PATHOLOGICAL GAMBLING: IMPULSE, COMPULSION, OR ADDICTION? THE ADDICTION PERSPECTIVE

1. Addiction PATHOLOGICAL GAMBLING:IMPULSE, COMPULSION, OR ADDICTION?THE ADDICTION PERSPECTIVE Nady el-Guebaly, MD*, Heidi Friesen BSR (OT)C, Jennifer Corbiell MSW. *Prof & Head, Addiction Division, U of Calgary Consultant, Addiction Centre & Program, Alberta Health Services Chair, Alberta Gaming Research Institute [AGRI] Program Network AGRI: www.abgaminginstitute.ualberta.ca

2. BURDEN OF HISTORY • 1952 DSM: Sociopathic Personality Disorder (Addiction – alcoholism & drugs) • 1968 DSM II: Personality Disorders • 1980 DSM III: Substance Use Disorders:Dependence > Addiction by 1 vote (criteria for abuse & dependence; Tolerance & Withdrawal) Disorders of Impulse Control: Pathological Gambling • 1987 DSM III-R: Psychoactive Substance Use Disorders (T & W now 2 among any 3); Impulse Control Disorders • 1994 DSM IV: Substance Related Disorders (criteria reduced to 7, with any 3 for diagnosis. Neither T or W necessary) Impulse Control Disorders, incl Pathological Gambling • 2010 DSM-V ?Addiction & Related Disorders with Pathological Gambling

3. Overlapping Constructs • Impulse Control Disorders NOT ELSEWHERE CLASSIFIED (SUD, Cluster B PD, eating dis) “Recurrent failure to resist impulse, drive, or temptation to perform an act harmful to the person / others” Motivation: Increasing tension/arousal Pleasure/relief “Ego-syntonic” ± Regret/Guilt • Obsessive-Compulsive Disorders ”Ego-dystonic” products of one’s mind! “Persistent ideas, thoughts, impulses, or images EXPERIENCED AS INTRUSIVE & INAPPROPRIATE” Motivation: Suppress/neutralize thoughts’ tension Compulsions(wash, lock, gambling rituals?) • Addictions ASAM: A primary disease characterized by behaviors, including one or more of 4 C’s Act

4. WHY AM I CONFUSED? • IMPULSIVE/COMPULSIVE SPECTRUM ALONG HARM AVOIDANCE (HA) High HALow HA OCD ICD BUT DIFFERENCE IS NOT CONSTANT • In OCD & PG , Mix of impulsivity & harm avoidance vary i.e., suicidality (despair), course severity, appreciation of consequences • Gender differences • WHAT ABOUT ADDICTION’S MOTIVATION in HA? • Varied “impaired control” i.e., initial caution disappears;apprecofconsequences • WHAT ABOUT DENIAL? Unconscious disclaimer of intolerable thoughts / feelings / realities to allay anxiety. • Scarce investigation of triad OCT, ICD, & Addiction • Cultural differences?

5. P G “ADDICTION vs. ICD NEC” - A • Addiction “without a drug” • Similarities to substance dependence • Epidemiology M2 : F1 (OCD 1:1) • Course • Lifecycle: low in childhood, high in adolesc. & young adult, lower in seniors (OCD & Impulsivity common in childhood) • Telescoping course among women • Criteria (DSM IV borrowed terminology?) • Tolerance & Withdrawal • Unsuccessful attempts to cutback/quit • Interference with life functioning

6. P G “ADDICTION vs. ICD NEC” - B • Clinical differences • Low salience of physical manifestations • High salience of financial problems • No biological tests or urine monitoring • PG is not always welcome as an Addiction?! • Stigma of term • Trivialization of hard-fought recognition of SUD • Turf: research funding…

7. CO-OCCURING DISORDERS “BIRDS OF A FEATHER!”NESARC (Nat Epid Survey Alc & Related Conditions) N=43000 – Petry ‘05

8. Genes / Neurobiology • THE REWARD SYSTEM: MRI & PET Contributions to SUD & PG Limbic – pre frontal cortex with “reward deficiency syndrome”; “reward circuit disorders; some differences • ROLE OF SEROTONIN (5HT1B) - risk taking behaviors - prefrontal cortex  impulse • ROLE OF DOPAMINE - translates drive into action – the “go” signal - release in nucleus acumbens - surge with uncertain rewards: “it is not about money; it is about the hunt” • NOREPINEPHRINE - mediation of arousal & attention; “heart race” • OPIOID SYSTEM - “cravings” - endorphin linked with dopamine via GABA Genetic 35-54% liability  link with alcohol, antisocial PD & major depression ’05 OCD? Other 5HT genes in some; Orbito-frontal Cortex – Caudate nucleus circuitry

