Disordered gamblers with and without ADHD: the role of coping in elevated psychological distress

Attention-deficit/hyperactivity disorder (ADHD) is significantly more prevalent among disordered gamblers than in the general adult population. Despite this, it remains unclear whether co-occurring ADHD is associated with clinically significant differences that call for specialized assessments and treatment planning. The purpose of this article was to explore differences in psychological distress and coping strategies among individuals presenting to an outpatient gambling treatment centre with and without co-occurring adult ADHD. Participants (n = 99) were primarily female (69%) and Caucasian (86%) outpatient treatment-seeking disordered gamblers. At intake, individuals completed self-report measures of coping (Coping Inventory for Stressful Situations – Adult Form), psychological distress (Beck Depression Inventory II) and ADHD (Brown Attention-Deficit Disorder Scales – Adult Form). Results indicated that individuals with ADHD (n = 42) reported significantly more psychological distress and less adaptive coping strategies than those without co-occurring ADHD (n = 57). Mediation analyses showed that an ADHD diagnosis had an indirect effect on psychological distress via the mediator of maladaptive coping. Assessment and treatment should be tailored to address the variety of presentations of gambling disorder. Screening for ADHD at intake may be helpful in creating an individualized treatment plan for disordered gamblers.     

An Empirical Study of Personality Disorders Among Treatment-Seeking Problem Gamblers

The primary aims of this study were to examine the prevalence of personality disorders in problem gamblers, to explore the relationship between personality disorders and problem gambling severity, and to explore the degree to which the psychological symptoms highlighted in the biosocial developmental model of borderline personality disorder (impulsivity, distress tolerance, substance use, PTSD symptoms, psychological distress and work/social adjustment) are associated with problem gambling. A secondary aim was to explore the strength of the relationships between these symptoms and problem gambling severity in problem gamblers with and without personality disorder pathology. Participants were 168 consecutively admitted problem gamblers seeking treatment from a specialist outpatient gambling service in Australia. The prevalence of personality disorders using the self-report version of the Iowa Personality Disorders Screen was 43.3 %. Cluster B personality disorders, but not Cluster A or C personality disorders, were associated with problem gambling severity. All psychological symptoms, except alcohol and drug use, were significantly higher among participants with personality disorder pathology compared to those without. Finally, psychological distress, and work and social adjustment were significantly associated with problem gambling severity for problem gamblers with personality disorder pathology, while impulsivity, psychological distress, and work and social adjustment were significantly associated with problem gambling severity for those without personality disorder pathology. High rates of comorbid personality disorders, particularly Cluster B disorders, necessitate routine screening in gambling treatment services. More complex psychological profiles may complicate treatment for problem gamblers with comorbid personality disorders. Future research should examine the applicability of the biosocial developmental model to problem gambling in community studies.     

Cortisol Rise Following Awakening Among Problem Gamblers: Dissociation from Comorbid Symptoms of Depression and Impulsivity

Gambling pathology has been associated with elevated levels of distress, depression and impulsivity. The present investigation assessed whether these behavioral features would be evident among problem gamblers as they are among pathological gamblers. As well, given that gambling has been associated with increased life stress, as an objective index of ongoing distress, elevations of morning cortisol levels were assessed in problem and pathological gamblers relative to recreational gamblers, and their relations to depressive symptoms and impulsivity were assessed. Recreational, problem, and pathological gamblers (N = 140) completed the Beck Depression Inventory and the Barratt Impulsiveness Scale-11, and provided saliva samples at awakening, 30 min, 3.5 h, and 5.5 h afterward. Consistent with the view that problem and pathological gambling are associated with elevated life stressors, the rise of morning cortisol from awakening to 30 min following awakening was greater than in recreational gamblers. Heightened impulsivity was evident among both problem and pathological gamblers, whereas depressive symptoms were only evident among pathological gamblers. In neither instance were these psychological indices related to the morning cortisol rise. Indeed, increased depressive symptoms were not evident among problem gamblers, despite the fact that elevated morning cortisol levels were evident. The elevated morning cortisol rise may be secondary to gambling problems or distress related to gambling problems. Furthermore, the sustained morning cortisol elevations may be indicative of allostatic overload, and could potentially be a harbinger for potential health risks among problematic gamblers.     

