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Gambling addiction

Age at Onset of DSM-IV Pathological Gambling in a Non-Treatment Sample: Early- versus Later-Onset

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Gambling addiction raymond md

Postby Faemuro В» 09.08.2019

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Addiction professionals and the public are recognizing that certain nonsubstance behaviors—such as gambling, Internet use, video-game playing, sex, eating, and shopping—bear resemblance to alcohol and drug dependence.

At present, only gambling disorder has been placed in this category, with insufficient data for other proposed behavioral addictions to justify their inclusion. This review summarizes recent advances in our understanding of behavioral addictions, describes treatment considerations, and addresses future directions.

Current evidence points to overlaps between behavioral and substance-related addictions in phenomenology, epidemiology, comorbidity, neurobiological mechanisms, genetic contributions, responses to treatments, and prevention efforts. Differences also exist. Recognizing behavioral addictions and developing appropriate diagnostic criteria are important in order to increase awareness of these disorders and to further prevention and treatment strategies.

Addiction has been proposed to have several defining components: 1 continued engagement in a behavior despite adverse consequences, 2 diminished self-control over engagement in the behavior, 3 compulsive engagement in the behavior, and 4 an appetitive urge or craving state prior to engaging in the behavior. Excessive engagement in behaviors such as gambling, Internet use, video-game playing, sex, eating, and shopping may represent addictions.

Several converging lines of evidence show an overlap between these conditions and substance dependence in terms of clinical expression e. Both forms of addiction typically have onsets in adolescence or young adulthood, with higher rates observed in these age groups than among older adults. Much remains to be understood, however, in the relatively novel field of behavioral addictions. Additionally, wide gaps exist between research advances and their application in practice or public policy settings.

This lag is due, in part, to the public perception of behavioral addictions. Whereas drug abuse has well-known and severe negative consequences, those associated with behavioral addictions e. Moreover, because engagement in some behaviors with addictive potential is normative and adaptive, individuals who transition to maladaptive patterns of engagement may be considered weak willed and be stigmatized. Thus, research, prevention, and treatment efforts must be furthered, and educational efforts enhanced.

Establishing nomenclature and criteria for behavioral addictions will enhance our capacity to recognize and define their presence. The new term and category, and their location in the new manual, lend additional credence to the concept of behavioral addictions; people may be compulsively and dysfunctionally engaged in behaviors that do not involve exogenous drug administration, and these behaviors can be conceptualized within an addiction framework as different expressions of the same underlying syndrome.

Although the inclusion of this disorder in the provisional diagnosis section of DSM-5 represents an important advance, the conflation of problematic Internet use and problematic gaming may prove unhelpful; the result may be gaps in research on problematic Internet use that is unrelated to gaming e. This review will highlight the recent neurobiological, genetic, and treatment findings on behavioral addictions. An emphasis will be placed on disordered gambling since it is arguably the best-studied behavioral addiction to date.

Other behavioral addictions, despite being less well studied, have been receiving considerable attention from researchers and clinicians and will also be discussed in this review. We will then discuss the similarities and differences between behavioral and substance-related addictions.

A literature search was conducted using the PubMed database for articles in English pertaining to behavioral addictions. Case reports and studies with insufficient statistical information were excluded from this review. Because of the overlapping terms used to describe each condition, search items included the many different names found in the literature. These methodological differences should be considered when interpreting the findings.

Disordered gambling can include frequent preoccupations with gambling, gambling with greater amounts of money to receive the same level of desired experience tolerance , repeated unsuccessful efforts to control or stop gambling, restlessness or irritability when trying to stop gambling withdrawal , and the interference of gambling in major areas of life functioning. However, the contrast in the thresholds for gambling disorder 4 of 9 criteria and substance use disorders SUDs; 2 of 11 criteria will likely underestimate the relative prevalence and impact of gambling disorder.

Epidemiological studies that have employed screening instruments like the South Oaks Gambling Screen 21 have frequently generated higher prevalence estimates than have those employing DSM criteria. Definitions of other behavioral addictions have often used DSM criteria for disordered gambling as a blueprint. However, sample and measurement differences, coupled with the lack of universally agreed-upon diagnostic criteria, may contribute to variable prevalence estimates for Internet addiction.

