Constructions of Cravings in Disordered Gambling Research: Theory and Evidence

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1 Constructions of Cravings in Disordered Gambling Research: Theory and Evidence Glenn W. Harrison (1, 2, 3), Morten I. Lau (4), Don Ross (2, 3, 5), J. Todd Swarthout (6) 1 Department of Risk Management and Insurance, J. Mack Robinson School of Business, Georgia State University; 2 Center for Economic Analysis of Risk (CEAR), Robinson School of Business, Georgia State University; 3 School of Economics, ; 4 Copenhagen Business School; 5 School of Sociology, Philosophy, Criminology, Government & Politics, University College Cork; 6 Department of Economics, Georgia State University Contact: Don Ross, don.ross@uct.ac.za University College Cork

2 Cravings in the Theory of Addiction Addictive cravings result from neuroadaptation: Addiction is based on this neuroadaptation. Unblocked midbrain elicitation of motor system preparation is experienced as craving for the addictive target, which triggers thoughts about it and directs attention to seek predictive cues for it. University College Cork Learning in VS that gambling reliably produces a dopamine signal depresses tonic GABA and serotonin levels in OFC and VMPFC and thereby reduces cortical interference with midbraingoverned preparation of motor responses. Glutamate increase is the brain s recognition that its environment is extra stimulating (= confronts it with a difficult learning problem, the slot machine, for which there s a clear exploration method). Responding to the continuous dopamine signaling, glutamate rewires the addict s memory and learning pathways to make the system a more efficient detector and tracker of its new source of what Ainslie calls will.

3 Cravings as a Psychological Construct Cravings are reflected in behavioral measures of: preoccupation anhedonic inability to attend to alternative stimuli efforts at relief associated with visceral discomfort (withdrawal symptom responses) University College Cork

4 Addicts in Samples of Disordered Gamblers Gambling addicts have been identified using fmri in small samples. But this says nothing about frequencies. Taxometric analysis in a South African community sample (Kincaid et al 2013) suggests some addicts as a subset of PGs as scored by the PGSI. But sub frequency can t be estimated from the data or by this method; and the PGSI doesn t probe for preoccupation or experience of withdrawal symptoms. University College Cork

5 Instruments for Measuring Cravings or Preoccupation in Gamblers Gambling Urge Scale (GUS) Raylu, Namrata, & Oei, Tian P., Psychology of Addictive Behaviors, Gambling Craving Scale (GACS) Young, Matthew M., & Wohl, Michael J., Psychology of Addictive Behaviors, Focal Adult Gambling Screen (FLAGS) Two preoccupations constructs ( Desire, Obsessions ). Schellinck, T., Schrans, T., Schellinck, H.,& Bliemel, M., Journal of Gambling Issues 2015 University College Cork

6 Assumptions Behind the Instruments GUS is unidimensional GACS measures on three dimensions (sub constructs): 1. Anticipation Gambling would be fun right now If I had an opportunity to gamble right now, I would probably take it I would not enjoy gambling right now 2. Desire I crave gambling right now I need to gamble now I have an urge to gamble 3. Relief If I were gambling now, I would think more clearly I could control things better now if I could gamble Gambling would make me less depressed University College Cork

7 The GACS Construct vs the Addiction Theory Construct There s little reason for supposing that the first GACS dimension (Anticipation) depends on addictive preoccupation, especially since thoughts of gambling will be triggered by the prompt itself. The Relief construct more plausibly probes addictive cravings. University College Cork

8 FLAGS Constructs FLAGS is a long screen, with scoring based on a specific causal theory of DG composed out of 10 constructs. 4 constructs are deemed reflective: Preoccupation (Desire) Preoccupation (Obsession) Impaired Control Continue Play Impaired Control Begin Play 6 constructs are deemed formative: Erroneous Cognitions Beliefs Erroneous Cognitions Motives Risky Behaviours Earlier Risky Behaviours Later Negative Consequences Persistence University College Cork

9 Reflective vs Formative A reflective construct is an indicator of a latent variable that is believed to partly constitute the reflected construct as manifest in behaviour. A formative construct is one that is often, but not always, found along the etiological pathway to, or looping back into, the target behavioural marker. Thus reflective constructs should show high inter correlation, while no such expectation applies, independently of a specified structural model, to formative constructs. The FLAGS reflective constructs, as reflective, are well grounded in the main thread of DG literature. The formative constructs and the causal theory raise special issues, which aren t relevant here. University College Cork

