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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
AGRI: www.abgaminginstitute.ualberta.ca
Network
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
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 Act Pleasure/relief “Ego-syntonic”

Obsessive-Compulsive Disorders
± Regret/Guilt
”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
ASAM
• Impaired control over drug use
• Compulsive use
• Continual use despite harm
• Craving
DSM IV
• (or failure to cut down)
•
Larger/longer than intended
+
-
CSAM/ISAM
• Substance use &/or Behaviour
• Mood change
WHY AM I CONFUSED?

IMPULSIVE/COMPULSIVE SPECTRUM ALONG HARM AVOIDANCE (HA)
High HA
Low 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
 Cultural differences?
Gender differences
WHAT ABOUT ADDICTION’S MOTIVATION in HA?
•
Varied “impaired control” i.e., initial caution disappears; apprec of consequences

WHAT ABOUT DENIAL?

Scarce investigation of triad OCT, ICD, & Addiction
Unconscious disclaimer of intolerable thoughts / feelings /
realities to allay anxiety.
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
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…
CO-OCCURING DISORDERS
“BIRDS OF A FEATHER!”
NESARC (Nat Epid Survey Alc & Related Conditions) N=43000 – Petry ‘05
Diagnosis
Alcohol
Drug
Major Depression
Dysthymia
Mania*
Gen Anxiety
Panic
Agoraphobia
Phobias
OCD**
PG / %
Non-Gamblers %
Odds Ratio
73.2
38.1
37.0
13.2
22.8
11.2
13.1
5.1
23.5
-
25.0
8.8
12.3
3.8
2.5
3.6
4.2
1.0
7.8
-
6.0
4.4
3.3
3.3
3.1
3.1
4.2
5.2
3.5
- (.6 Cunningham Williams)
ICD* never assessed as entire group
Any PG fire-setters or pulling their hair? vs. anger or stealing
“ICD”, “OCD”, & “Addiction” signs & symptoms can be shaped by ADHD, depression, & others.
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
- 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”

ROLE OF DOPAMINE

NOREPINEPHRINE

OPIOID SYSTEM
- mediation of arousal & attention; “heart race”
- “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
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?
“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
“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; selfdisgust; secretive about amounts incl sister”

DRUG USE – Some social experimentation as teenager; 2 alcohol drinks/mt

PSYCHIATRIC HISTORY – Shy – Social Phobia
“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
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
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