of GD in 97.4% and 100% of the patients, respectively. Other addictive behaviors such as compulsive spending, Internet, video games, or SUD (59.5%, 27.6%, 11.2%, and 13.8%, respectively) were also identified. The most used substances were tobacco (42.2%) and alcohol (5.2%). Half of the patients suffered from ADHD, 30.2% showed moderate or severe depression, and 17.2% suffered from a social anxiety problem. The majority (76.7%) also presented a phe- notype with high impulsiveness. The cluster analysis identified two different clinical profiles of severity in patients with GDD. One profile showed higher severity of other mental disorders (ADHD, depression, anxiety, SUD, or insomnia), impulsivity, general psychopathological burden, and disability. In conclusion, our study provides further evidence on the co-occurrence of GD and other mental disorders supporting the GDD existence, shows impulsiveness as a vulnerabil- ity factor for GD, and identifies two clinical severity profiles.
... This highlights the importance to consider not only gambling symptoms themselves when evaluating patients but also wider gambling-related harms that are not quantified by these instruments or necessarily the target of current interventions. 30 Interestingly, treatment responses in our studies did not significantly differ based on whether a person had committed an illegal act second to their gambling. This was also found in the study by Ledgerwood and colleagues. ...
Article
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Background and objectives: Gambling disorder has been associated with illegal behaviors; however, research using validated scales and in-person assessments has been less common. Methods: Four hundred and twenty-seven people with gambling disorders taking part in clinical trials completed multiple instruments and select cognitive tasks. Two groups were identified: those with illegal behaviors linked to gambling disorder and those without. Differences between the groups were examined. Results: 43.3% of people with gambling disorders reported gambling-related illegal behaviors. Illegal behaviors were associated with earlier gambling symptom onset, higher levels of depressive symptoms, worse quality of life, and higher non-planning impulsivity. In those with illegal behaviors, the most common activities reported were writing bad checks/paying bills from accounts that no longer had funds (75.1%), and theft (9.6%). People with illegal gambling-related behaviors did not differ from those without, in terms of levels of symptom severity, or likelihood of responding to treatment in the subsequent clinical trials. Discussion and conclusions: Illegal behaviors are commonplace in people with gambling disorders and linked to worse quality of life, but people with gambling-related illegal behaviors respond to core treatments to the same extent as people without these behaviors. Scientific significance: The findings from this study extend previous research and support the novel notion that rather than more intensive treatment being indicated for gambling disorders linked to illegal activities, it may be prudent to consider illegal behaviors as part of a wider profile of gambling-related harms that merit interventions in their own right.
... Yet, the evidence that not only these brain regions but the dopamine neurotransmitter itself plays a role in the expectation of reward is compelling: dopaminergic neurons can code the probability of the reward in a primate model 5 . Moreover, a known side-effect of Parkinson (known to impair dopamine production) treatment is to dramatically increase impulsivity 6 . The dopamine receptor gene DRD4 fulfills many criteria as a good candidate gene: it is highly polymorphic 7,8 , expressed in the prefrontal cortex, it shows an unusually large variable repeat region coding for 16 amino acids in the third cytoplasmic loop, a region interacting with SH3 domain-binding proteins. ...
Preprint
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It has been shown that living in risky environments, as well as having a risky occupation, can moderate risk-tolerance. Despite the involvement of dopamine in the expectation of reward described by neurobiologists, a GWAS study was not able to demonstrate a genetic contribution of genes involved in the dopaminergic pathway in risk attitudes and gene candidate studies gave contrasting results. We test the possibility that a genetic effect of the DRD4-7R allele in risk-taking behavior could be modulated by environmental factors. We show that the increase in risk-tolerance due to the 7R allele is independent of the environmental risk in two populations in Northern Senegal, one of which is exposed to a very high risk due to dangerous fishing.
... The former tends to refer to styles of acting and making decisions with limited foresight and a proneness to errors (Tzagarakis et al., 2019), whilst the latter marks, in contrast, a behavioral "stickiness" with an abnormal perseveration on actions and strategies that are often maladaptive (Luigjes et al., 2019;Muela et al., 2022). Crucially, impulsivity and compulsivity can sometimes be perceived to mutually reinforce a vicious cycle in a number of conditions, such as gambling (Bowden-Jones et al., 2022) and, possibly, eating disorders, where both traits can co-occur (Howard et al., 2020). This observation and the questions it inevitably generates regarding possible shared or closely interrelated neurophysiological mechanisms (Belin et al., 2008) are at the core of this Research Topic. ...
Article
In our ever digitalising society, our engagement with the online world has significant potential to have a negative impact on our mental health. Although the roles of public health and psychiatry are debated, clinicians are in a strategic position to assess usage and intervene, to prevent harms from problematic engagement with the internet.
Article
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Background Understanding and treating the harm caused by gambling is a growing international psychiatric and public health challenge. Treatment of gambling harm may involve psychological and pharmacological intervention, in conjunction with peer support. This scoping review was conducted to identify, for the first time, the characteristics and extent of United Kingdom (UK) based gambling treatment research. We reviewed studies conducted among people seeking treatment for disordered or harmful gambling in the UK, the settings, research designs, and outcome measures used, and to identify any treatment research gaps. Methods Systematic searches of PsycInfo, PsycArticles, Scopus, PubMed, and Web of Science databases were carried out for gambling treatment research or evaluation studies conducted in the UK. Studies were included if they evaluated the effectiveness of an intervention or treatment designed to improve symptoms of harmful or problematic gambling, reported outcomes of interventions on treatment adherence, gambling symptoms, or behaviours using standardised measures, were conducted in the UK, and were published since 2000. Results Eight studies met the inclusion criteria. Four were retrospective chart reviews, two were single-participant case reports, one described a retrospective case series, and one employed a cross-sectional design. None used an experimental design. Conclusion The limited number of studies included in this review highlights a relative paucity of gambling treatment research conducted in UK settings. Further work should seek to identify potential barriers and obstacles to conducting gambling treatment research in the UK.
Chapter
Other categories of personality disorders, apart from borderline personality disorder are encountered in clinical practice and these are described and named in DSM-5 but not in ICD-11. The clinical features and diagnostic criteria of all these types are reviewed here. They are grouped into three clusters: Cluster A, the eccentric PDs – which include paranoid, schizoid and schizotypal PDs – and Cluster B, the dramatic group. The most important of these is antisocial personality disorder as well as borderline and histrionic PDs. Cluster C, which are the avoidant or fearful PDs, include avoidant, dependent and obsessive-compulsive types. Also included in this chapter are a category of conditions known as ’impulse disorders’, where subjects experience an impulse to commit some action which may give them pleasure and are said to be ego-syntonic, yet result in distress to the individual or harm to others. These include gambling, gaming disorder, intermittent explosive disorder, kleptomania and pyromania.
Article
Background: Previous research has shown that nostalgia for the pre-addicted self can motivate people living with addiction to engage in behavior change. Objective: Herein, we explored nostalgia for the addictive behavior-labeled addiction-related nostalgia (ARN)-among people in recovery from engaging in addictive behavior. We tested the novel idea that ARN is positively associated with ambivalence about recovery. We also hypothesized that ARN may counteract the positive influence of optimism on individuals' commitment to recovery. Results: In two studies involving individuals in recovery from a gambling (Study 1; N=301) or alcohol use disorder (Study 2; N=604), ARN was linked to increased ambivalence about recovery, while optimism was associated with decreased ambivalence. As expected, the interaction between optimism and ARN revealed that nostalgia either eliminated (Study 1) or reduced (Study 2) the negative relation between optimism and ambivalence. Conclusions: These findings underscore the challenges posed by ARN in the recovery process and emphasize the importance of interventions that address and mitigate its impact while considering the moderating role of optimism.
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Relevance. Gambling addiction (gambling) involves frequent repeated episodes of gambling that dominate to the detriment of social, professional, material and family values. Gambling addiction is often combined with posttraumatic stress disorder (PTSD). Objective. To study the effect of predator presentation stress on the manifestations of gambling addiction in an animal model in a test of probability and magnitude of reinforcement in the IOWA Gambling task, and monoamine metabolism in the prefrontal cortex in rats. Methods. Rats were trained in a test of probability and magnitude of reinforcement, in the IOWA Gambling task. in a 3-beam maze. Each run in arm 1 of the maze was reinforced with 1 sunflower seed, each second run in arm 2 was reinforced with 2 seeds, and each third run in arm 3 was reinforced with 3 seeds. Correspondingly, half of the runs in arm 2 and 2/3 of the runs in arm 3 were left unreinforced. After training, the animals were placed in a terrarium with a tiger python, where one of them was victimized for its food requirements. On day 14 after predator presentation, dopamine and serotonin metabolism in the prefrontal cortex was determined using high-performance liquid chromatography with electrochemical detection. Results and Analysis. A decrease in the content of the dopamine metabolite dioxyphenylacetic acid and the ratio of dioxyphenylacetic acid to dopamine content in the prefrontal cortex was shown. A decrease in the content of serotonin, its metabolite 5-hydroxyindoleacetic acid and the ratio of 5-hydroxyindoleacetic acid to serotonin in the prefrontal cortex was also found in rats after exposure to a predator. At the same time, predator presentation induced significant behavioral changes in rats, increasing impulsivity in making choices in a test of probability and magnitude of reinforcement in the IOWA Gambling task. The acute vital stress of predator presentation increased the number of escapes to the third arm of the maze, suggesting that the animals exhibited more risky behavior observed in the situation of choosing reinforcements of different strength and probability. Conclusion. The animal model shows that depletion of dopaminergic and serotoninergic systems of the prefrontal cortex underlies pathological gambling addiction and inadequate decision making caused by PTSD.
