Gambling Disorder as a Behavioral Addiction

Transcription

1 Gambling Disorder as a Behavioral Addiction Petros Levounis, MD, MA Chair, Department of Psychiatry Rutgers New Jersey Medical School New York Coalition for Asian American Mental Health NYS Office of Alcoholism and Substance Abuse Services Thursday, October 1, 2015 Outline 1. Gambling Disorder 2. Behavioral Addictions 3. Neurobiology of Addiction 4. Psychosocial Treatments 5. Pharmacological Treatments 6. Conclusions 2 1

2 1 Gambling Disorder

3 The Shell Game PRACTICE 5 The Shell Game PLAY 6 3

4 What would you do? 1. Switch.? 2. Stick to my original choice. 3. It doesn t matter; either way my chance of winning is 50%. 4. You ve lost me. I have no idea. 7 The Shell Game CARD # 1 CARD # 2 CARD # 3 IF YOU STAY: King/Chosen Win Lose King Chosen Lose Win King Chosen Lose Win Chosen King Lose Win King/Chosen Win Lose King Chosen Lose Win Chosen King Lose Win Chosen King Lose Win King/Chosen Win Lose CHANCE OF WINNING: 33% 66% IF YOU SWITCH: 8 4

5 Epidemiology US Gambling Statistics: $ 37 billion/year casino revenue (2012 data). 82% of US residents gamble. 1% - 3% meet criteria for PG. Problematic Gamblers: $ 40,000 average individual debt. 25 hours/week average time spent. Dickson-Gillespie L, Rugle L, Rosenthal R, Fong T: Preventing the incidence and harm of gambling problems. J Prim Prev 29:37-55, Commercial Casinos US Consumer Spending

6 Assessment 11 The Lie/Bet Test Screening Tools Have you ever felt the need to bet more and more money? Have you ever had to lie to people important to you about how much you gambled?.99 sensitivity,.91 specificity. Johnson EE, Hamer R, Nora RM, et al: The lie/bet questionnaire for screening pathological gamblers. Psychological Reports 80:83-88,

7 Clinical Presentation Winning Phase Loss Phase Desperation Phase Hopelessness Phase 13 Blanco C, Cohen O, Luján JJ, et al: Pathological gambling and substance use disorders, in Substance Dependence and Co-Occurring Psychiatric Disorders: Best Practices for Diagnosis and Treatment. Edited by Nunes EV, Selzer J, Levounis P, Davies CA. New York, Civic Research Institute, Diagnosis 14 7

8 DSM-IV-TR One of the Impulse-Control Disorders 15 American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 4 th Edition, Text Revision. Washington, DC: American Psychiatric Association,

9 DSM-5 One of the Substance-Related and Addictive Disorders 17 American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 5 th Edition. Washington, DC: American Psychiatric Association, Substance-Related and Addictive Disorders Alcohol Caffeine Cannabis Hallucinogen Inhalant Opioid Sedative Stimulant Tobacco Gambling Disorder 18 9

10 Diagnosing Any Addiction PHYSIOLOGY The Tolerance Wise Withdrawal Know: Decline Tender Loving Care, THE CORE PROBLEM OF ADDICTION Knowledge of adverse consequences, yet continued use INTERNAL PREOCCUPATION Desire to cut down Time a great deal of time spent using Larger amounts or longer periods of use than intended Craving EXTERNAL CONSEQUENCES and Activities given up Respect Role obligations neglected Silver Social or interpersonal problems Hair. Hazardous use Levounis, Academic Psychiatry, Gambling Disorder Criteria 1. Larger wagers than intended. 2. Restless and irritable when attempting to cut down or stop. 3. Continuous, unsuccessful efforts to decrease gambling. 4. Gambling prevents usual social and/or occupational activities. 5. Continuation of gambling in an attempt to reinstate losses. 20 American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 5 th Edition. Washington, DC: American Psychiatric Association,

11 2 The Behavioral Addictions 21 History Impulse Control Disorders, Substance Use Disorders, Somatoform Disorders, and Behavioral Addictions. The tobacco companies, the lawsuits, and organized medical professional organizations