Multiple Co-occurring Behaviours among Gamblers in Treatment: Implications and Assessment

A substantial portion of gamblers in treatment may have co-occurring mental health disorders including substance use disorders, especially alcohol dependency, personality disorders, affective disorders, anxiety disorders and impulse control disorders. Co-occurring mental health disorders affect treatment seeking, the treatment process and its outcome, quality of life and functioning in many mental health disorders. Participants in this study were 78 adults enrolled in state-supported out-patient services for pathological gambling and current Gamblers Anonymous attendees. The majority of participants (76.6%) had co-occurring behaviours; 55.8% had multiple co-occurring behaviours. Participants with multiple co-occurring behaviours were more likely to report that a co-occurring behaviour increased the severity of their gambling symptoms. A dose/response relationship between number of co-occurring behaviours and severity of gambling problems was found. Co-occurring behaviours can interact with gambling behaviour. Brief, validated screening instruments are available for screening and diagnosing co-occurring behaviours among gamblers presenting for treatment.     

The Relationship Between Problem Gambling and Attention Deficit Hyperactivity Disorder

Recent studies indicate that treatment-seeking problem gamblers display elevated rates of ADHD and that adolescents who screen positive for ADHD are more likely to engage in gambling, develop gambling problems, and experience a greater severity in gambling problems. This study aimed to (a) compare the prevalence of ADHD in treatment-seeking problem gamblers to the general population; (b) investigate the relationships between ADHD and problem gambling severity, cluster B personality disorders, motor impulsivity, alcohol use, substance use, gender, and age; and (c) investigate the degree to which these factors moderate the relationship between ADHD and problem gambling severity. Participants included 214 adults (154 males, 58 females, 2 unspecified) who sought treatment for their gambling problems at a specialist gambling agency in Melbourne, Australia. Almost one-quarter (24.9 %) of treatment-seeking problem gamblers screened positively for ADHD, which was significantly higher than the 14 % prevalence in a community sample. ADHD was significantly positively correlated with problem gambling severity, motor impulsivity, and cluster B personality disorders, but was not associated with alcohol and substance use, gender or age. None of the factors significantly moderated the relationship between ADHD and problem gambling severity. These findings suggest that a considerable proportion of treatment-seeking problem gamblers report ADHD and that their clinical profile is complicated by the presence of high impulsivity and cluster B personality disorders. They highlight the need for specialist gambling agencies to develop screening, assessment, and management protocols for co-occurring ADHD to enhance the effectiveness of treatment.     

Professional and Pathological Gamblers: Similarities and Differences

Although much recent research has focused on the gambling practices and psychosocial functioning of pathological gamblers, few investigations have examined the characteristics of professional gamblers. The current project sought to address this gap in the literature by conducting a quantitative comparison of professional and pathological gamblers. Pathological gamblers were recruited and balanced with professional gamblers on demographic variables and preferred gambling activity. A total of 22 professional gamblers and 13 pathological gamblers completed an extensive self-report battery including instruments assessing demographics, gambling behaviors and problems, other psychiatric disorders, current psychosocial functioning, recent stressful events, personality characteristics, and intelligence. Pathological and professional gamblers reported similar rates of gambling frequency and intensity and types of games played. Pathological gamblers endorsed poor psychosocial functioning, whereas professional gamblers reported a rate of psychiatric distress within a normative range. Pathological gamblers also reported lower gambling self-efficacy, greater impulsivity, and more past-year DSM-IV Axis I disorders than professional gamblers. The results of the present study shed light on the unique circumstances of professional gamblers, as well as underscore important differences between such individuals and pathological gamblers that could prove fruitful in future research and intervention and prevention efforts.     

Mental Health and Online,Land-Based and Mixed Gamblers

Although high rates of problem gambling have been identified among Internet gamblers, most studies have failed to identify the relative contribution of multiple forms of gambling as opposed to the exclusive participation in online forms. The aim of this study was to investigate differences in mental health status in exclusive online, exclusive land-based, and mixed Internet and land-based samples of gamblers drawn from the general population. A sample of 4594 respondents completing an online survey were categorised as exclusive online, land-based and mixed form gamblers. Participants completed a questionnaire eliciting demographic details, participation on all forms of gambling, use of alcohol, tobacco and drugs, help-seeking, and personal problems experienced due to gambling, as well as measures of problem gambling and psychological distress. Findings indicated that mixed gamblers exhibited higher problem gambling scores, level of gambling involvement, and consumption of alcohol during gambling than exclusive online gamblers. Land-based gamblers experienced higher levels of psychological distress, self-acknowledged need for treatment, and help-seeking behaviour. These findings suggest that exclusive online gamblers represent a different subpopulation at lower risk of harm compared to gamblers engaging in multiple forms. Understanding the characteristics of different problem gambling subpopulations may inform the development of more effective targeted interventions.     

