Download Slide 1

Attention-Deficit/Hyperactivity
Disorder (ADHD) and Gambling
Disorders in Adults
RORY C. REID, Ph.D., LCSW
Assistant Professor,
Research Psychologist / Neuropsychology
Department of Psychiatry
University of California, Los Angeles
UCLA Gambling Studies Program
Overview of Presentation
 What is ADHD: Brief Summary?
 The ADHD Brain
 What Causes ADHD?
 Why ADHD and Problem Gambling?
 Assessing ADHD: DSM-5 Criteria
 Treatments / Special Considerations
What is ADHD?
A Brief Summary
ADHD and Gambling Disorders
What is ADHD: Brief Summary
 Attention-deficit/hyperactivity (ADHD) is a
neurodevelopmental disorder beginning in
childhood with symptoms persisting into adulthood
for a substantial number of individuals.
 The essential feature of ADHD is a persistent pattern
of inattention and/or hyperactivity-impulsivity that
interferes with functioning or development.
 Population surveys suggest that ADHD occurs in
most cultures in about 5% of children and about 2.5%
of adults.
What is ADHD: Brief Summary cont…
 Inattention manifests behaviorally in ADHD as
wandering off task, lacking persistence, having
difficulty sustaining focus, and being disorganized
and is not due to defiance or lack of comprehension.
 Hyperactivity refers to excessive motor activity and
in adults, hyperactivity may manifest as extreme
restlessness or wearing others out with their activity.
What is ADHD: Brief Summary cont…
 Impulsivity refers to hasty actions that occur in the
moment without forethought and that have high
potential for harm to the individual (e.g., risky sexual
behavior, reckless driving). Impulsivity may reflect a
desire for immediate rewards or an inability to delay
gratification. Impulsive behaviors may manifest as
social intrusiveness (e.g., interrupting others
excessively) and/or as making important decisions
without consideration of long-term consequences
(e.g., taking a job without adequate information).
The ADHD Brain
The ADHD Brain
 Diminished arousal of the Nervous System
 Decreased blood flow to prefrontal cortex and
pathways connecting limbic system (caudate
nucleus and striatum)
 PET scans show decreased glucose metabolism
throughout the brain.
 Similarities of ADHD symptoms to those
from injuries and lesions of frontal lobe
and prefrontal cortex.
The ADHD Brain cont…
MRI Scans in ADHD patients show:
 Smaller anterior right frontal lob suggesting
abnormal development in frontal and striatal regions
 Significantly smaller splenium or corpus callosum
potentially contributing to diminished
communication and information processing between
brain hemispheres.
 Smaller caudate nucleus.
Attention Networks in the Brain
There are primary 3 different attentional networks
 Alerting
 Orienting
 Executive
Petersen, S. E. & Posner, M. I. (2012). The attention system
of the human brain: 20 years after. Annual Review of
Neuroscience, 35, 73-89.
What Causes ADHD?
What Causes ADHD?
Underlying cause or etiology is still unknown with
conflicting data between studies.
 Strong evidence of genetic component
 Predominant theory: Catecholamine
neurotransmitter dysfunction or imbalance that
impacts decreased dopamine and/or norepinephrine
uptake.
 Premature birth (under developed brain)
 Maternal alcohol and tobacco use
 Exposure to high levels of led in early childhood
 Brain injuries, especially involving prefrontal cortex
Why ADHD
AND
Problem Gambling?
Why ADHD and Problem Gambling?
 Current studies suggest that the prevalence of adult
ADHD in problem gamblers is ~ 10 – 20%.
 Perhaps the more relevant question is why are
individuals with ADHD at increased risk for a
variety of addictive behaviors, in particular:
Alcohol and Drug
Addictions (19% - 33%)
Hypersexual Behavior
Sex Addiction (23% to 28%)
ADHD Vulnerability to Hypersexual Behavior
Common ADHD challenges:










Social rejection
Loneliness
Academic underachievement
Emotional dysregulation
Difficulties with task-completion
Poor self-concept
Diminished identity-formation
Relationship difficulties
Attrition from college
Poor work performance
Increased tendency to escape,
disconnect, numb out, etc…
Attentional Model of Problem Gambling
Inability to sustain attention and vigilance on the target
stimuli, and inhibit focused attention to the distractor
stimuli.
Target Stimuli
Distractor Stimuli
Alternative Attentional Model of Problem Gambling
Signal Strength
Attentive Condition
Inattentive Condition
Work
Gambling
Gambling
Target
Distractor
Work
Target
Distractor
Assessing ADHD:
DSM-5 Criteria
Assessing Adult ADHD: DSM-5 Criteria
Typically Adult ADHD can be assessed using several
approaches including:
 Diagnostic interview for ADHD
 Self-report questionnaires
 Collateral information
 Neuropsychological testing
Note: No biological marker is diagnostic for ADHD. As a group,
compared with peers, children with ADHD display increased slow
wave electroencephalograms, reduced total brain volume on
magnetic resonance imaging, and possibly a delay in posterior to
anterior cortical maturation, but these findings are not diagnostic.
Assessing Adult ADHD: DSM-5 Criteria cont…
Meaningful changes to the DSM-5 criteria include:
 Age of onset raised from age 7 to 12
 Fewer symptoms required for adults; 5 out of 9
 More examples of symptoms manifest in adults
 Comorbidity with autistic spectrum disorders allowed
Assessing Adult ADHD: DSM-5 Criteria cont…
Omissions in DSM-5:
 Behaviorally-focused emphasis that does not adequately
reflect the underlying cognitive difficulties
 Inadequate information on important role of emotions in
ADHD. It does not pick up the impaired motivational
aspect of emotions which makes it so difficult for many
with ADHD to get started on or sustain effort for tasks
not intrinsically interesting to them. And it does not
include any symptoms that reflect characteristic problems
of persons with ADHD in modulating their experience
and expression of emotions.
Assessing Adult ADHD: DSM-5 Criteria cont…
Omissions in DSM-5:
 DSM-5 does not recognize the importance of problems in
regulating sleep and alertness which have been identified
in research on ADHD in children and adults.
Thomas E. Brown, Ph.D.
Yale University
Assessing Adult ADHD: DSM-5 Criteria cont…
Review





Self-Report Questionnaires
ADHD Diagnostic Interview of DSM-5 Criteria
Neuropsychological Testing
Example of ADHD Diagnostic Protocol
Special Consideration with Gambling Disorders
Assessing Adult ADHD: DSM-5 Criteria cont…
Self-Report Questionnaires
 Adult ADHD Self-Report Scale
 Conners Adult ADHD Rating Scale
 Behavior Rating Inventory of Executive Functions
Neuropsychological / Psychological Testing
 Wechsler Adult Intelligence Scale
 Delis–Kaplan Executive Function System
Inattention & Time Estimation: An Illustration
An accurate estimation of how long something will take
to complete requires several aspects of attention.
Associated Issues in Adults with ADHD
Problems with Sleep Disorders
Problems with Obesity
Treatment Issues &
Special Considerations for
Adult ADHD and
Gambling Disorders
Treatment of ADHD and Gambling Disorders
Handout on Treatment Recommendations
Example of Referral Letter to Medical Provider
Mindfulness and Attention
Using Mindfulness to Increase
Focus and Attention
Mindfulness Applications
 Outcome studies have provided evidence that
mindfulness can be helpful for attenuating
psychological distress associated with a number of
mental health issues including:
 Anxiety / Depression
 Eating Disorders
 Obsessive-Compulsive Disorders
 Pathological Gambling
 Substance-Related Disorders
 Hypersexual Behavior
Mindfulness and Attention
Goodness of Fit for Mindfulness & Gambling
Thoughts
Emotion
Attention
Boredom
Gambling
Impulsivity
Cravings
Stress
Mindfulness and Cravings
Addictive cravings are powerful and can be intense
Patients often get into a tug-of-war with cravings
Patients often give special status to cravings
Patients have an adversarial relationship with cravings
Cravings
Gambling
Consequences
Reorganize relationship with craving to co-exist
Neither avoiding nor indulging, just being present in a
non-judgmental, curious manner
Developing a New Relationship with Cravings
Dr. Hedy Kober, Assistant Professor
Yale University School of Medicine
Mindfulness, Emotions, Stress, Impulsivity, & Gambling
Gambling
Anxiety
Depression
Stress
Mindfulness
Impulsivity
Shame and Self-Compassion
Focus of Mindfulness in Gambling & ADHD
Using Mindfulness, we attempt to target:
 Increased tolerance for cravings and urges
 Increased tolerance for emotionally uncomfortable
experiences
 Increase stress tolerance
 Increased ability to focus attention
 Increased ability to be present with the self
THE END
Attention-Deficit/Hyperactivity
Disorder (ADHD) and Gambling
Disorders in Adults
RORY C. REID, Ph.D., LCSW
Assistant Professor,
Research Psychologist / Neuropsychology
Department of Psychiatry
University of California, Los Angeles
UCLA Gambling Studies Program