DSM 5 & ASAM: ASSESSMENT & CASE MANAGEMENT FOR GAMBLERS Jeffrey M. Beck, LPC, CCGC, JD, ABD National Council on Problem Gambling
DSM 5 Diagnostic & Statistical Manual of Mental Disorders by American Psychiatric Association Important tool for clinicians, dictates diagnosis and treatment of thousands of mental illnesses Changes to DSM influences psychiatry, academia, pharmaceutical, insurance, treatment and legal community
DSM 5 Change in nomenclature- new term is gambling disorder Many terms have been used: pathological gambler, compulsive gambler, problem gambler, at-risk gambler, type 1, Type 2 Type 3 Less pejorative, consistent with listing of other mental illnesses Certainty of language
QUESTIONS FOR DISCUSSION Will new language allow for better metaanalysis- combining studies What impression does the word disorder have for you? Do you use pathological or compulsive language- does it matter who you are talking to? How important is language?
CHANGE IN CLASSIFICATION Moved from Impulse Disorders NOS to Addictions and Related Disorders Separate category called Behavioral Addiction, sole condition in category Internet addiction and sex addiction considered but further study required, listed in Appendix First classification of disorder as addiction not involving digestion of substance
ADDICTION CLASSIFICATION Scientific literature on brain reward shows commonalities: cravings, hereditary nature, similar forms of treatment ( 12 step, CBT), tolerance and withdrawal Neuro-adaptation of brain wiring Similar in clinical presentation, co-morbidity with Axis 1 and Axis II Disorders, association with personality factors, neurotransmitter involvement,.. Not true of other impulse control disorders
SIGNIFICANCE OF GAMBLING AS ADDICTION Characterization as disorder gives it medical legitimacy, no longer can be dismissed as excuse for excessive behavior From a policy perspective important for funding Increasing movement not to pay for anything without a medical label Increased likelihood of being governed by parity requirements for insurance
SIGNIFICANCE OF GAMBLING AS ADDICTION American with Disabilities Act Gambling has sometimes fallen into a gap between mental health and addiction Gambling placement in ASAM Criteria May lead to expansion of levels of care and type of services
DSM 5 CRITERIA Persistent and recurrent problematic gambling behavior leading to clinically significant impairment or distress, as indicated by the individual exhibiting four or more of the following in a 12 month period: Need to gamble with increasing amounts of money to achieve desired excitement Is restless or irritable when attempting to cut down or stop gambling
DSM 5 CRITERIA Has made repeated efforts to control, cut back or reduce gambling Is often preoccupied with gambling Often gambles when feeling distressed ( helpless, guilty, anxious depressed) After losing money gambling often returns another day to get even Lies to conceal extent of involvement with gambling
DSM Criteria Has jeopardized or lost a significant relationship, job, educational or career activity because of gambling Relies on others to provide money to relieve desperate financial situation caused by gambling Gambling episode not better explained by a manic episode
DSM 5 ELIMINATION OF ILLEGAL ACTS AS CRITERIA Argues that it is least likely criteria to be endorsed, seldom needed to meet standard Seen as consequence of gambling rather than symptom of gambling Anecdotally most GA members answer question positively Criterion did not require arrest or conviction, often crime against family and friends and not prosecuted
ILLEGAL ACTS COMMENTARY May be better to label as diversion or misappropriation of funds, maybe falls under bailout Has been used as a mitigating factor in support of diversion, reduced sentencing and court mandated programs Different nations and cultures have different laws, attempt to universalize criteria
QUESTIONS FOR DISCUSSION Have you ever worked with an individual where you needed illegal acts to reach threshold level? Does illegal acts have more of a severity context than a diagnostic one? Do you believe illegal act to support gambling is a symptom or result of the disorder?