10 Cravings in FLAGS Preoccupation: Desire (POD) I would like to gamble almost every day Compared to many other things I can do I would rather gamble I wish I could gamble more often Preoccupation: Obsession (POO) I plan my life around my gambling I am obsessed with gambling, thinking about when I will next gamble all the time I spend a lot of my time thinking about gambling or how to get money to gamble Thoughts of gambling or playing the games fill my mind day and night University College Cork

11 FLAGS Constructs vs Addiction Theory Construct of Cravings The POD focuses on a new construct roughly, enthusiasm for gambling not directly probed by any other instrument. The POO might be interpreted as asking respondents whether they re aware of addictive cravings. It might be more accurate at detecting established than early addictions. University College Cork

12 Misleading Aggregate Screen Scores? The upshot of the foregoing is that if a sample contains both addicted and non addicted gamblers, aggregated scores on both the GACS and the FLAGS preoccupation items risk producing (at least) two types of error: (1) the overall frequency of DGs is underestimated because non addicts answer no to GACS Relief and POO questions, which are equally weighted with other questions in overall scoring. (2) the overall frequency of DGs is underestimated because established addicts have aversive feelings about their gambling and answer no to GACS Anticipation and POD questions. University College Cork

13 Studies in Denmark We obtained 8,405 (12.8%) completed survey responses from a sample frame of 65,592 Danish adults The sample was stratified according to sex and age across three regions: i. greater Copenhagen, ii. Jutland and iii. Funen and Zealand Among subjects that completed, all selfadministered FLAGS plus 2 3 other instruments in varying orders Higher weight (50%) on sample from greater Copenhagen for later recruitment into experiments University College Cork

14 Other Administered Instruments Problem Gambling Severity Index (PGSI) DSM IV problem gambling screen Gambling Craving Scale (GACS) Gambling Related Cognitions Scale (GRCS) Gambling Urge Screen (GUS) Alcohol Use Disorders Identification Test (AUDIT) Beck Anxiety Index (BAI) Beck Depression Index (BDI) Barratt Impulsivity Scale (BIS) University College Cork

15 Survey Sub Pools with Tests for Order Effects 1A: FLAGS, PGSI, BIS 1B: PGSI, FLAGS, BIS 2A: FLAGS, DSM IV, BAI, AUDIT 2B: DSM IV, FLAGS, BAI, AUDIT 3A: FLAGS, GACS, AUDIT 3B: GACS, FLAGS, AUDIT 4A: FLAGS, GUS, BDI, AUDIT 4B: GUS, FLAGS, BDI, AUDIT 5A: FLAGS, GRCS, AUDIT 5B: GRCS, FLAGS, AUDIT University College Cork

16 Raw responses: FLAGS FLAGS Risk Level Frequency Percent Cumulated No Detectable Risk 6, Early Risk 1, Intermediate Risk Advanced Risk Problem Gambler Total 8, University College Cork

17 Figure 8: Correlation of FLAGS Scores with Other Instruments Correlation DSM PGSI GACS GRCS GUS AUDIT BAI BDI BIS University College Cork

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23 Inferences? In the overall FLAGS assessment, are there very few addicts in the sample, or are they getting lost because GACS Anticipation questions are bringing down their scores? Are GACS Anticipation and Relief questions canceling one another out in the GACS aggregate contribution to risk level classification? University College Cork

24 Experiments Subjects played multiple payline slots in our virtual casino. First they played with house money. After a fixed number of rounds, subjects who still had money could choose to leave (with their winnings) or voluntarily enter the casino and continue gambling for as long as they wished This replicates an original GACS experiment We also elicited subjects incentivized risk preferences, subjective beliefs about probabilities, and intertemporal discounting. University College Cork

25 Preliminary peek at experimental data related to cravings We jointly examined GACS overall score, GACS Relief, POD, and POO as potential predictors of whether a subject chose to enter the lab casino (Gambler?), and time on machine (TOM) in terms of spins and minutes. In the original Young & Wohl GACS experiment, Relief predicted the above behavioral outcomes but overall GACS score didn t. Neither POD nor POO predicted behaviour. Our results are consistent with the original ones on TOM but not on Gambler? University College Cork

26 Conclusion: It s Time for Radical Empiricism Aggregated scores on batteries of survey questions are a problematic basis for inference in the absence of a theory of DG. (FLAGS design assumes a strong theory, but its method of derivation assumed that all DG has the same etiology.) We can use cravings constructs as a canary in the coal mine because there is a theory of addiction. In going forward with our Danish data, we ll treat each survey question as an independent item with controlled lab behaviour, incentivized risk preferences, and incentivized subjective beliefs to use for leverage. The idea is to use the experimental economics lab to build a theory of gambling related welfare effects from data. University College Cork

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