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Background Increasing evidence suggests an association between third-generation antipsychotics (TGAs) and impulse control disorders (ICDs). This is thought to be due to their partial agonism of dopamine receptors. However, neither the relative nor absolute risks of ICDs in those prescribed TGAs are well established. To inform clinical practice, this systematic review and meta-analysis summarizes and quantifies the current evidence for an association. Methods An electronic search of Medline, PsychINFO, EMBASE, and the Cochrane Clinical Trials Database was undertaken from database inception to November 2022. Three reviewers screened abstracts and reviewed full texts for inclusion. A random-effects meta-analysis was conducted with eligible studies. Results A total of 392 abstracts were retrieved, 214 remained after duplicates were removed. Fifteen full texts were reviewed, of which 8 were included. All 8 studies found that TGAs were associated with increased probability of ICDs. Risk of bias was high or critical in 7 of 8 studies. Three studies were included in the pooled analysis for the primary outcome, 2 with data on each of aripiprazole, cariprazine, and brexpiprazole. Exposure to TGAs versus other antipsychotics was associated with an increase in ICDs (pooled odds ratio, 5.54; 2.24–13.68). Cariprazine and brexpiprazole were significantly associated with ICDs when analyzed individually. Aripiprazole trended toward increased risk, but very wide confidence intervals included no effect. Conclusions Third-generation antipsychotics were associated with increased risk of ICDs in all studies included and pooled analysis. However, the risk of bias is high, confidence intervals are wide, and the quality of evidence is very low for all TGAs examined.
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Background: Guidelines remain unclear on which medications for gambling disorder are to be preferred in terms of efficacy and tolerability. Aims: To compare pharmacological treatments for gambling disorder with each other and placebo on efficacy and tolerability, using network meta-analysis (NMA). Methods: We searched a broad range of databases for double-blind randomized controlled trials (RCTs) of medications for gambling disorder. Outcomes were gambling symptom severity and quality of life (for efficacy); as well as tolerability. Confidence in the network estimates was assessed using the CINeMA framework. Results: We included 21 RCTs in the systematic review and 15 RCTs (n = 940 participants) in the NMA. Compared with placebo, high confidence evidence indicated that nalmefene [Standardized Mean Difference (SMD): -0.87; 95% confidence interval (CI: -1.33,-0.41)] reduced gambling severity, followed by naltrexone [-0.43; -0.83,-0.02)]. Nalmefene [Odds Ratio (OR): 7.55; 95%CI: 2.24-24.41] and naltrexone (7.82; 1.26-48.70) had significantly higher dropout (lower tolerability) compared with placebo. As compared with placebo, naltrexone (SMD: -0.49; 95%CI: -0.81,-0.18) and nalmefene (-0.36; -0.72,-0.01) were beneficial in terms of quality of life. Conclusions: Nalmefene and naltrexone currently have the most supportive evidence for the pharmacological treatment of gambling disorder. Further clinical trials are needed, as well as analysis of individual participant data, to strengthen and broaden the evidence base, and to help tailor treatments at the individual patient level.
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Chronic illnesses are a major threat to global population health through the lifespan into older age. Despite world-wide public health goals, there has been a steady increase in chronic and non-communicable diseases (e.g., cancer, cardiovascular and metabolic disorders) and strong growth in mental health disorders. In 2010, 67% of deaths worldwide were due to chronic diseases and this increased to 74% in 2019, with accelerated growth in the COVID-19 era and its aftermath. Aging and wellbeing across the lifespan are positively impacted by the presence of effective prevention and management of chronic illness that can enhance population health. This paper provides a short overview of the journey to this current situation followed by discussion of how we may better address what the World Health Organization has termed the “tsunami of chronic diseases.” In this paper we advocate for the development, validation, and subsequent deployment of integrated: 1. Polygenic and multifactorial risk prediction tools to screen for those at future risk of chronic disease and those with undiagnosed chronic disease. 2. Advanced preventive, behavior change and chronic disease management to maximize population health and wellbeing. 3. Digital health systems to support greater efficiencies in population-scale health prevention and intervention programs. It is argued that each of these actions individually has an emerging evidence base. However, there has been limited research to date concerning the combined population-level health effects of their integration. We outline the conceptual framework within which we are planning and currently conducting studies to investigate the effects of their integration.
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Young people, in particular young men, are at risk of harm from gambling. Indeed, gambling disorder is a neglected public health issue. Recent government proposals in the UK aim to address the problem, but they may not be enough. In this article the authors explore the complex issues around gambling disorder, especially as it relates to online gambling, including some of the factors that put young men at greater risk.
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Background: PTSD and gambling disorder (GD) are frequently comorbid. Gambling may provide escape-based coping for the emotions experienced by PTSD sufferers. Military personnel may be at increased risk of PTSD and/or GD. Acceptance and Commitment Therapy (ACT) has been found to improve both PTSD and GD outcomes, yet research into the potential effectiveness of ACT for PTSD and/GD in veterans is scarce. Objective: This review aimed to systematically assess and describe the evidence relating to the use of ACT and acceptance-based therapy for military populations with PTSD and/or GD. Method: Six databases were searched. Selection criteria included studies that featured the armed forces/military, delivered ACT/acceptance-based therapy, and aimed to improve PTSD and/or GD outcomes. A narrative synthesis approach was adopted. Results: From 1,117 results, 39 studies were fully screened and 14 met inclusion criteria. All studies originated from the USA and 9 were associated with United States Department of Veterans Affairs. Therapy use within each study produced an improvement in PTSD and/or GD, yet only one study examined GD and no studies considered comorbid PTSD/GD. The broad range of study designs made it difficult to compare the findings or make generalisations from the collective results. It is unclear which method of ACT delivery is superior (app-based, telehealth, face-to-face, groups, one-to-one, manualised, or unstructured), or what the true effect size is of ACT for PTSD and/or GD. Conclusions: These preliminary findings are promising, yet more research is needed on the delivery format and content of ACT sessions, and whether findings generalise beyond USA-recruited military samples. The cost-effectiveness of remote-based ACT also warrants investigation. HIGHLIGHTS • Among veterans, psychological interventions such as Acceptance and Commitment Therapy (ACT) may be effective for Post-Traumatic Stress Disorder (PTSD) and/or Gambling Disorder (GD). • There is a paucity of evidence on ACT approaches for treating PTSD and GD in veterans. • Further work is needed on context-specific delivery (in-person vs. group), method of ACT intervention (manualised vs unstructured, digital therapeutics) with non-US samples.
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Autism spectrum disorders (hereafter autism) are prevalent and often associated with elevated rates of substance use disorders. A subset of people who gamble develop gambling disorder, which is functionally impairing. Characterization of relationships between autism and gambling, particularly as relates to cognition, may have important implications. We conducted a systematic review of the literature. Nine out of 343 publications were found eligible for inclusion. Most studies examined decision-making using cognitive tasks, showing mixed results (less, equivalent or superior performance in autistic people compared to non-autistic people). The most consistent cognitive finding was relatively slower responses in autistic people on gambling tasks, compared to non-autistic people. One study reported a link between problem gambling and autism scores, in people who gamble at least occasionally. This systematic review highlights a profound lack of research on the potential neurocognitive overlap between autism and gambling. Future work should address the link between autism and behavioral addictions in adequately powered samples, using validated tools.
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Since the onset of COVID-19, studies suggest a significant increase in gambling over the internet, potentially facilitated by increased time at home, social isolation and boredom. This study aimed to address what is known about the impact of the pandemic on gambling behaviours by conducting a mapping review. A systematic literature search was conducted using four online databases. Additional studies were identified by reading reference lists. The studies were quality scored and their findings synthesised in terms of overall changes at the population level and potentially vulnerable groups. The weight of evidence from 36 relevant reports across 13 countries indicated reductions of gambling during the pandemic at the level of the general population. However, marked increases in gambling amongst vulnerable sub-populations including amongst young people and people with pre-existing at-risk gambling were also noted. The impact of COVID-19 on gambling is highly contingent on context. If policy makers examine only population level data, this could overlook profound negative effects identified in those with at-risk gambling, gambling disorder, and young people.