CHANGE IN NEEDED CRITERIA FOR DIAGNOSIS 4 out of 9 (44.5) instead of 5 out of 10 Several resources cited in DSM 5 suggested 4 as benchmark May result in increase in state, local, and national prevalence which has public health and funding implications Gambling to be viewed on severity basis: 4-5 mild, 6-7 moderate, 8-9 severe
CHANGE IN NEEDED CRITERIA Specifically stated in DSM 5 that individuals presenting for treatment will have moderate to severe levels of gambling disorder Easier to assess, harder to justify in treatment. Diagnosis doe not merit treatment Impacts on primary, secondary and tertiary prevention Reduced treatment numbers suggest that responsible gaming practices have reduced size of problem
SPECIFICATIONS Episodic- meet criteria at more than one time with symptoms subsiding for several months Persistent- Continuous symptoms for multiple years Early remission- after full criteria met no criteria are met for at least 3 months but less than 12 months Sustained remission- No criteria met for period of 12 months or longer
ASAM For years clinical experts have applied diagnostic and treatment methods used for substance use disorders in evaluation and management of cases of pathological gambling, even though it was not in DSM under addiction Inclusion of gambling as an addiction in DSM 5 has led to gambling inclusion in ASAM patient placement criteria
ASAM NEW DEFINITION OF ADDICTION (2011) Addiction as primary chronic illness, not caused by mental health or self-medication Proposed unified notion of disease not solely based on problematic use Conscious choice plays little role in addiction but plays role in seeking help Addiction is a disease of brain reward, motivation, memory and related circuits
ASAM NEW DEFINITION OF ADDICTION 2011 The disease of addiction is about brains, not drugs. It is underlying neurobiology, not outward actions Addiction is more than a behavioral disorder, it is a bio-psycho-social-spiritual illness characterized by damaged decision making, persistent risk and recurrence of relapse Addiction is a chronic disorder so it must be treated, monitored and maintained over lifetime
ASAM ADDICTION DEFINITION QUESTIONS Does calling addiction a brain disorder reduce stigma? Does lumping all addictions together into syndrome detract from specialization? Are people suffering from brain damage out of control and to be feared? Is chronic n accurate tem considering natural recovery? What are public policy implications?
ASAM CRITERIA ON INSURANCE FOR GAMBLING Uncommon for insurance to pay for residential treatment unless co-occurring medical or psychiatric problems Partial hospitalization or intensive outpatient considered non-covered benefit without meeting criteria for substance use or separate mental disorder Questions remain about applicability of Mental Health Parity & Addiction Equity Act of 2008 or Patient Protection and Affordable Care Act of 2010
ASAM ON STAFFING Staff providing treatment to patients with gambling disorder should have state-sponsored or approved gambling counselor certification Licensure as drugs and alcohol counselor not a substitute for gambling counselor certification Possibly in future all addiction counselors will receive sufficient gambling training to not need specific certification
ASAM RECOMMENDED SCREENING TOOLS Lie/Bet Screen - 2 questions and likelihood in use in community and clinical centers where clinicians feel overwhelmed with paperwork Have you ever had to lie to people important to you about how much you gambled? Have you ever felt the need to bet more and more money? Also recommends South Oaks Gambling Screen Also consider BBGS and NODS-PERC
ASAM & PURPOSE OF SCREENING Conduct preliminary inquiry to rule an individual in or out If ruled in assess using DSM 5 criteria
ASAM ON GAMBLING ASSESSMENT Comprehensive assessment with particular emphasis on financial and legal problems and suicidality Due to co-occurrence of gambling problems with substance abuse disorders, and one often being trigger for the other, screening for gambling problem should be a routine part of assessment on substance use disorder
DIMEMSION!- ACUTE INTOXICATION OR WITHDRAWAL Are there current signs of withdrawal ( restless or irritability when attempting to cut down or stop gambling)? Does patient have supports in community to enable safe tolerance of said restlessness or irritability? What forms of activity have been engaged in? Have psychoactive substances been used where withdrawal management is necessary?
DIMENSION 2- BIOMEDICAL CONDITIONS & COMPLICATIONS Are there current physical illnesses that may complicate treatment?-any acute conditions associated with prolonged periods of gambling? Is there need for medical services which might interfere with treatment? Are there chronic medical conditions that might be exacerbated by cessation or continuation of gambling?
DIMENSION 3: EMOTIONAL, BEHAVIORAL OR COGNITIVE Are there other current psychological, emotional or behavioral problems that must be addressed or will complicate treatment? Do any emotional/behavioral problems appear to be an expected part of gambling disorder or do they appear to be separate? Is patient suicidal and if so what is the lethality? Are her distortions in thinking such as superstitions, overconfidence or inflated sense of power and control?
DIMENSION 4: READINESS TO CHANGE Does patient feel coerced into treatment or is actively resistant? How ready is patient to change? If willing to accept treatment how strongly does he/she disagree with others perception of a gambling problem? Is patient internally or externally motivated? Is there leverage available?
DIMENSION 5: RELAPSE, CONTINUED USE, CONTINUED PROBLEMS How aware is patient of triggers for relapse, ways to cope with cravings and skills to control impulse to gamble? What is present level of preoccupation with craving gambling and how successfully can patient resist gambling behaviors? Is there an immediate danger of continued distress and gambling due to co-occurring substance use and mental health problems How severe will problems become if not treated?