12 Essential Features Failure to resist an impulse, drive, or temptation to perform an act that is harmful to the person or others. 23 Impulsivity vs. Compulsivity Both show inability to refrain from repetitive behaviors. Impulsivity is driven by an effort to obtain arousal and gratification. Compulsivity is driven by an effort to reduce anxiety. Ascher and Levounis The Behavioral Addictions, American Psychiatric Publishing,

13 Dimensional Approach Adapted from: Hollander E, Clinical Manual of Impulse-Control Disorders, COMPULSIVE END OCD Body Dysmorphic Disorder Anorexia Nervosa Depersonalization Disorder Hypochondriasis Tourette s Syndrome Trichotillomania Autism Binge Eating Compulsive Buying Kleptomania Pathological Gambling Self-Injurious Behaviors Sexual Compulsions Borderline Personality Disorder IMPULSIVE END Antisocial PD 26 13

14 The Behavioral Addictions in Exercise 2. Food 3. Gambling 4. Internet Gaming 5. Internet Surfing 6. Texting and ing 7. Kleptomania 8. Sex 9. Love 10. Shopping 11. Tanning 12. Work Ascher and Levounis The Behavioral Addictions, American Psychiatric Publishing, The Neurobiology of Addiction 28 14

15 ~ Addiction: A Biopsychosocial Illness Biological Psychological Social Use Brain Switch Addiction Relapse 1. Stress 2. Triggers (Cues) 3. Exposure (Primers) Olsen and Levounis, Sober Siblings,

16 Natural Rewards and Dopamine Levels % of Basal DA Output Food Empty Box Feeding Time (min) DA Concentration (% Baseline) Sex Female Present Sample Number Adapted from: Di Chiara et al, Neuroscience, 1999 Adapted from: Fiorino and Phillips, J Neuroscience, Effects of Drugs on Dopamine Levels % of Basal Release MORPHINE Dose mg/kg hr % of Basal Release COCAINE hr % of Basal Release NICOTINE % of Basal Release ETHANOL Dose (g/kg ip) hr hr 32 Adapted from: Di Chiara and Imperato, Proceedings of the National Academy of Sciences USA, 1988; courtesy of Nora D Volkow, MD 16

17 Pleasure-Reward Pathways National Institute on Drug Abuse,

18 Reward Systems GAME 1? A. A sure gain of $250. B. 25% chance to gain $1,000, 75% chance to gain nothing. Adapted from: Tversky and Kahneman, Science, Reward Systems GAME 1? A. A sure gain of $ % B. 25% chance to gain $1,000, 16% 75% chance to gain nothing. Adapted from: Tversky and Kahneman, Science,

19 Antireward Systems GAME 2? A. A sure loss of $750. B. 25% chance to lose nothing, 75% chance to lose $1,000. Adapted from: Tversky and Kahneman, Science, Antireward Systems GAME 2? A. A sure loss of $ % B. 25% chance to lose nothing, 87% 75% chance to lose $1,000. Adapted from: Tversky and Kahneman, Science,

20 MATHEMATICS GAME 1 25% % % % GAME 2 25% % % % HUMAN NATURE People avoid risks to ensure gains (even small gains). People take risks (even big risks) to avoid definite losses. Psychology trumps probability

21 The Sunk Cost Effect Lose money, then gamble wildly to recoup the loses. Gambling behavior continues because of money and time already spent. Independent, rational decisions are ignored Psychosocial Treatments 42 21

22 The Current Approach 1. Mutual Help Groups (12-step) 2. Cognitive Behavioral Therapy 3. Motivational Interviewing 4. Financial Cousneling 5. Family Therapy 6. Mental Health Services 7. Aftercare 43 Nunes, Selzer, Levounis, Davies, Substance Dependence and Co-Occurring Psychiatric Disorders, Current Approaches 44 22

