Download el-Guebaly - University of Calgary

Centre
PROGRAM
Network
Addressing Comorbidities*
in the Treatment of
Gambling Problems
Nady el-Guebaly, MD
Professor & Head, Division of Substance Abuse,
University of Calgary
Medical Director, Addictions Program, Calgary Health Region
* “Two or more concurrent, independent disorders in single individual
interacting in the clinical picture”
Community Prevalence: Problem vs Non-Gambler OR
ECA (2)
1 problem = 161
incl 29 PG DSM III
Comorbidities with (1):
Substance Use Disorders: Alc
Nicotine
Illicit
Mood Disorders:
Bipolar
Suicidality
Anxiety Disorders, spec Phobias (not OCD)
Somatoform Disorders
Schizophrenia (severe & persistent MI)
ADHD?
Antisocial Personality (1ery & 2 ary)
1.
2.
3.
4.
5.
OR
3.3
2.1
1.3
3.3
3.4
1.6
2.3
3.0
3.5
--6.1
NESARC (3)
N=42898
PG .42; N=195
Lifetime
73%
60%
38%
50%
41%
OR
6.0
6.7
4.4
4.4
----3.9
-----
CCHS (4) N=36984
Gamblers 14934;
Problem = 1513
OR
2.9
1.8 (Mood & Anx)
2.3 (5)
Both 5.2
20% trt
61% PD
6.0
(obsC, par)
>F
Crockford, el-Guebaly. Can Psych 1998;43:43-50.
Cunningham-Williams, et al. Am J Public Health 1998;88:1093-1096; St. Louis DSM III DIS
Petry et al. J Clin Psychiatry 2005; 66:564-573; Nat Epid S Alc & Related Conditions; DSM IV AUDADIS; lifetime
el-Guebaly N et al J Gambling Stud 2006; 22: 275-287; CPGI, 12 m prev
McIntyre et al. J Affective Dis 2007 [In Press]
Correlation with Smoking & Alcohol –
Can Community Health Survey (CCHS) 2003 – Stats Can
GAMBLING
$
All sample
Frequency Smoke
0-Daily Current
Frequency Alcohol
0-daily, last 12 m
5 Drinks +
0 to > 1/wk
Frequency
CIDI-adult
Risk/adult G
CPGI 9
Pearson
N
.093***
1806
.157***
1372
.219***
1064
Pearson
N
.090***
1353
.180***
1187
.064*
965
Pearson
N
.082**
1353
.083**
1187
.171***
965
Signif .000 = ***
- Other drugs including marijuana NS
RISK OF GAMBLING CPGI 8-16
Thinking about the past 12 months (scale 1-4):

Have you bet more than you could really afford to lose?

Have you needed to gamble larger amounts to get same excitement?

Have you gone back another day to try & win back the money you lost?

Have you borrowed money or sold anything to get money to gamble?

Have you felt that you might have a problem with gambling?

Have people criticized your betting or told you that you had a problem?

Have you felt guilty about the way you gamble?

Has your gambling caused you any health problems (stress & anxiety)?

Has your gambling caused any financial problems?
Correlation with Personality Assessment Inventory (PAI) – Morey, 1991
GAMBLING (Pearson)
$
N = 1370
Frequency
CIDI N=1371
Risk CPGI 9
N=1063
Depression
.065*
.030
.265***
Mania
.018
-.086**
.176***
Suicidal Ideation
.033
-.005
.236***
.074**
-.070*
.238***
Anxiety related Dis
(OCD, Phobia)
.038
-.068*
.227***
Aggression
.059*
.058*
.136***
Somatic Complaints
.064*
.035
.219***
Schizophrenia
.038
-.023
.244***
Paranoia
.069*
-.013
.231***
Antisocial Features
.118***
.028
.231***
Anxiety
Signif .000 = ***
- Composite Intern Diagn Interview (CICD-SF/DSM IV) = NS
Correlation for SF-8 Health Survey (Ware et al, 2001)
GAMBLING (Pearson)
$ N=1370
Frequency
CIDI N=1371
Risk CPGI 9
N=1063
.082**
.060*
.174***
.043
.097***
.128***
.088**
.072**
.167***
.026
.083**
.095**
Vitality
.089**
.050*
.182***
Physical/Emotional Problems limit
social function
.113***
-.030
.227***
Presence of Emotional Problems
.107***
-.052*
.201***
Impact of Mental Health in Daily Life
.093**
-.070**
.220***
General Health
V poor- Excellent
Physical Health
Impact of Physical Health in Daily Life
Bodily Pain
0 – V severe
Signif .000 = ***
Correlation with Childhood Trauma Questionnaire (CTQ)
– Bernstein & Fink, 1998
GAMBLING (Pearson)
$
N=1806
Frequency (CIDI)
N= 1372
Risk CPGI 9
N=1064
Emotional Abuse
.013
.043
.125***
Physical Abuse
.038
.105***
.129***
Sexual Abuse
.016
.044
.097**
Emotional Neglect
.021
.098***
.124***
Physical Neglect
.034
.096***
.155***
ALSO:
Vietnam Vets Twins Registry – Health Related QOL: gambling, SUD & MH> Physical
PG & Depression (Potenza et al): Overlap Genetics> Environment
Shared stress response, impulse control? µ alleles & naltrexone?
Sig .000 = ***
Case “A” (1)