DIMENSION 6: RECOVERY/LIVING ENVIRONMENT Are there barriers to access to treatment such as transportation or child care needs? Are there legal, vocational, social service agency or criminal justice mandates that may enhance motivation for engagement in treatment? Are there dangerous family, significant other, living, school or work situations threatening treatment engagement and success? Does patient have supportive friendship and financial resources?
ASAM & PLACEMENT Level of care more complicated with gambling due to limited resources. Significant lack of resources in rural areas, need to encourage existing treatment programs to develop gambling treatment services. Early intervention and SBIRT may be utilized for at-risk gamblers
ASAM & PLACEMENT Gambling problems not severe enough to reach diagnostic thresholds - outpatient should be considered based on multidimensional ASAM criteria for gambling and substance abuse ( 1, 2.1, 2.5) Those diagnosed with gambling disorders likely a co-occurring problem on dimension 1, 2 or 3. may justify inpatient, so to address concerns dimension 5 and 6 l (3.1,3.3,3.5)
ASAM & PLACEMENT Payment for treatment as obstacle Most insurance companies that do not categorically exclude residential or inpatient treatment require there is another primary diagnosis such as major depressive disorder State or local drug and alcohol authority could elect to pay for treatment of gambling disorder, regardless of level of care
DSM VS ASAM DSM focuses on outward manifestations that can be observed and the presence of which can be confirmed through a clinical interview or standardized questionnaire ASAM definition focuses on what is happening in the brain, hoping it leads to better understanding od addiction as biological, psychological, social and spiritual in its manifestations
CASE MANAGEMENT FOR GAMBLERS Counselor as advocate for increased gambling services Needs to convince insurance company of appropriateness of care Needs to work within state agency or gambling council to obtain funding Needs to be advocate for some federal funding of gambling services- should treatment depend on where we live
CASE MANAGEMENT FOR GAMBLERS Often limited time with limited resources Need to focus on reducing or stopping gambling behavior, may not allow for detailed discussion on causation Address crisis caused by gambling disorder Focus on finance, legal, safety needs, thinking, co-occurring and suicide
FINANCIAL ISSUES FOR DISCUSSION Beliefs about money Control of money Emotional attachment to money Concepts of credit Monitoring spending Juggling of money Doing a budget
FINANCIAL ISSUES FOR DISCUSSION Contacting creditors Monitoring mail- refusing to cosign loans Checkbook control Direct deposit Direction towards GA Pressure Relief Group
ADDRESSING HIERARCHY OF NEEDS Eviction and homelessness Inability io pay for food and utilities Family discovers savings accounts wiped out Coping with financial stressors as part of treatment Addressing necessities like food and shelter Prioritize needs to avoid overwhelming client
ADDRESSING LEGAL CRISIS Embezzling and writing bad checks State of panic- borrowing to payoff debtsborrowing from Peter to pay Paul Self exclusion options Domestic violence concerns Need for legal counsel prior to impulsive actions Addressing unrepaid markers from casinos
ADDRESSING SUICIDE Understand risk factors and look for them Does the patient have a plan? Is the plan lethal, do they have means? Have they tried before? Are there support people willing to help? Has there been a recent loss? How severe is addictive behavior? Never be afraid of asking suicide question
COGNITIVE DISTORTIONS Illusion of control Magical thinking Selective attention and recall Independence of events- gambler s fallacy Near miss beliefs 20/20 hindsight- Monday morning quarterbacking
COGNITIVE DISTORTIONS All or nothing thinking Overgeneralizations Jumping to conclusions Emotional reasoning based on intuition, not evidence Anchoring- one piece of information for decision I have money problem not gambling problem
CO-OCCURRING DISORDERS Assess for drugs and alcohol Look for mood disorders- depression, anxiety ADHD, ASPD, PTSD Did gambling precede onset of other disorder? Are there common family and environmental vulnerability? Are severity of disorders related? Need for integrated treatment
CONCLUSIONS Addiction classification may get involvement of Federal Agencies in gambling- NIDA, NIMH, SAMHSA Classification as gambling may reduce stigma DSM 5 and ASAM may end gambling falling through cracks as mental health or addiction Insurance coverage will be an important issue Counselors need to be advocates for clients
CONCLUSIONS Counselors need to advocate for more types of services available Assume limited time, focus on areas of most importance Be aware of newer short term approaches for at-risk or below threshold gambling Work to integrate gambling screening into mental health and addiction settings
CONTACT INFORMATION Jeffrey M. Beck, LPC, CCGC, JD, ABD, CART Assistant Director for Clinical Services, Treatment & Research Council on Compulsive Gambling of New Jersey 609-588-5515 ex 14 Ccgnjjeff@aol.com