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Background There is a need to improve retention and outcomes for treatment of problem gambling and gambling disorder. Contingency management (CM) is a behavioural intervention involving identification of target behaviours (such as attendance, abstinence, or steps towards recovery) and the provision of incentives (such as vouchers or credits towards the purchase of preferred items) contingent on objective evidence of these behaviours. Contingency management for abstinence and attendance in substance misuse treatment has a substantial evidence base but has not been widely adopted or extended to other addictive behaviours such as gambling. Potential barriers to the widespread adoption of CM may relate to practitioners’ perceptions about this form of incentive-based treatment. The present study sought to explore United Kingdom (UK) gambling treatment providers’ views of CM for treatment of problem gambling and gambling disorder. Methods We conducted semi-structured interviews with 30 treatment providers from across the UK working with people with gambling problems. Participants were provided with an explanation of CM, several hypothetical scenarios, and a structured questionnaire to facilitate discussion. Thematic analysis was used to interpret findings. Results Participants felt there could be a conflict between CM and their treatment philosophies, that CM was similar in some ways to gambling, and that the CM approach could be manipulated and reduce trust between client and therapist. Some participants were more supportive of implementing CM for specific treatment goals than others, such as for incentivising attendance over abstinence due to perceived difficulties in objectively verifying abstinence. Participants favoured providing credits accruing to services relevant to personal recovery rather than voucher-based incentives. Conclusions UK gambling treatment providers are somewhat receptive to CM approaches for treatment of problem gambling and gambling disorder. Potential barriers and obstacles are readily addressable, and more research is needed on the efficacy and effectiveness of CM for gambling.
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The COVID-19 pandemic (including lockdown) is likely to have had profound but diverse implications for mental health and well-being, yet little is known about individual experiences of the pandemic (positive and negative) and how this relates to mental health and well-being, as well as other important contextual variables. Here, we analyse data sampled in a large-scale manner from 379,875 people in the United Kingdom (UK) during 2020 to identify population variables associated with mood and mental health during the COVID-19 pandemic, and to investigate self-perceived pandemic impact in relation to those variables. We report that while there are relatively small population-level differences in mood assessment scores pre- to peakUK lockdown, the size of the differences is larger for people from specific groups, e.g. older adults and people with lower incomes. Multiple dimensions underlie peoples’ perceptions, both positive and negative, of the pandemic’s impact on daily life. These dimensions explain variance in mental health and can be statistically predicted from age, demographics, home and work circumstances, pre-existing conditions, maladaptive technology use and personality traits (e.g., compulsivity). We conclude that a holistic view, incorporating the broad range of relevant population factors, can better characterise people whose mental health is most at risk during the COVID-19 pandemic.
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Gambling is a common activity amongst young adults in the UK, and was a behavior of interest during the early mitigation against COVID-19 (first lockdown). The Avon Longitudinal Study of Parents and Children (ALSPAC) was used to investigate attitudes, moods and behavior during lockdown in England. ALSPAC participants were invited to complete online questionnaires in May 2020, including a set of questions about frequency of gambling and gambling activities which had been asked three years previously. Mental health and wellbeing data and alcohol use were also collected as part of lockdown questionnaires. Gambling questions were completed by 2632 young adults, 71% female, with a mean age of 27.8 years. Overall, gambling frequency reduced during lockdown for both males and females, but more males engaged in regular (weekly) gambling. Gambling activities became more restricted compared to previous reports, but online gambling (e.g. online poker, bingo, casino games) was more frequent. Previous gambling behaviour predicted gambling frequency during lockdown. No associations were apparent between gambling frequency and measures of mental health and well-being. Heavy alcohol use was strongly linked with regular gambling during lockdown. Gamblers were more than twice as likely as non-gamblers to have experienced financial difficulties pre-COVID, but gambling frequency was not related to employment status during lockdown. Online gambling increased during lockdown, whilst offline gambling activities decreased in frequency. A small minority of regular weekly gamblers, who tended to be male and heavy users of alcohol, participated in a wide range of online and offline gambling activities.
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Objectives: To investigate changes over time and identify predictors of online gambling among gamblers by using three Norwegian representative samples covering a 6-year (2013–2019) period. We also aimed to identify different characteristics (including video game participation and video gaming problems) of online compared to offline gamblers. Methods: Data from gamblers (N = 15,096) participating in three cross-sectional surveys (2013, 2015, and 2019) based on random sampling from the Norwegian Population Registry were analyzed. Participants were asked how frequently they engaged in online gambling on different platforms (e.g., mobile phone). Data on sociodemographics, games gambled, gambling problems, gaming, and problem gaming were collected and analyzed by logistic regression analyses. Results: Overall, an increase in online gambling from 2013 to 2015 was found (a larger percentage of gamblers reported having gambled online at least once during the last year), and an increase in online gambling from 2015 to 2019 was found (more gamblers reported having gambled online at least once last year and at least once per week). The increase was largest for gambling on mobile phone. Consistent predictors of online gambling (at least once last year and at least once per week) were male gender, high income, being unemployed, being on disability pension, having work assessment allowance, being a homemaker or retiree, number of games gambled, and gambling problems. Conclusions: Online gambling, especially on mobile phones, has increased significantly during the last 6 years in Norway. Hence, gambling availability seems to have grown, which may pose a risk for development of gambling problems. Compared to offline gamblers, online gamblers were more likely to be men, young, not working or studying, gambling on several games, and having gambling problems. Responsible gambling efforts aiming at preventing or minimizing harm related to online gambling should thus target these groups.
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Gambling is an ordinary pastime for some people, but is associated with addiction and harmful outcomes for others. Evidence of these harms is limited to small-sample, cross-sectional self-reports, such as prevalence surveys. We examine the association between gambling as a proportion of monthly income and 31 financial, social and health outcomes using anonymous data provided by a UK retail bank, aggregated for up to 6.5 million individuals over up to 7 years. Gambling is associated with higher financial distress and lower financial inclusion and planning, and with negative lifestyle, health, well-being and leisure outcomes. Gambling is associated with higher rates of future unemployment and physical disability and, at the highest levels, with substantially increased mortality. Gambling is persistent over time, growing over the sample period, and has higher negative associations among the heaviest gamblers. Our findings inform the debate over the relationship between gambling and life experiences across the population.
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Impulsive and compulsive symptoms are common, tend to co-occur, and collectively account for a substantive global disease burden. Latent phenotyping offers a promising approach to elucidate common neural mechanisms conferring vulnerability to such symptoms in the general population. We utilised the Neuroscience in Psychiatry Network (NSPN), a cohort of young people (aged 18–29 years) in the United Kingdom, who provided questionnaire data and Magnetic Resonance Imaging scans. Partial Least Squares was used to identify brain regions in which intra-cortical myelination (measured using Magnetisation Transfer, MT) was significantly associated with a disinhibition phenotype, derived from bi-factor modelling of 33 impulsive and compulsive problem behaviours. The neuroimaging sample comprised 126 participants, mean 22.8 (2.7 SD) years old, being 61.1% female. Disinhibition scores were significantly and positively associated with higher MT in the bilateral frontal and parietal lobes. 1279 genes associated with disinhibition-related brain regions were identified, which were significantly enriched for functional biological interactions reflecting receptor signalling pathways. This study indicates common microstructural brain abnormalities contributing to a multitude of related, prevalent, problem behaviours characterised by disinhibition. Such a latent phenotyping approach provides insights into common neurobiological pathways, which may help to improve disease models and treatment approaches. Now that this latent phenotyping model has been validated in a general population sample, it can be extended into patient settings.
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Background: Gambling disorder (GD) is the most common behavioral addiction and shares pathophysiological and clinical features with substance use disorders (SUDs). Effective therapeutic interventions for GD are lacking. Non-invasive brain stimulation (NIBS) may represent a promising treatment option for GD. Objective: This systematic review aimed to provide a comprehensive and structured overview of studies applying NIBS techniques to GD and problem gambling. Methods: A literature search using Pubmed, Web of Science, and Science Direct was conducted from databases inception to December 19, 2019, for studies assessing the effects of repetitive transcranial magnetic stimulation (rTMS) and transcranial direct current stimulation (t-DCS) on subjects with GD or problem gambling. Studies using NIBS techniques on healthy subjects and those without therapeutic goals but only aiming to assess basic neurophysiology measures were excluded. Results: A total of 269 articles were title and abstract screened, 13 full texts were assessed, and 11 were included, of which six were controlled and five were uncontrolled. Most studies showed a reduction of gambling behavior, craving for gambling, and gambling-related symptoms. NIBS effects on psychiatric symptoms were less consistent. A decrease of the behavioral activation related to gambling was also reported. Some studies reported modulation of behavioral measures (i.e., impulsivity, cognitive and attentional control, decision making, cognitive flexibility). Studies were not consistent in terms of NIBS protocol, site of stimulation, clinical and surrogate outcome measures, and duration of treatment and follow-up. Sample size was small in most studies. Conclusions: The clinical and methodological heterogeneity of the included studies prevented us from drawing any firm conclusion on the efficacy of NIBS interventions for GD. Further methodologically sound, robust, and well-powered studies are needed.