9. ACADEMIC DEBATE OR MANAGEMENT IMPLICATIONS • PHARMACEUTICAL TRIALS – SHORT TERM • SSRIs: OCD, Anxiety / mood • MOOD STABILIZERS: Impulsivity • Opioid antagonist “Naltrexone” / Nalmefene, most robust data (like alcohol & opioids but worsens OCD) • Dopamine & Parkinson meds; antagonist olanzepine n.s.; haloperidol primes motivation • N-Acetyl cysteine – glutamate modulator No FDA approved medication for PG • PSYCHOTHERAPIES – LONGER TERM • CBT – ROBUST targeting of cognitive distortions, cravings & coping strategies • Motivational therapies • MUTUAL HELP / 12 STEPS • GA is the most widely available intervention in N. America • OC-A? IC-A?

10. “Linda” – Impulsivity • 49 y/o; married 10 years; press technician; - son has schizophreniform disorder & a mgt challenge • GAMBLING - 2 y ago “X-mas gift” of a cell phone “quickly addicted” to poker game & opening cash account Two initial wins at casino, now $20,000 in debt - “Excitement, fun, due to win, lucky, strong urges” Now stays up gambling online, purchases scratch tickets & plays VLTs with sister in law “an escape” • DRUG USE– “Whatever was around” as teenager but no longer • “SEX ADDICTION”issues in the past with STDs • PSYCHIATRIC HISTORY– “Conduct disorder” as child

11. “Cindy” - Compulsivity • 45 y/o, spinster, living alone most of her life, customer rep in bank for 15 yrs; interpersonal difficulties at work • GAMBLING - 2 y ago began regular gambling, accompanying her sister to casino whose husband had cancer • Casino Gambling 10 days/mt; no substantial win; loss $2,000/mt • Power of attorney & spending her mother’s $45,000; “her dirty little secret!”; relieved to talk to someone because of distress • “Preoccupied with gambling & losses”, which leads to “significant anxiety, guilt, shame, & sleeping problems” “Trying to put limits on spending or abstinence 1 mt max; self-disgust; secretive about amounts incl sister” • DRUG USE– Some social experimentation as teenager; 2 alcohol drinks/mt • PSYCHIATRIC HISTORY– Shy – Social Phobia

12. “Mary” - Addictions • 54 y/o married; LPN & Rec Therapist; Osteoporosis with pain in neck, spine, & knees • GAMBLING • Bingo & Scratch ticket for 25 y; problem for 7 yrs since “supportive” mother died; takes care of “abusive” father • Initially slot machine $200, twice/wk; then “extreme problem” $1,000 daily; maxing Credit Cards • Declared bankruptcy 5 yrs ago $36,000; 1 yr ago, charged with theft of $87,000 in financial trust of a cousin with MS; jail term & now on Pre-release • “Oh to be alone with the machine, not thinking of anything else”, “restless when trying to cut down”, “If not caught, I would have continued”, “certain machines were lucky”, “wore a guardian angel for luck” • ALCOHOL & DRUG USE • Non-user except half a pack/day cigs for yrs, assoc with gambling; but urine cannabis-positive; now computer video game 7 hrs • PSYCHIATRIC HISTORY • Overdose 2 mts ago on “mother’s grave”; Prior depressive episodes

13. CONCLUSIONS • Evidence favors the Addiction Model, overall; DSM V? • Impulse control shapes some types of PG • OCD is also relevant but more distant • Patients should be assessed for all 3 with valid & reliable instruments; • Studies of their relative frequency (full/partial syndrome) ? • Distinctive Therapeutic trials could improve outcome

14. Clinical Red Flags • Ego syntonic / dystonic • Harm avoidance • Locus of Control: External for impulsive vs. less so for addiction & compulsion • Description of gambling: addiction & denial • Comorbidities • Family history? • Trt: Individualize