23 Mutual Help 45 Cognitive-Behavior Therapy 46 23

24 Motivational Interviewing REDS 1. Roll with Resistance 2. Express Empathy 3. Develop Discrepancy 4. Support Self-Efficacy Miller and Rollnick, Motivational Interviewing: Preparing People for Change, 2 nd Edition, Financial Counseling Financial planners Tax advisors Estate lawyers Credit/debit counselors Employee Assistance Prorgrams (EAPs) 48 Blanco C, Cohen O, Luján JJ, et al: Pathological gambling and substance use disorders, in Substance Dependence and Co-Occurring Psychiatric Disorders: Best Practices for Diagnosis and Treatment. Edited by Nunes EV, Selzer J, Levounis P, Davies CA. New York, Civic Research Institute,

25 Emerging Approaches Talk about nutritional choices: We all have foods we like and foods we dislike! 2. Use journals: 3. Model: Include all meals, snacks, and beverages. Drink tea during the interview. Give patient a tea bag. 4. Crowd out less healthy foods: Use the 80/20 rule. Nutrition 50 Levounis, Zerbo, and Aggarwal, The DSM-5 Pocket Guide to Addiction Assessment and Treatment, American Psychiatric Publishing, manuscript in preparation,

26 Exercise 1. For most patients: 30 minutes of moderate exercise Three days a week 2. For low dopamine levels: minutes per day Five days a week Social types of exercise, such as martial arts and competitive team sports 51 Levounis, Zerbo, and Aggarwal, The DSM-5 Pocket Guide to Addiction Assessment and Treatment, American Psychiatric Publishing, manuscript in preparation, Mindfullness Between stimulus and response there is a space. In that space is our power to choose our response. In our response lie our growth and our freedom. Viktor E. Frankl Frankl V, Man s Search for Meaning,

27 53 And Back to Psychodynamics % reporting any substance use disorders Only same-sex Mostly same-sex Equally both sexes Mostly other sex Only other sex 0 * 11.4 *** * 9.6 Women *** 13.2 Ref Men *p<0.05, ***p<.001 based on logistic regression analysis adjusted for race, age, educational level, personal income, employment status, relationship status, health insurance status, geographic location, MSA, age at alcohol onset, and family history of AOD problems. Reference group was heterosexual group. Courtesy of Sean McCabe, PhD

28 5 Pharmacological Treatments 55 Gambling Disorder Adapted from: Hollander E, Clinical Manual of Impulse-Control Disorders,

29 GD as an Impulsive Disorder Opioid Antagonists Naltrexone and Nalmefene. Block opioid receptors, decrease dopamine function, and reduce Reward Cravings. Best with family history of alcoholism. 57 Grant JE, Kim SW, Hollander E, et al: Predicting treatment response to opiate antagonists and placebo in the treatment of pathological gambling. Psychopharmacol 200: , Grant JE, Potenza MN: Pathological Gambling: A Clinical Guide to Treatment. Washington, DC, American Psychiatric Publishing, GD as an Compulsive Disorder Selective Serotonin Reuptake Inhibitors Fluvoxamine, Paroxetine, Escitalopram. Block serotonin reuptake, increase serotonin function, and reduce Self- Medication. Best with co-occurring depression or anxiety. 58 Hollander E, Sood E, Pallanti S, et al: Pharmacological treatments of pathological gambling. Journal of Gambling Studies 21: ,

30 Sertraline for Alcohol Dependence 60% 50% 40% Abstinence rates during a 14-week treatment trial with sertraline 200 mg QD. 30% 20% 10% 0% Early (n=45) Placebo Late (n=55) Sertraline Sertraline helped Late- Onset alcoholics stay abstinent, but worsened the condition for Early-Onset alcoholics. Pettinati, Alcohol Clin Exp Res, Conclusions 60 30

31 1. Gambling Disorders falls within an impulsivity-compulsivity spectrum of illness. 2. Psychology trumps probability. 3. Psychosocial treatments work. 4. Medications have fallen short. 5. Emerging treatments focus on differentiating among different populations of patients who suffer from gambling disorder. 61 Thank you NJMS.Rutgers.edu/Psychiatry 62 31