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Background: Neuroimaging and neuropsychological studies have suggested that common features characterize both Gambling Disorder (GD) and Alcohol Use Disorder (AUD), but these conditions have rarely been compared. Methods: We provide evidence for the similarities and differences between GD and AUD in neural correlates of executive functions by performing an activation likelihood estimation meta-analysis of 34 functional magnetic resonance imaging studies involving executive function processes in individuals diagnosed with GD and AUD and healthy controls (HC). Results: GD showed greater bilateral clusters of activation compared with HC, mainly located in the head and body of the caudate, right middle frontal gyrus, right putamen, and hypothalamus. Differently, AUD showed enhanced activation compared with HC in the right lentiform nucleus, right middle frontal gyrus, and the precuneus; it also showed clusters of deactivation in the bilateral middle frontal gyrus, left middle cingulate cortex, and inferior portion of the left putamen. Conclusions: Going beyond the limitations of a single study approach, these findings provide evidence, for the first time, that both disorders are associated with specific neural alterations in the neural network for executive functions.
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The Emerging Adults Gambling Survey is a longitudinal survey of young adults aged 16-24 living in Great Britain. It aims to explore a range of gambling behaviours and harms among young adults and examine how this changes over time. It is part of a broader project funded by Wellcome into the gambling behaviours of young people and its relationship with technological change. Funding is currently available for two waves of data collection: the first collected in June/August 2019 (n=3549) and the second to be collected in June/August 2020. The second wave of data collection will also obtain information about the immediate impact of coronavirus on gambling behaviours. With a sample size of 3549 for Wave 1, this is one of the largest study of gambling behaviours among young adults to be conducted in Great Britain and is a resource for other researchers to draw on. Data will be deposited in the UK Data Archive upon completion of Wave 2 data collection and analysis. This protocol is intended to support other researchers to use this resource by setting out the study design and methods.
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Objectives Problem gamblers in treatment are known to be at high risk for suicidality, but few studies have examined if this is evident in community samples. Evidence is mixed on the extent to which an association between problem gambling and suicidality may be explained by psychiatric comorbidity. We tested whether they are associated after adjustment for co-occurring mental disorders and other factors. Study design Secondary analysis of the Adult Psychiatric Morbidity Survey 2007, a cross-sectional national probability sample survey of 7403 adults living in households in England. Methods Rates of suicidality in problem gamblers and the rest of the population were compared. A series of logistic regression models assessed the impact of adjustment on the relationship between problem gambling and suicidality. Results Past year suicidality was reported in 19.2% of problem gamblers, compared with 4.4% in the rest of the population. Their unadjusted odds ratios (OR) of suicidality were 5.3 times higher. Odds attenuated but remained significant when depression and anxiety disorders, substance dependences, attention-deficit/hyperactivity disorder, and other factors were accounted for (adjusted OR = 2.9, 95% confidence interval = 1. 1, 8.1 P = 0.023). Conclusions Problem gamblers are a high-risk group for suicidality. This should be recognised in individual suicide prevention plans and local and national suicide prevention strategies. While some of this relationship is explained by other factors, a significant and substantial association between problem gambling and suicidality remains.
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Background: Childhood maltreatment has been associated with significant impairment in social, emotional and behavioural functioning later in life. Nevertheless, some individuals who have experienced childhood maltreatment function better than expected given their circumstances. Main body: Here, we provide an integrated understanding of the complex, interrelated mechanisms that facilitate such individual resilient functioning after childhood maltreatment. We aim to show that resilient functioning is not facilitated by any single 'resilience biomarker'. Rather, resilient functioning after childhood maltreatment is a product of complex processes and influences across multiple levels, ranging from 'bottom-up' polygenetic influences, to 'top-down' supportive social influences. We highlight the complex nature of resilient functioning and suggest how future studies could embrace a complexity theory approach and investigate multiple levels of biological organisation and their temporal dynamics in a longitudinal or prospective manner. This would involve using methods and tools that allow the characterisation of resilient functioning trajectories, attractor states and multidimensional/multilevel assessments of functioning. Such an approach necessitates large, longitudinal studies on the neurobiological mechanisms of resilient functioning after childhood maltreatment that cut across and integrate multiple levels of explanation (i.e. genetics, endocrine and immune systems, brain structure and function, cognition and environmental factors) and their temporal interconnections. Conclusion: We conclude that a turn towards complexity is likely to foster collaboration and integration across fields. It is a promising avenue which may guide future studies aimed to promote resilience in those who have experienced childhood maltreatment.
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Non-gambling specialist services, such as primary care, alcohol and other drug use, and mental health services, are well placed to enhance the identification of people with gambling problems and offer appropriate generalist first level interventions or referral. Given time and resource demands, many of these clinical services may only have the capacity to administer very short screening instruments. This systematic review was conducted to provide a resource for health service providers and researchers in identifying the most accurate brief (1-5 item) screening instruments to identify problem and at-risk gambling for their specific purposes and populations. A systematic search of peer-reviewed and grey literature from 1990 to 2019 identified 25 articles for inclusion. Meta-analysis revealed five of the 20 available instruments met criteria for satisfactory diagnostic accuracy in detecting both problem and at-risk gambling: Brief Problem Gambling Screen (BPGS-2), NODS-CLiP, Problem Gambling Severity Index-Short Form (PGSI-SF), NODS-PERC, and NODS-CLiP2. Of these, the NODS-CLiP and NODS-PERC have the largest volume of diagnostic data. The Lie/Bet Questionnaire and One-Item Screen are also promising shorter options. Because these conclusions are drawn from a relatively limited evidence base, future studies evaluating the diagnostic accuracy of existing brief instruments across settings, age groups, and timeframes are needed.
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Background: Problematic use of the Internet has been highlighted as needing further study by international bodies, including the European Union and American Psychiatric Association. Knowledge regarding the optimal classification of problematic use of the Internet, subtypes, and associations with clinical disorders has been hindered by reliance on measurement instruments characterized by limited psychometric properties and external validation. Methods: Non-treatment seeking individuals were recruited from the community of Stellenbosch, South Africa (N = 1661), and Chicago, United States of America (N = 827). Participants completed an online version of the Internet Addiction Test, a widely used measure of problematic use of the Internet consisting of 20-items, measured on a 5-point Likert-scale. The online questions also included demographic measures, time spent engaging in different online activities, and clinical scales. The psychometric properties of the Internet Addiction Test, and potential problematic use of the Internet subtypes, were characterized using factor analysis and latent class analysis. Results: Internet Addiction Test data were optimally conceptualized as unidimensional. Latent class analysis identified two groups: those essentially free from Internet use problems, and those with problematic use of the Internet situated along a unidimensional spectrum. Internet Addiction Test scores clearly differentiated these groups, but with different optimal cut-offs at each site. In the larger Stellenbosch dataset, there was evidence for two subtypes of problematic use of the Internet that differed in severity: a lower severity "impulsive" subtype (linked with attention-deficit hyperactivity disorder), and a higher severity "compulsive" subtype (linked with obsessive-compulsive personality traits). Conclusions: Problematic use of the Internet as measured by the Internet Addiction Test reflects a quasi-trait - a unipolar dimension in which most variance is restricted to a subset of people with problems regulating Internet use. There was no evidence for subtypes based on the type of online activities engaged in, which increased similarly with overall severity of Internet use problems. Measures of comorbid psychiatric symptoms, along with impulsivity, and compulsivity, appear valuable for differentiating clinical subtypes and could be included in the development of new instruments for assessing the presence and severity of Internet use problems.