Anxiety,Depression and Emotion Regulation Among Regular Online Poker Players

Poker is a type of gambling that has specific features, including the need to regulate one’s emotion to be successful. The aim of the present study is to assess emotion regulation, anxiety and depression in a sample of regular poker players, and to compare the results of problem and non-problem gamblers. 416 regular online poker players completed online questionnaires including sociodemographic data, measures of problem gambling (CPGI), anxiety and depression (HAD scale), and emotion regulation (ERQ). The CPGI was used to divide participants into four groups according to the intensity of their gambling practice (non-problem, low risk, moderate risk and problem gamblers). Anxiety and depression were significantly higher among severe-problem gamblers than among the other groups. Both significantly predicted problem gambling. On the other hand, there was no difference between groups in emotion regulation (cognitive reappraisal and expressive suppression), which was linked neither to problem gambling nor to anxiety and depression (except for cognitive reappraisal, which was significantly correlated to anxiety). Our results underline the links between anxiety, depression and problem gambling among poker players. If emotion regulation is involved in problem gambling among poker players, as strongly suggested by data from the literature, the emotion regulation strategies we assessed (cognitive reappraisal and expressive suppression) may not be those involved. Further studies are thus needed to investigate the involvement of other emotion regulation strategies.     

Problem Gambling Family Impacts: Development of the Problem Gambling Family Impact Scale

Although family members of problem gamblers frequently present to treatment services, problem gambling family impacts are under-researched. The most commonly endorsed items on a new measure of gambling-related family impacts [Problem Gambling Family Impact Measure (PG-FIM: Problem Gambler version)] by 212 treatment-seeking problem gamblers included trust (62.5 %), anger (61.8 %), depression or sadness (58.7 %), anxiety (57.7 %), distress due to gambling-related absences (56.1 %), reduced quality time (52.4 %), and communication breakdowns (52.4 %). The PG-FIM (Problem Gambler version) was comprised of three factors: (1) financial impacts, (2) increased responsibility impacts, and (3) psychosocial impacts with good psychometric properties. Younger, more impulsive, non-electronic gaming machine (EGM) gamblers who had more severe gambling problems reported more financial impacts; non-EGM gamblers with poorer general health reported more increased responsibility impacts; and more impulsive non-EGM gamblers with more psychological distress and higher gambling severity reported more psychosocial impacts. The findings have implications for the development of interventions for the family members of problem gamblers.     

Latent Class Analysis of Gambling Activities in a Sample of Young Swiss Men: Association with Gambling Problems,Substance Use Outcomes,Personality Traits and Coping Strategies

The study aimed to identify different patterns of gambling activities (PGAs) and to investigate how PGAs differed in gambling problems, substance use outcomes, personality traits and coping strategies. A representative sample of 4989 young Swiss males completed a questionnaire assessing seven distinct gambling activities, gambling problems, substance use outcomes, personality traits and coping strategies. PGAs were identified using latent class analysis (LCA). Differences between PGAs in gambling and substance use outcomes, personality traits and coping strategies were tested. LCA identified six different PGAs. With regard to gambling and substance use outcomes, the three most problematic PGAs were extensive gamblers, followed by private gamblers, and electronic lottery and casino gamblers, respectively. By contrast, the three least detrimental PGAs were rare or non-gamblers, lottery only gamblers and casino gamblers. With regard to personality traits, compared with rare or non-gamblers, private and casino gamblers reported higher levels of sensation seeking. Electronic lottery and casino gamblers, private gamblers and extensive gamblers had higher levels of aggression-hostility. Extensive and casino gamblers reported higher levels of sociability, whereas casino gamblers reported lower levels of anxiety–neuroticism. Extensive gamblers used more maladaptive and less adaptive coping strategies than other groups. Results suggest that gambling is not a homogeneous activity since different types of gamblers exist according to the PGA they are engaged in. Extensive gamblers, electronic and casino gamblers and private gamblers may have the most problematic PGAs. Personality traits and coping skills may predispose individuals to PGAs associated with more or less negative outcomes.     

Vulnerability and Comorbidity Factors of Female Problem Gambling

This study helps to address a deficiency of gender-specific research into problem gambling. It focuses on the gambling behaviors, family and personal histories and comorbid psychological disorders of 365 female gamblers from across Ontario, Canada, who responded to a mail-in survey. Specifically, this study looks at rates of depression and anxiety, concurrent struggles with other behaviors (such as alcohol and drug use, disordered eating, overspending and criminal activity) and abuse history reported by female gamblers. The reported rates are considerably higher than for the general female population. The findings of this study agree with previous research. They suggest that prevention strategies and treatment practices for female problem gamblers should take into account women’s mental health, addiction and trauma history as contributing factors in the development of problematic gambling.     