Estimates for adolescents have ranged from 4. Data from the U. National Comorbidity Survey Replication—a U. Disordered gambling also frequently co-occurs with various psychiatric conditions, including impulse-control, mood, anxiety, and personality disorders.

Especially relevant to addictions are aspects of motivation, reward processing, and decision making. Individuals with behavioral and substance addictions score high on self-report measures of impulsivity and sensation seeking, and generally low on measures of harm avoidance. The extent to which behavioral tendencies like harm avoidance may shift e. Other research suggests that aspects of compulsivity are typically higher among individuals with behavioral addictions.

For example, although groups with disordered gambling or with OCD both score highly on measures of compulsivity, among disordered gamblers these impairments appear limited to poor control over mental activities and to urges and worries about losing control over motor behaviors. Neurocognitive measures of disinhibition and decision making have been positively associated with the severity of problem gambling 54 and may predict relapse of disordered gambling.

Attempts to control or eliminate addictive behaviors may be motivated by immediate reward or the delayed negative consequences of use—that is, temporal or delay discounting. This process may be mediated via diminished top-down control of the prefrontal cortex over subcortical processes promoting motivations to engage in addictive behavior. Dopamine has been implicated in learning, motivation, salience attribution, and the processing of rewards and losses including their anticipation [reward prediction] and the representation of their values.

A recent single-photon emission computed tomography study suggests that dopamine release in the ventral striatum during a motorbike-riding computer game 64 is comparable to that induced by psychostimulant drugs such as amphetamine 65 and methylphenidate. Although a gambling task induced no differences in the magnitude i.

For example, obese rats but not lean rats had downregulated D2 receptors, and their consumption of palatable food was resistant to disruption by an aversive or punishing condition stimulus. Several recent studies have examined this marker among disordered gamblers.

Evidence exists for serotonergic involvement in behavioral addictions. Serotonin is implicated in emotions, motivation, decision making, behavioral control, and inhibition of behavior. Dysregulated serotonin functioning may mediate behavioral inhibition and impulsivity in disordered gambling. Striatal binding of a ligand with high affinity for the serotonin 1B receptor correlated with problem-gambling severity among individuals with disordered gambling. These studies observe different biological and behavioral responses in individuals with behavioral or substance addictions compared to those without in response to m-CPP.

Less is known about the integrity of other neurotransmitter systems in behavioral addictions. A dysregulated hypothalamic-pituitary-adrenal axis and increased levels of noradrenergic moieties have been observed in disordered gambling.

Neuroimaging studies suggest shared neurocircuitry particularly involving frontal and striatal regions between behavioral and substance addictions. Studies using reward-processing and decision-making tasks have identified important contributions from subcortical e.

Among disordered gamblers, versus healthy controls, both decreased 99 — and increased vmPFC activity has been reported during simulated gambling and decision-making tasks. Similarly, gambling stimuli has been reported to be associated with both decreased and increased , vmPFC activity in disordered gamblers. The findings from these studies may have been influenced by the specific tasks used, the populations studied, or other factors.

Individuals playing World of Warcraft a massive, multiplayer, online role-playing game more than 30 hours per week, compared to nonheavy players playing less than 2 hours per day displayed significantly greater orbitofrontal, dorsolateral prefrontal, anterior cingulate, and nucleus accumbens activation when exposed to game cues. Moreover, both ventral striatal and vmPFC activity was inversely correlated with problem-gambling severity in problem-gambling subjects during simulated gambling.

Unlike findings from patients with SUDs, studies involving small samples of disordered gamblers did not display significant volumetric differences in white or gray matter from controls, , suggesting that volumetric differences observed in SUDs may represent possible neurotoxic sequelae of chronic drug use. More recent data using larger samples, however, show smaller amygdalar and hippocampal volumes in individuals with disordered gambling, similar to findings in SUDs.