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Objective: While many individuals gamble responsibly, some develop maladaptive symptoms of a gambling disorder. Gambling problems often first occur in young people, yet little is known about the longitudinal course of such symptoms and whether this course can be predicted. The aim of this study was to identify latent subtypes of disordered gambling based on symptom presentation and identify predictors of persisting gambling symptoms over time. Methods: 575 non-treatment seeking young adults (mean age [SD] = 22.3 [3.6] years; 376 (65.4%) male) were assessed at baseline and annually, over three years, using measures of gambling severity. Latent subtypes of gambling symptoms were identified using latent mixture modeling. Baseline differences were characterized using analysis of variance and binary logistic regression respectively. Results: Three longitudinal phenotypes of disordered gambling were identified: high harm group (N = 5.6%) who had moderate-severe gambling disorder at baseline and remained symptomatic at follow-up; intermediate harm group (19.5%) who had problem gambling reducing over time; and low harm group (75.0%) who were essentially asymptomatic. Compared to the low harm group, the other two groups had worse baseline quality of life, elevated occurrence of other mental disorders and substance use, higher body mass indices, and higher impulsivity, compulsivity, and cognitive deficits. Approximately 5% of the total sample showed worsening of gambling symptoms over time, and this rate did not differ significantly between the groups. Conclusions: Three subtypes of disordered gambling were found, based on longitudinal symptom data. Even the intermediate gambling group had a profundity of psychopathological and untoward physical health associations. Our data indicate the need for large-scale international collaborations to identify predictors of clinical worsening in people who gamble, across the full range of baseline symptom severity from minimal to full endorsement of current diagnostic criteria for gambling disorder.
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Importance Young relative age within the school year has previously been associated with attention-deficit/hyperactivity disorder (ADHD) diagnosis and, based on limited evidence, diagnosis of intellectual disability. No study to date has examined the association between relative age and diagnosis of depression. Objectives To estimate the associations with intellectual disability and ADHD and investigate a potential novel association between relative age and childhood depression. Design, Setting, and Participants This population-based cohort study of 1 042 106 children aged 4 to 15 years used electronic record data collected before January 3, 2017, from more than 700 general practices contributing to the UK Clinical Practice Research Datalink. Multivariable Cox proportional hazards regression modeling was used to explore the association between relative age and the incidence of intellectual disability, ADHD, and depression before age 16 years. Data were analyzed between July 2017 and January 2019. Exposures Relative age within school year determined by month of birth and categorized into four 3-month groups. Main Outcomes and Measures Intellectual disability, ADHD, and depression. Results In the total cohort of 1 042 106 children, 532 876 were male (51.1%) and the median age at study entry was 4.0 years (interquartile range, 4.0-5.0). There was evidence that being born in the last quarter of the school year (ie, being the youngest group in a school year) was associated with diagnosis of intellectual disability (adjusted hazard ratio [aHR], 1.30; 95% CI, 1.18-1.42), ADHD (aHR, 1.36; 95% CI, 1.28-1.45), and depression (aHR, 1.31; 95% CI, 1.08-1.59) compared with being born in the first quarter. A graded association was seen with intermediate age groups at a smaller increased risk of each diagnosis compared with the oldest group, with aHRs for intellectual disability for those born in the second quarter of 1.06 (95% CI, 0.96-1.17) and for those born in the third quarter of 1.20 (95% CI, 1.09-1.32); aHRs for ADHD for those born in the second quarter of 1.15 (95% CI, 1.08-1.23) and for those born in the third quarter of 1.31 (95% CI, 1.23-1.40); and aHRs for depression for those born in the second quarter of 1.05 (95% CI, 0.85-1.29) and for those born in the third quarter of 1.13 (95% CI, 0.92-1.38). Conclusions and Relevance In this study, relative youth status in the school year is associated with an increased risk of diagnosis of ADHD, intellectual disability, and depression in childhood. Further research into clinical and policy interventions to minimize these associations appears to be needed.
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It is well known that many problem gamblers also suffer from other psychiatric conditions. However, knowledge regarding the temporal sequencing of the conditions is lacking, as well as insight in possible gender specific patterns. The aim of this study was to examine the risk for psychiatric comorbidity among problem gamblers compared to non-problem gamblers in the general Swedish population, as well as the age of onset and the temporal sequencing of problem gambling and the comorbid psychiatric conditions among lifetime problem gamblers. A case–control study nested in the Swelogs cohort was used. For both the female and the male problem gamblers, the risk for having had a lifetime psychiatric condition was double or more than double compared to the controls. Having experienced anxiety or depression before gambling onset, constituted a risk for developing problem gambling for the women but not for the men. Further, the female cases initiated gambling after their first period of anxiety, depression and problems with substances, and problem gambling was the last condition to evolve. Opposite this, the male cases initiated gambling before any condition evolved, and depression and suicidal events emerged after problem gambling onset. There were large differences in mean age of onset between the female cases and their controls, this was not the case for the males. Gender specific patterns in the association between problem gambling and psychiatric comorbidity, as well as in the development of problem gambling needs to be considered in treatment planning as well as by the industry in their advertising.
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Gambling Disorder is a prevalent psychiatric condition often linked to dysfunction of cognitive domains regulating impulsive behavior. Despite the centrality of impulsivity to neurobiological models of Gambling Disorder, a comprehensive meta-analysis of all impulsive cognitive domains has yet to be conducted. It is also not clear whether cognitive deficits in Gambling Disorder extend to those with problem (at-risk) gambling. A systematic review was undertaken of case–control studies examining the following cognitive domains in Gambling Disorder or in at-risk (problem) gambling: attentional inhibition, motor inhibition, discounting, decision-making, and reflection impulsivity. Case–control differences in cognition were identified using meta-analysis (random-effects modeling). Moderation analysis explored potential influences of age, gender, presence/absence of comorbidities in cases, geographical region, and study quality on cognitive performance. Gambling Disorder was associated with significant impairments in motor (g = 0.39–0.48) and attentional (g = 0.55) inhibition, discounting (g = 0.66), and decision-making (g = 0.63) tasks. For problem gambling, only decision-making had sufficient data for meta-analysis, yielding significant impairment versus controls (g = 0.66); however, study quality was relatively low. Insufficient data were available for meta-analysis of reflection impulsivity. There was evidence for significant publication bias only for the discounting domain, after an outlier study was excluded. Study quality overall was reasonable (mean score 71.9% of maximum), but most studies (~85%) did not screen for comorbid impulse control and related disorders. This meta-analysis indicates heightened impulsivity across a range of cognitive domains in Gambling Disorder. Decision-making impulsivity may extend to problem (at-risk) gambling, but further studies are needed to confirm such candidate cognitive vulnerability markers.
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The structural MRI evidence for gray matter deficits in GD is currently inconclusive, although a conservative statement would be that any reductions are modest in comparison to the reliable deterioration seen in SUDs [57,58,59]. This conclusion is supported by GD studies employing direct 3-group designs with an SUD comparison group [28, 44]. Nevertheless, individual differences in brain anatomy correlate with vulnerability factors, including impulsivity, which may be transdiagnostic across addictive disorders [44, 46]. DTI studies indicate more consistent reductions in white matter integrity that are of a distributed nature and similar to changes described in SUDs. It is currently unclear whether gray matter or white matter alterations in GD relate directly to reward-based symptom clusters.
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Background The U.S. National Institutes of Mental Health Research Domain Criteria (RDoC) seek to stimulate research into biologically validated neuropsychological dimensions across mental illness symptoms and diagnoses. The RDoC framework comprises 39 functional constructs designed to be revised and refined, with the overall goal to improve diagnostic validity and treatments. This study aimed to reach a consensus among experts in the addiction field on the ‘primary' RDoC constructs most relevant to substance and behavioural addictions. Methods Forty‐four addiction experts were recruited from Australia, Asia, Europe and the Americas. The Delphi technique was used to determine a consensus as to the degree of importance of each construct in understanding the essential dimensions underpinning addictive behaviours. Expert opinions were canvassed online over three rounds (97% completion rate), with each consecutive round offering feedback for experts to review their opinions. Results Seven constructs were endorsed by ≥80% of experts as ‘primary' to the understanding of addictive behaviour: five from the Positive Valence System (Reward Valuation, Expectancy, Action Selection, Reward Learning, Habit); one from the Cognitive Control System (Response Selection/Inhibition); and one expert‐initiated construct (Compulsivity). These constructs were rated to be differentially related to stages of the addiction cycle, with some more closely linked to addiction onset, and others more to chronicity. Experts agreed that these neuropsychological dimensions apply across a range of addictions. Conclusions The study offers a novel and neuropsychologically informed theoretical framework, as well as a cogent step forward to test transdiagnostic concepts in addiction research, with direct implications for assessment, diagnosis, staging of disorder, and treatment.