42 y/o, married female; postal clerk 8 y; 2 daughters: 20 y & 14 y
“Job was stressful”; ending a 4 yr educational leave;
Quite involved in her union
PRESENTING COMPLAINT: GAMBLING (last 3 yrs):
- progressive increase in VLT use
- currently gambles ~ once/week, 8-10 hours/session,
spending 3-600$ each time
- last month, stole husband’s bank card: worried!
- reported being given the “run-around” when seeking
help & no follow-up
“A” (2)
SUBSTANCES
- age 18-24, 26 oz liquor every W/E, many blackouts;
currently drinking once/week, 4 drinks/sitting
- one joint of cannabis/day, “most difficult to give up”
- 1/2 pack cigs/day
- experimented with solvents, LSD & cocaine
- FH +ve: mother & 5 out of 7 siblings from 4 fathers have
alcohol problems
“A” (3)
DEPRESSION/DYSTHYMIA
- emotional abuse from parents & siblings,
no sexual abuse
- episodes of depression throughout her life, particularly
severe 1 yr ago
- occasional suicide ideation & one serious attempt
- Paroxetine 20 mgm/day
“A” (4)
CHRONIC PAIN
- chronic cervical disc degeneration from “repetitive movement at work”
- history of TM Jaw pain & fainting spells for 6 years
- Medications: Tylenol #3, 3 times/day
Elavil, 150 mgm hs, for sleep & pain
Physical comorbidities?
Stress related disorders,
Medication side-effects
CHR 1000/3 hospital-wide consults: 12 Prob G, all MH
Survey of 51 New Zealand urban & rural practices (N=2536): no relation
with physical inactivity or weight concerns
“A” (5)
PERSONALITY
- 5 y ago, 6 m psychological FU for Union “bullying”
- Charge of mischievous conduct; running key down
co-workers’ cars with whom she had difficulty
- Postal service may release her; on probation for
abusing educational leave. She plans legal action.
COURSE: motivated to seek help for GAMBLING!
- Residential program entered but on relapse wished to deal
with “one addiction at a time”
- Repeated complaints up “the managerial chain” about
“personality conflicts” with therapist!
The Role of Gambling?
PRESENTING COMPLAINT: GAMBLING (last 3 years) BUT
 Substances
 Depression/Dysthymia
 Chronic Pain
 Personality
 Treatment Course
WHERE TO START?
 Rules of engagement “common ground”
 Find out sources of strength & your true friends “co-therapists”: sig other;
daughters?
 Address the behaviors!
 No RCTs! the closest :
- Hollander et al ’02: lithium & bipolar spectrum gamblers
- Grant & Potenza ’06: Escitalopram “open label” anxiety & gamblers (N=13 - 12 w)
(1) PATHOLOGICAL GAMBLING
Persistent & recurrent maladaptive gambling
5+ (if not mania)
(2) SUBSTANCE DEPENDENCE
Maladaptive pattern of substance use
3+ within 12 months:
1.
2.
3.
4.
Increasing amounts of money for excitement
Restless or irritable when cutting down/ stop
Unsuccessful efforts to control, stop…
Preoccupied with gambling
1.
2.
3.
4.
5.
Escaping from problems or dysphoria
5.
6.
Lies to family members, therapist, or others
6.
7.
8.
9.
10.
Illegal acts to finance gambling
Jeopardized or lost significant opportunities
“Chasing” one’s losses
Relies on others for money
7.
Tolerance
Withdrawal
Unsuccessful efforts to cut/control
A great deal of time spent to obtain
substance
Substance taken in larger amounts
or over a longer period than intended
Important social, occupation or
recreation given up or reduced
Use is continued despite physical or
psychological problems
COMORBID IMPACT:
- Rosenthal & Lesieur DSM “plot” addiction-impulsivity-compulsivity
Loss of control? Is persistence of erroneous cognition = physiological craving?
- See-Saw association
- Anti-craving meds: Naltr/Nalmefine
- Range of Support: OP  residential; Twelve Steps
(3) MOOD DISORDERS