Twin studies suggest that genetic factors may contribute more than environmental factors to the overall variance of risk for developing disordered gambling. Few molecular genetic studies of behavioral addictions have been conducted. Genetic polymorphisms putatively related to dopamine transmission e. A recent genome-wide association study reported that no single nucleotide polymorphism reached genome-wide significance for disordered gambling.

Nonetheless, differences are also apparent. Although the concept of behavioral addiction appears to be increasingly prominent in the literature, the scientific and empirical evidence remains insufficient for these disorders to be treated as part of one comprehensive, homogenous group.

The gaps in our knowledge need to be addressed in order to determine whether behavioral and substance-related addictions represent two different addictions or whether they are different expressions of a core addiction syndrome. Furthermore, separate diagnoses can be clinically useful since individuals may present to practitioners with concerns in specific addiction domains.

Nonetheless, the overlaps between the disorders suggest that specific treatments for SUDs may also be beneficial for behavioral addictions. Treatments for addiction may be divided into three phases. First, a detoxification phase aims to achieve sustained abstinence in a safe manner that reduces immediate withdrawal symptoms e.

This first phase may involve medications to assist the transition. The second phase is one of recovery, with emphasis on developing sustained motivation to avoid relapse, learning strategies to cope with cravings, and developing new, healthy patterns of behavior to replace addictive behavior.

This phase may involve medications and behavioral treatments. Third, relapse prevention aims to sustain abstinence in the long term. This last phase is perhaps the most difficult to achieve, with waning motivation, the revival of associated learning cues linking hedonic experience to addictive behavior, and temptations that may threaten the recovery process, originating from external e.

Most clinical trials for behavioral addictions have focused on short-term outcomes. No medication has received regulatory approval in the United States as a treatment for disordered gambling. However, multiple double-blind, placebo-controlled trials of various pharmacological agents have demonstrated the superiority of active drugs to placebo. At present, the medications with the strongest empirical support are the opioid receptor antagonists e. These medications have been used in the clinical management of drug- particularly opiate- and alcohol-dependent patients for several decades , and have more recently been evaluated for treating disordered gambling and other behavioral addictions.

One double-blind study suggested the efficacy of naltrexone in reducing the intensity of urges to gamble, gambling thoughts, and gambling behavior; in particular, individuals reporting higher intensity of gambling urges responded preferentially to treatment. With respect to food, preclinical research suggested that high doses of the opiate antagonist naloxone increased sugar consumption and opiate-like withdrawal symptoms—including elevated plus maze anxiety, teeth chattering, and head shakes—in sugar-binging rats following a period of abstinence.

Although selective serotonin reuptake inhibitors SSRIs were one of the first medications that were used to treat disordered gambling, controlled clinical trials assessing SSRIs have demonstrated mixed results for both behavioral and substance addictions. Citalopram, another SSRI, was found effective in reducing hypersexual disorder symptoms among homosexual and bisexual men but, among individuals with Internet addiction disorder, did not reduce the number of hours spent online or improve global functioning.

Glutamatergic treatments have shown mixed promise in small controlled trials. N-acetyl cysteine has shown preliminary efficacy both as a stand-alone agent and in conjunction with behavioral treatment.

Meta-analyses of psychotherapeutic and behavioral treatment approaches for disordered gambling suggest that they can result in significant improvements.

Positive effects can be retained though to a lesser degree over follow-ups of up to two years. One approach that has gained empirical support from randomized trials is cognitive behavioral therapy CBT.

This semistructured, problem-oriented approach focuses, in part, on challenging the irrational thought processes and beliefs that are thought to maintain compulsive behaviors. During therapy, patients learn and then implement skills and strategies to change those patterns and interrupt addictive behaviors.

CBT is multifaceted but typically involves keeping a diary of significant events and associated feelings, thoughts, and behaviors; recording cognitions, assumptions, evaluations, and beliefs that may be maladaptive; trying new ways of behaving and reacting e.

The particular therapeutic techniques that are employed may vary according to the particular type of patient or issue.

The fall and rise of a gambling addict - Justyn Rees Larcombe - TEDxRoyalTunbridgeWells, time: 16:05
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