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Background: Disorders of impulsivity are common, functionally impairing, and highly relevant across different clinical and research settings. Few structured clinical interviews for the identification and diagnosis of impulse control disorders exist, and none have been validated in a community sample in terms of psychometric properties. Methods: The Minnesota Impulse control disorders Interview (MIDI v2.0) was administered to an enriched sample of 293 non-treatment seeking adults aged 18-35 years, recruited using media advertisements in two large US cities. In addition to the MIDI, participants undertook extended clinical interview for other mental disorders, the Barratt impulsiveness questionnaire, and the Padua obsessive-compulsive inventory. The psychometric properties of the MIDI were characterized. Results: In logistic regression, the MIDI showed good concurrent validity against the reference measures (versus gambling disorder interview, p < 0.001; Barratt impulsiveness attentional and non-planning scores p < 0.05), and good discriminant validity versus primarily non-impulsive symptoms, including against anxiety, depression, and obsessive-compulsive symptoms (all p > 0.05). Test re-test reliability was excellent (0.95). Conclusions: The MIDI has good psychometric properties and thus may be a valuable interview tool for clinical and research studies involving impulse control disorders. Further research is needed to better understanding the optimal diagnostic classification and neurobiology of these neglected disorders.
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Background Emotion (dys)regulation as well as the interventions for improving these difficulties are receiving a growing attention in the literature. The aim of the present paper was to conduct a systematic review about the efficacy of mindfulness-based interventions (MBIs) in both substance and behavioral addictions (BAs). Method A literature search was conducted using Cochrane, PubMed, and Web of Science. Fifty-four randomized controlled trials published in English since 2009 to April 2017 were included into a narrative synthesis. Results Mindfulness-based interventions were applied in a wide range of addictions, including substance use disorders (from smoking to alcohol, among others) and BAs (namely, gambling disorder). These treatments were successful for reducing dependence, craving, and other addiction-related symptoms by also improving mood state and emotion dysregulation. The most commonly used MBI approaches were as follows: Mindfulness-Based Relapse Prevention, Mindfulness Training for Smokers, or Mindfulness-Oriented Recovery Enhancement, and the most frequent control group in the included studies was Treatment as Usual (TAU). The most effective approach was the combination of MBIs with TAU or other active treatments. However, there is a lack of studies showing the maintenance of the effect over time. Therefore, studies with longer follow-ups are needed. Conclusion The revised literature shows support for the effectiveness of the MBIs. Future research should focus on longer follow-up assessments as well as on adolescence and young population, as they are a vulnerable population for developing problems associated with alcohol, drugs, or other addictions.
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Background and aims: Problematic internet use (PIU; otherwise known as Internet Addiction) is a growing problem in modern societies. There is scarce knowledge of the demographic variables and specific internet activities associated with PIU and a limited understanding of how PIU should be conceptualized. Our aim was to identify specific internet activities associated with PIU and explore the moderating role of age and gender in those associations. Methods: We recruited 1749 participants aged 18 and above via media advertisements in an Internet-based survey at two sites, one in the US, and one in South Africa; we utilized Lasso regression for the analysis. Results: Specific internet activities were associated with higher problematic internet use scores, including general surfing (lasso β: 2.1), internet gaming (β: 0.6), online shopping (β: 1.4), use of online auction websites (β: 0.027), social networking (β: 0.46) and use of online pornography (β: 1.0). Age moderated the relationship between PIU and role-playing-games (β: 0.33), online gambling (β: 0.15), use of auction websites (β: 0.35) and streaming media (β: 0.35), with older age associated with higher levels of PIU. There was inconclusive evidence for gender and gender × internet activities being associated with problematic internet use scores. Attention-deficit hyperactivity disorder (ADHD) and social anxiety disorder were associated with high PIU scores in young participants (age ≤ 25, β: 0.35 and 0.65 respectively), whereas generalized anxiety disorder (GAD) and obsessive-compulsive disorder (OCD) were associated with high PIU scores in the older participants (age > 55, β: 6.4 and 4.3 respectively). Conclusions: Many types of online behavior (e.g. shopping, pornography, general surfing) bear a stronger relationship with maladaptive use of the internet than gaming supporting the diagnostic classification of problematic internet use as a multifaceted disorder. Furthermore, internet activities and psychiatric diagnoses associated with problematic internet use vary with age, with public health implications.
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Recent research points to a shift from categorical diagnoses to a dimensional understanding of psychopathology and mental health disorders. In parallel, there has been a rise in newer psychosocial treatment modalities, which are inherently transdiagnostic. Transdiagnostic approaches are those that identify core vulnerabilities and apply universal principles to therapeutic treatment. As treatment of substance use disorders (SUD) must invariably accommodate such vulnerabilities, clinicians are finding such interventions useful. Therapies like Acceptance and Commitment Therapy (ACT), Dialectical Behavioural Therapy (DBT), Metacognitive Therapy, Mindfulness-Based Relapse Prevention (MBRP) use a transdiagnostic framework and are backed by evidence in the last 3-5 years. In this paper we first highlight the conceptual understanding of SUD through these frameworks and then discuss their clinical applications along with specific techniques that have been particularly useful with this population. Key words: Third wave interventions, Dialectical behaviour therapy, radical acceptance, dialectical abstinence, Acceptance Commitment Therapy, Schema Therapy
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Compulsivity is a core feature of addictive disorders, including gambling disorder. However, it is unclear to what extent this compulsive behavior in gambling disorder is associated with abnormal compulsivity-related neurocognitive functioning. Here, we summarize and synthesize the evidence for compulsive behavior, as assessed by compulsivity-related neurocognitive tasks, in individuals with gambling disorder compared to healthy controls (HCs). A total of 29 studies, comprising 41 task-results, were included in the systematic review; 32 datasets (n=1,072 individuals with gambling disorder; n=1,312 HCs) were also included in the meta-analyses, conducted for each cognitive task separately. Our meta-analyses indicate significant deficits in individuals with gambling disorder in cognitive flexibility, attentional set-shifting, and attentional bias. Overall, these findings support the idea that compulsivity-related performance deficits characterize gambling disorder. This association may provide a possible link between impairments in executive functions related to compulsive action. We discuss the practical relevance of these results, their implications for our understanding of gambling disorder and how they relate to neurobiological factors and other 'disorders of compulsivity'.
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Various therapeutic approaches are available for the treatment of gambling disorder (GD), especially cognitive behavioral therapy (CBT; the most widely used treatment). However, CBT has high dropout and relapse rates as well as non-compliance issues, which may be partly due to resistance to changing core characteristics, such as executive functioning, attention, and emotional regulation abnormalities. Finding new therapeutic approaches to treat GD is thus a key challenge. Cognitive remediation (CR) interventions represent a promising approach to GD management, which has recently been demonstrated to have efficacy for treating other addictive disorders. The objective of this review is to describe the possible benefits of CR interventions for GD management. Two systematic searches in MEDLINE and ScienceDirect databases were conducted up until January 2017. Potential neurocognitive targets of CR interventions for GD were reviewed, as is the use and efficacy of such interventions for GD. While there is evidence of several neurocognitive deficits in individuals with GD in terms of impulsive, reflective, and interoceptive processes, the literature on CR interventions is virtually absent. No clinical studies were found in the literature, apart from a trial of a very specific program using Playmancer, a serious videogame, which was tested in cases of bulimia nervosa and GD. However, neurocognitive impairments in individuals with addictive disorders are highly significant, not only affecting quality of life, but also making abstinence and recovery more difficult. Given that CR interventions represent a relatively novel therapeutic approach to addiction and that there is currently a scarcity of studies on clinical populations suffering from GD, further research is needed to examine the potential targets of such interventions and the effectiveness of different training approaches. So far, no consensus has been reached on the optimal parameters of CR interventions (duration, intensity, frequency, group vs. individual, pencil-and-paper vs. computerized delivery, etc.). Although no firm conclusions can be drawn, CR interventions represent a promising adjunct treatment for GD. Such a novel therapy could be associated with common interventions, such as CBT and educational and motivational interventions, in order to make therapies more effective and longer-lasting and to decrease the risk of relapse.
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Online interventions for gambling, alcohol, and illegal drug related problems have been developing at a fast pace over the past decade. Yet, little is known about the content and efficacy of interventions provided entirely online for reducing drug/alcohol use and gambling, or about the characteristics of those who use these interventions. This systematic review aims to describe the characteristics of online interventions, their efficacy, and the profile of their clientele. Documentation was mainly obtained through four scientific databases in psychology, technology, and medical research (PsychINFO, MedLine, Francis, and INSPEC) using three keywords (substances or gambling, intervention, Internet). Of the 4,708 documents initially identified, 18 studies meeting admissibility criteria were retained and analyzed after exclusion of duplicates and non-relevant documents. No study in the review related to problem gambling. The majority of interventions were based upon motivational or cognitive-behavioral theoretical approaches and called upon well-established therapeutic components in the field of addictions. The participants in these studies were generally adults between 30 and 46 years old with a high school education and presenting a high risk or problematic use. More than three quarters of the studies showed a short-term decrease in use that was maintained 6 months later, but only two studies included a 12 months follow-up. Online interventions seem promising and appear to meet the needs of participants who are in the workforce and seeking help for the first time. Long-term efficacy studies should nonetheless be conducted.