Sadness  MAJOR DEPRESSIVE EPISODE > 2 wks
A. Depressed Mood
+
B. 4 for either:
- change in weight, sleep …
- feelings of worthlessness or guilt,
- difficulty thinking or concentrating
- recurrent thoughts of death/suicide + plan

DYSTHYMIC DISORDER > 2 yrs
More days than not, chronic, less severe depressive symptoms

COMORBID IMPACT: Role of SSRI’s; ineffectual with substance
CBT – gambling + depression?
Suicide assessment
MANIC/BIPOLAR EPISODES
Mood Stabilizers:
Group Support, ie,
Lithium; Anticonvulsants
Integrated Group Therapy (Weiss)
Interpers & Social Rhythm Therapy (Frank)?
ANXIETY DISORDERS
Fear & Tension reduction  “lost in machine”
Bi-directional and complex, i.e., social phobia
preceding & GAD following alcohol!
SCHIZOPHRENIA
Withdrawal  AISH & Internet
Lower “cumulative” threshold of care!
Concurrent approach
Review diagnoses after behavior ends!
(4) CHRONIC PAIN & DISABILITY
TREATMENT PHASES

Assessment

Education & CBT group – 10 wkly Sessions

Claresholm Residential Program for Taper & Rehab 3 – 24 wks

Follow-up support groups
(5) AXIS II - PERSONALITY DISORDER
CLUSTERS
A. Paranoid* B. ANTISOCIAL: impulsivity + disregard rights C. Avoidant
Schizoid
Borderline: impulsivity + affect instability
Dependent
Schizotypa
Histrionic
Obsessive-Compulsive*
Narcissistic* (N Petry P109)
> 33% NOS
COMORBID IMPACT:
Idiopathic or Symptomatic?
Continuum with Normalcy  Stigma
Therapy subject to: Crisis/Consequences
Introspection potential
ADDICTION CENTRE ADULT OUTPATIENT
SEQUENTIAL/CONCURRENT FLEXIBILITY = RETENTION!
Case management
+
SPECIFIC OBJECTIVES
Level I (Pre-Contemplation)
< 6 individual
Build motivation for change
Level II (Pre-Contemplation)
Group (2/wk for 3 wks)
Engagement & assessment;
Assess group treatment suitability
Level III (Contemplation)
(3 days/wk)
Move patient into action ( Level IV)
Reduce psychiatric/Add symptoms
Engage supports (e.g., AA).
Level IV (Action & Maintenance)
(5 days/wk)
Prevent relapse
 Confidence;  Psychiatric/SA symptoms
Speciality groups
Open: harm reduction & support
Couple: prevent relapse,  communication
Chr pain: reduce med reliance,  non-drug coping
GAMBLING: CBT & PREVENT RELAPSE (8 sessions)
Inpt for Crisis stabilization only
What about Mrs. “A”?
July
Assessment; Family? enabling or detached
Sept-Oct
Second residential program
During childhood was the family social worker
H sold marihuana; she gambled his money!
Strengths: a leader in groups; attended GA; spiritual life
Oct-Dec
On discharge: no shows, no GA; using alcohol & marihuana
Anxious about return to work; enquired about ADHD?
Requested sole focus on “gambling” which was refused
Angry phone call to managers in Nov about “personality conflict”
& need to switch therapist
Dec
Discharge back to GP with information – latter acknowledged PD
PROGNOSIS
“It’s a long life!” – she is a bright, resourceful lady
Loss of job/income may be the crisis required
Couple therapy? Or separation? Anger management
Crisis management until meaningful involvement
PG: TYPOLOGY OF BEHAVIORAL DRIVERS?
A. GENO-PHENOTYPES?
B. SEVERITY LEVELS

Serotonin – impulse control
Social Abuse & Dependence LI, LII, L III

Endorphin – urges, cravings
Non-problem  Problem  Pathological

Dopamine – reward, re-enforcement

Norepinephrine – arousal, excitement
C. ONSET (Early  Late), Childhood stability &
Psychopathology
Blaszczynski’s Pathways
COMPULSIVE
Body dysmorphia
Anorexia
Tourette
Path Gambling
Sexual
compulsions
Impulsive PD
D.
CORMORBIDITIES
SUD incl nicotine
Mood
Anx/PTSD
Impulse control
(sex, spending)
Antisocial
% range
20 – 70
30 – 75
20 – 40
20
20-40
IMPULSIVE
“Repetitive behavior with inhibition defect,
i.e., from hyper-vigilance & rituals to risk seeking
ADDICTION: Behavior with tolerance, withdrawal
& loss of control causing harm “cravers”