The role of natural recovery in alcoholism and pathological gambling

While most pathological gamblers, like most alcohol abusers, recover on their own, it seems likely that they are at greater risk for relapse than those who have been through successful treatment. Accordingly, a substantial increase in treatment resources for pathological gamblers, along with greater efforts to establish the effectiveness of these treatments, ought to receive national priority. If the data on alcohol-abusing self-changers are generalizable to self-changing pathological gamblers, the prognosis for gamblers who stop gambling all together is better than for those who aspire to controlled or nonproblem gambling. While pathological gamblers with comorbid substance abuse are more difficult to treat than those without it, the impact of comorbid substance abuse on the decision by pathological gamblers to change has not yet been explored, although it should be. Similarly, the impact of other Axis I pathology on pathological gambling self-change, especially depression and anxiety, should be thoroughly explored. The most pressing problem in this field appears to be definitional. As a consequence, until consensus is reached on a reliable, valid, and useful classification scheme for pathological gambling, both research and clinical efforts will continue to suffer.     

Pathological Gambling: Influence of Quality of Life and Psychological Distress on Abstinence After Cognitive-Behavioral Inpatient Treatment

The aim of this study is to understand the influence of psychological distress and quality of life on the maintenance of therapy success during a 1 year follow-up in pathological gamblers after inpatient cognitive-behavioral treatment. In a sample of 281 pathological gamblers (247 men, 34 women) the following measures were taken: psychological distress (beginning and end of treatment, and follow up), quality of life and abstinence from gambling. The results showed that relapsed pathological gamblers suffer of higher psychological distress at discharge and of lower quality of life during follow-up than abstinent gamblers. In a mediator analysis the causal relations between the three variables could be clarified: psychological distress has an impact on abstinence during follow-up, and quality of life can be considered a mediator variable for the relation between psychological distress and abstinence from pathological gambling.     

Metacognitions in Problem Gambling

Problem gambling is heterogeneous in nature, ranging in severity from occasional but problematic gambling episodes, to extreme, impulsive and pervasive gambling behaviour. Problem gambling may be accompanied by a sense of impaired control and can give rise to financial, interpersonal, legal and vocational costs for the sufferer, their families and society. This study investigated the relationship among metacognitions, anxiety, depression and gambling in a sample of problem gamblers. A total of 91 individuals attending gambling treatment services completed a battery of self-report instruments that consisted of the Metacognitions Questionnaire 30 (MCQ-30), the Hospital Anxiety and Depression Scale (HADS) and the South Oaks Gambling Scale (SOGS). Correlation analyses showed that anxiety, depression and metacognitions were positively and significantly correlated with both gambling consequences and behaviour. Hierarchical regression analyses indicated that two metacognitive constructs (negative beliefs about thoughts concerning uncontrollability and danger and beliefs about the need to control thoughts) predicted gambling behaviour independently of anxiety and depression. These findings are consistent with the hypothesis that metacognitions play a role in problem gambling.     

Disordered gambling and co-morbidity of psychiatric disorders among college students: An examination of problem drinking,anxiety and depression

We assessed the occurrence of co-morbid psychiatric disorders (i.e., problem drinking, anxiety, and depression) among college students who met the threshold for disordered gambling. The participants included a large sample of undergraduate students (n = 1,430) who were enrolled in an introductory health course at a large, southeastern university in Spring 2011 and completed an online assessment that included scales to assess disordered gambling, problem drinking, anxiety, and depression. We calculated screening scores, computed prevalence rates for each disorder, and calculated Pearson correlations and Chi square tests to examine correlations and co-morbid relationships between the four disorders. Analyses indicated that all disorders were significantly associated (p < .01) except for disordered gambling and anxiety. Because college students who experience disordered gambling (and other psychiatric disorders) are at increased risk of experiencing co-occurring disorders, it might be useful for college health professionals to concurrently screen and intervene for co-occurring disorders.     