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Gambling problems impact 0.2%-4.0% of the population, and research related to treating gambling has burgeoned in the last decades. This article reviews trials for psychosocial treatments of gambling problems. Using Preferred Reporting Items for Systematic Reviews and Meta-Analyses Standards, we identified 21 randomized trials. Eleven studies evaluated interventions delivered via multisession, in-person therapy: cognitive therapies, cognitive-behavioral (CB) therapies, and motivational interventions (MI) alone or with CB therapies. An additional 10 studies used approaches that involved 1 or fewer in-person sessions; these included workbooks with CB exercises alone or in combination with MI and brief feedback or advice interventions. Although most studies found some benefits of CB therapy (alone or combined with MI) and brief feedback or advice relative to the control condition in the short term, only a handful of studies demonstrated any long-term benefits. Nearly half the studies used waitlist controls, precluding an understanding of long-term efficacy, and standardized outcomes measures are also lacking. Populations also differ markedly across studies, from nontreatment-seeking persons who screened positive for gambling problems to those with severe gambling disorder, and these discrepant populations may require different interventions. Although problem gamblers with less pronounced symptoms may benefit from very minimal interventions, therapist contact generally improved outcomes relative to entirely self-directed interventions, and at least some therapist contact may be necessary for patients with more severe gambling pathology to benefit from CB interventions. As treatment services for gambling continue to grow, this review provides timely information on best practices for gambling treatment. (PsycINFO Database Record
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It is common for jurisdictions tasked with minimising gambling-related harm to conduct problem gambling prevalence studies for the purpose of monitoring the impact of gambling on the community. However, given that both public health theory and empirical findings suggest that harms can occur without individuals satisfying clinical criteria of addiction, there is a recognized conceptual disconnect between the prevalence of clinical problem gamblers, and aggregate harm to the community. Starting with an initial item pool of 72 specific harms caused by problematic gambling, our aim was to develop a short gambling harms scale (SGHS) to screen for the presence and degree of harm caused by gambling. An Internet panel of 1524 individuals who had gambled in the last year completed a 72-item checklist, along with the Personal Wellbeing Index, the PGSI, and other measures. We selected 10 items for the SGHS, with the goals of maximising sensitivity and construct coverage. Psychometric analysis suggests very strong reliability, homogeneity and unidimensionality. Non-zero responses on the SGHS were associated with a large decrease in personal wellbeing, with wellbeing decreasing linearly with the number of harms indicated. We conclude that weighted SGHS scores can be aggregated at the population level to yield a sensitive and valid measure of gambling harm.
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Prior estimates of the population-level impact of gambling have relied on economic costings. Recent work has derived disability weights for the Problem Gambling Severity Index, which measure per-person impact of gambling on quality of life on a scale of zero to one. This provided scope for the present study to calculate the 'burden of gambling harm' , which captures the aggregate impact of harms arising from gambling on quality of life in a population. Gambling-related harm was associated with 101,675 years of life lost in Victoria, Australia: approximately two-thirds that of alcohol use and dependence, and major depressive disorder. Problem gamblers suffer more individually (disability weight = .44) compared to those in moderate (.29) and low (.13) risk categories. Nevertheless, moderate and low-risk gamblers account for 85% of population-level harm, due to greater prevalence of these groups. Overall, the scale of gambling-related harm is large relative to other significant health issues, with milder yet non-negligible harm accruing to a relatively broad segment of the gambling population. The article suggests that the tendency to conflate the (typically low) prevalence of problem gambling with total gambling impact is misleading, and argues for a broader population-health based measure.
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Background: Gambling disorder has been associated with cognitive dysfunction and impaired quality of life. The current definition of non-pathological, problem, and pathological types of gambling is based on total symptom scores, which may overlook nuanced underlying presentations of gambling symptoms. The aims of the current study were (i) to identify subtypes of gambling in young adults, using latent class analysis, based on individual responses from the Structured Clinical Interview for Gambling Disorder (SCI-GD); and (ii) to explore relationships between these gambling subtypes, and clinical/cognitive measures. Methods: Total 582 non-treatment seeking young adults were recruited from two US cities, on the basis of gambling five or more times per year. Participants undertook clinical and neurocognitive assessment, including stop-signal, decision-making, and set-shifting tasks. Data from individual items of the Structured Clinical Interview for Gambling Disorder (SCI-GD) were entered into latent class analysis. Optimal number of classes representing gambling subtypes was identified using Bayesian Information Criterion and differences between them were explored using multivariate analysis of variance. Results: Three subtypes of gambling were identified, termed recreational gamblers (60.2% of the sample; reference group), problem gamblers (29.2%), and pathological gamblers (10.5%). Common quality of life impairment, elevated Barratt Impulsivity scores, occurrence of mainstream mental disorders, having a first degree relative with an addiction, and impaired decision-making were evident in both problem and pathological gambling groups. The diagnostic item 'chasing losses' most discriminated recreational from problem gamblers, while endorsement of 'social, financial, or occupational losses due to gambling' most discriminated pathological gambling from both other groups. Significantly higher rates of impulse control disorders occurred in the pathological group, versus the problem group, who in turn showed significantly higher rates than the reference group. The pathological group also had higher set-shifting errors and nicotine consumption. Conclusions: Even problem gamblers who had a relatively low total SCI-PG scores (mean endorsement of two items) exhibited impaired quality of life, objective cognitive impairment on decision-making, and occurrence of other mental disorders that did not differ significantly from those seen in the pathological gamblers. Furthermore, problem/pathological gambling was associated with other impulse control disorders, but not increased alcohol use. Groups differed on quality of life when classified using the data-driven approach, but not when classified using DSM cut-offs. Thus, the current DSM-5 approach will fail to discriminate a significant fraction of patients with biologically plausible, functionally impairing illness, and may not be ideal in terms of diagnostic classification. Cognitive distortions related to 'chasing losses' represent a particularly important candidate treatment target for early intervention.
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Background: Primary care is an important context for addressing health-related behaviours, and may provide a setting for identification of gambling problems. Aim: To indicate the extent of gambling problems among patients attending general practices, and explore settings or patient groups that experience heightened vulnerability. Design and setting: Cross-sectional study of patients attending 11 general practices in Bristol, South West England. Method: Adult patients (n = 1058) were recruited from waiting rooms of practices that were sampled on the basis of population characteristics. Patients completed anonymous questionnaires comprising measures of mental health problems (for example, depression) and addictive behaviours (for example, risky alcohol use). The Problem Gambling Severity Index (PGSI) measured gambling problems, along with a single-item measure of gambling problems among family members. Estimates of extent and variability according to practice and patient characteristics were produced. Results: There were 0.9% of all patients exhibiting problem gambling (PGSI ≥5), and 4.3% reporting problems that were low to moderate in severity (PGSI 1-4). Around 7% of patients reported gambling problems among family members. Further analyses indicated that rates of any gambling problems (PGSI ≥1) were higher among males and young adults, and more tentatively, within a student healthcare setting. They were also elevated among patients exhibiting drug use, risky alcohol use, and depression. Conclusion: There is need for improved understanding of the burden of, and responses to, patients with gambling problems in general practices, and new strategies to increase identification to facilitate improved care and early intervention.
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Introduction The prevalence of disordered gambling worldwide has been estimated at 2.3%. Only a small minority of disordered gamblers seek specialist face-to-face treatment, and so a need for alternative treatment delivery models that capitalise on advances in communication technology, and use self-directed activity that can complement existing services has been identified. As such, the primary aim of this study is to evaluate an online self-directed cognitive–behavioural programme for disordered gambling (GamblingLess: For Life). Methods and analysis The study will be a 2-arm, parallel group, pragmatic randomised trial. Participants will be randomly allocated to a pure self-directed (PSD) or guided self-directed (GSD) intervention. Participants in both groups will be asked to work through the 4 modules of the GamblingLess programme over 8 weeks. Participants in the GSD intervention will also receive weekly emails of guidance and support from a gambling counsellor. A total of 200 participants will be recruited. Participants will be eligible if they reside in Australia, are aged 18 years and over, have access to the internet, have adequate knowledge of the English language, are seeking help for their own gambling problems and are willing to take part in the intervention and associated assessments. Assessments will be conducted at preintervention, and at 2, 3 and 12 months from preintervention. The primary outcome is gambling severity, assessed using the Gambling Symptom Assessment Scale. Secondary outcomes include gambling frequency, gambling expenditure, psychological distress, quality of life and additional help-seeking. Qualitative interviews will also be conducted with a subsample of participants and the Guides (counsellors). Ethics and dissemination The study has been approved by the Deakin University Human Research and Eastern Health Human Research Ethics Committees. Findings will be disseminated via report, peer-reviewed publications and conference presentations. Trial registration number ACTRN12615000864527; results.
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Cue reactivity is an established procedure in addictions research for examining the subjective experience and neural basis of craving. This experiment sought to quantify cue-related brain responses in gambling disorder using personally tailored cues in conjunction with subjective craving, as well as a comparison with appetitive non-gambling stimuli. Participants with gambling disorder (n=19) attending treatment and 19 controls viewed personally tailored blocks of gambling-related cues, as well as neutral cues and highly appetitive (food) images during a functional magnetic resonance imaging (fMRI) scan performed ~2–3 h after a usual meal. fMRI analysis examined cue-related brain activity, cue-related changes in connectivity and associations with block-by-block craving ratings. Craving ratings in the participants with gambling disorder increased following gambling cues compared with non-gambling cues. fMRI analysis revealed group differences in left insula and anterior cingulate cortex, with the gambling disorder group showing greater reactivity to the gambling cues, but no differences to the food cues. In participants with gambling disorder, craving to gamble correlated positively with gambling cue-related activity in the bilateral insula and ventral striatum, and negatively with functional connectivity between the ventral striatum and the medial prefrontal cortex. Gambling cues, but not food cues, elicit increased brain responses in reward-related circuitry in individuals with gambling disorder (compared with controls), providing support for the incentive sensitization theory of addiction. Activity in the insula co-varied with craving intensity, and may be a target for interventions.
Article
Introduction: Impulsivity and compulsivity are important constructs, relevant to understanding behaviour in the general population, as well as in particular mental disorders (e.g. attention deficit hyperactivity disorder, obsessive-compulsive disorder). The current paper provides a narrative review of self-report impulsivity and compulsivity scales. Methods: A literature search was conducted using the following terms: (“impulsivity” OR “compulsivity”) AND (“self-report” OR “questionnaire” OR “psychometric” OR “scale”). Results: 25 impulsive and 11 compulsive trans-diagnostic scales were identified, which varied considerably in psychometric properties, convenience, and validity. For impulsivity, the most commonly used scales were the BIS and the UPPS-P, whilst for compulsivity, the Padua Inventory was commonly used. The majority of compulsivity scales measured OCD symptoms (obsessions and compulsions) rather than being trans-diagnostic or specific to compulsivity (as opposed to obsessions). Scales capable of overcoming these limitations were highlighted. Discussion: This review provides clarity regarding relative advantages and disadvantages of different scales relevant to the measurement of impulsivity and compulsivity in many contexts. Areas for further research and refinement are highlighted.
Article
There is a growing consensus that gambling is a public health issue and that preventing gambling related harms requires a broad response. Although many policy decisions regarding gambling are made at a national level in the UK, there are clear opportunities to take action at local and regional levels to prevent the negative impacts on individuals, families and local communities. This response goes beyond the statutory roles of licencing authorities to include amongst others the National Health Service (NHS), the third sector, mental health services, homelessness and housing services, financial inclusion support. As evidence continues to emerge to strengthen the link between gambling and a wide range of risk factors and negative consequences, there is also a strong correlation with health inequalities. Because the North of England experiences increasing health inequalities, it offers an opportunity as a specific case study to share learning on reducing gambling-related harms within a geographic area. This article describes an approach to gambling as a public health issue identifying it as needing a cross-cutting, systemwide multisectoral approach to be taken at local and regional levels. Challenges at national and local levels require policy makers to adopt a ‘health in all policy’ approach and use the best evidence in their future decisions to prevent harm. A whole systems approach which aims to reduce poverty and health inequalities needs to incorporate gambling harm within place-based planning and draws on the innovative opportunities that exist to engage local stakeholders, builds local leadership and takes a collaborative approach to tackling gambling-related harms. This whole systems approach includes the following: (1) understanding the prevalence of gambling related harms with insights into the consequences and how individuals, their family and friends and wider community are affected; (2) ensuring tackling gambling harms is a key public health commitment at all levels by including it in strategic plans, with meaningful outcome measures, and communicating this to partners; (3) understanding the assets and resources available in the public, private and voluntary sectors and identifying what actions are underway; (4) raising awareness and sharing data, developing a compelling narrative and involving people who have been harmed and are willing to share their experience; (5) ensuring all regulatory authorities help tackle gambling-related harms under a ‘whole council’ approach.
Article
Background: The Problem Gambling Severity Index (PGSI) was intended for use in epidemiological research with gamblers across the continuum of risk. Its utility within clinical settings, where the majority of clients are problem gamblers, has been brought into question. Aims: (1) Identify refined categories for the problem gambling category of the PGSI in help-seeking gamblers; (2) Validate these categories using the Gambling Symptom Assessment Scale (G-SAS); (3) Explore the relationship of these categories with indices of gambling and help-seeking behaviour. Methods: Secondary data analysis of help-seeking problem gamblers from the Australian online gambling counselling/support service (Gambling Help Online [GHO]) from October 2012 to December 2015 (n = 5,881) and trial data evaluating an Australian online self-directed program for gambling (GamblingLess; n = 198). Both datasets included the PGSI, gambling frequency and expenditure. The GamblingLess dataset also included the G-SAS and help-seeking behaviour. Results: A Latent Class Analysis, using GHO data, identified a 2-class solution. Multiple analytical methods identified a cut-off value of ≥ 19 distinguishing this 2-class solution (low problem severity: Median = 16; high problem severity: Median = 23). High problem severity gamblers had increased odds of being categorised in the higher GSAS category, greater gambling expenditure and having sought face-to-face support. The refined categories were not associated with gambling frequency, distance-based or self-directed help-seeking. Conclusion: These findings are consistent with a stepped-care approach, whereby individuals with higher severity may be better suited to more intensive interventions and individuals with lower severity could commence with less intensive interventions and step-up to intensive interventions.
Article
Background: Gambling is a behaviour engaged in by millions of people worldwide; for some, gambling can become a severely maladaptive behaviour, and previous research has identified a wide range of psychosocial risk factors that can be considered important for the development and maintenance of disordered gambling. Although risk factors have been identified, the homogeneity of risk factors across specific groups thought to be vulnerable to disordered gambling is to date, unexplored. Methods: To address this, the current review sought to conduct a systematic overview of literature relating to seven vulnerable groups: young people and adolescents, older adults, women, veterans, indigenous peoples, prisoners, and low socio-economic/income groups. Results: Multiple risk factors associated with disordered gambling were identified; some appeared consistently across most groups, including being male, co-morbid mental and physical health conditions, substance use disorders, accessibility and availability of gambling, form and mode of gambling, and experience of trauma. Further risk factors were identified that were specific to each vulnerable group. Conclusion: Within the general population, certain groups are more vulnerable to disordered gambling. Although some risk factors are consistent across groups, some risk factors appear to be group specific. It is clear that there is no homogenous pathway in to disordered gambling, and that social, developmental, environmental and demographic characteristics can all interact to influence an individual's relationship with gambling.
Article
Despite the increasing number of gamblers in the UK and the overuse of NHS services for associated physical and mental health harms, external agency problem identification for problem gamblers is still very limited. As with alcohol and drug misuse, GPs can have a critical role in early detection of disordered gambling, and referral to enable early intervention before crisis point. However, in the absence of suitable identification and accessible intervention strategies for gambling, there are legitimate reasons for debate regarding the appropriate role of GPs.
Chapter
Excessive gambling behavior is a complex psychopathological phenomenon, characterized by the interaction of multiple etiological factors and by a very heterogeneous symptomatological expression. To date, there are no existing evidence-based “best practice” treatment standards for gambling disorder. Healthcare providers and clinicians are further challenged by the difficulty in reaching out to individuals suffering from gambling problems. Despite a surge of empirical studies on various therapeutic approaches addressing disordered gambling, there is an urgent need for the development of suitable and cost-effective helping tools. This chapter presents a narrative overview of recent advances in the development of and research on innovative treatment approaches and treatment modalities for gambling problems, ranging from training interventions based on addiction models, such as Cognitive Bias Modification and general cognitive training programs; neuromodulation techniques, and employment of modern digital technology to promote large-scale support services and overcome treatment barriers, to personalization of existing interventions to individual and culture-based characteristics and preferences, and integration of multiple methods. Each section of this chapter presents existing preliminary evidence for such novel treatment approaches in the domain of disordered gambling and, when not available, results in the broader field of addictive behaviors. Altogether, these novel venues of research on gambling interventions share the goal of enhancing therapeutic effects and overcoming barriers and limitations to existing treatment programs by meeting the heterogeneous needs and demands of this peculiar clinical population.