Impact of a Casino Opening on Gambling Behaviors of People Engaged in Methadone Maintenance

This study examined gambling behavior in the context of a newly opening casino, comparing disordered gamblers to non-disordered gamblers, in a population of individuals involved in methadone maintenance treatment. Disordered gamblers (N = 50) and non-disordered gamblers (N = 50) were surveyed before and after the opening of a new casino on gambling behaviors, substance use, and psychological symptoms. No statistically significant changes in gambling behaviors were observed for disordered gamblers or non-disordered gamblers across time points; however, non-disordered gamblers demonstrated non-significant increases in horse and dog race betting, electronic games, and casino table games. As expected, disordered gamblers were found to spend significantly more money on electronic games and casino table games (p < 0.05) and demonstrated higher rates of drug use and impulsivity than non-disordered gamblers. The introduction of a new casino did not appear to have a major impact on gambling behaviors of individuals attending methadone maintenance treatment, though the non-significant increases in gambling among non-disordered gamblers may indicate that this population is preferentially impacted by the opening of a new casino. Future investigation into the longer term effects of opening a new casino on this population may be warranted.     

Pathological Gambling,Co-occurring Disorders,Clinical Presentation,and Treatment Outcomes at a University-Based Counseling Clinic

It is the intent of this study to examine the relationship between the number of co-occurring disorders in a sample of pathological gamblers and variables associated with clinical presentation and treatment outcomes. Participants were given screening tools for four common psychological disorders: the hands depression screen, the Mood Disorder Questionnaire, the Carroll-Davidson generalized anxiety disorder screen, and the Sprint-4 PTSD Screen. The number of co-occurring disorders, as indicated by the results of these screening instruments, was compared to severity of gambling problems at outset of treatment, as measured by the NORC diagnostic screen for gambling problems-self administered. The number of co-occurring disorders was also compared to psychosocial functioning at the outset of treatment, as well as level of improvement in psychosocial functioning through treatment. Psychosocial functioning was measured using the Outcome Questionnaire 45 (OQ-45). The number of co-occurring disorders was compared to participant satisfaction with the therapeutic relationship as measured by the working alliance inventory-short form. Results suggest that co-occurring disorders are commonplace among treatment seeking pathological gamblers. Over 86 % of the sample screened positively for at least one of the four targeted psychological disorders. Furthermore, the number of co-occurring disorders was found to be positively related to severity of gambling problems at outset of treatment and negatively related to level of psychosocial functioning at outset of treatment. However, the number of co-occurring disorders was not found to be significantly related to level of improvement in psychosocial functioning through treatment. Overall, those that attended at least six sessions reported significantly improved psychosocial functioning by the end of their sixth session. Finally, the number of co-occurring disorders was not found to be significantly related to participants’ reported level of satisfaction with the therapeutic relationship.     

Psychopathology in pathological gamblers seeking treatment

High rates of psychiatric symptoms have been reported in pathological gamblers. This study of psychiatric comorbidity in pathological gamblers is the first to use structured psychiatric interviews assessing DSM-III-R Axis I and II disorders. The Structured Clinical Interview for DSM III-R (SCID-P, SCID-II) was administered to 40 (25 male, 15 male) pathological gamblers seeking outpatient treatment in Minnesota for gambling, and 64 (41 male, 23 female) controls. High lifetime rates of Axis I (92%) but not Axis II (25%) psychopathology were found in pathological gamblers as compared to controls. No differences between male and female gamblers were found in rates of affective, substance use or personality disorders. Females had higher rates of anxiety disorders and histories of physical/sexual abuse. Possible associations between psychiatric disorders and pathological gambling are discussed along with gambler typologies and implications for future research.The authors wish to gratefully acknowledge the assistance of: Gary Christenson, M.D., Carol Peterson, Ph.D., William Meller, M.D., Thomas Mackenzie, M.D.     

The factorial structure of pathological gambling

Pathological gambling has been characterised by DSM-III-R and DSM-IV as a disorder of impulse control with a proportion of gamblers identified as meeting criteria for a co-morbid diagnosis of Antisocial Personality Disorder. To date, empirical evidence in support of the notion that pathological gamblers as a group manifest elevated traits of impulsivity remains equivocal. Principal components analysis was used to investigate relationships between the constructs of impulsivity, psychopathy, DSM-III-R criteria for Antisocial Personality Disorder, psychological distress, criminal offending behavior and a range of other common psychological measures employed with pathological gamblers. The sample comprised 115 pathological gamblers, 80 consecutive gamblers seeking treatment from a general hospital psychiatric inpatient behavior therapy unit, and 35 volunteer Gamblers Anonymous attenders. Four primary factors were determined: psychological distress, sensation seeking, crime and liveliness, and impulsive-antisocial. Results suggest that pathological gambling consists of a number of discrete and reproducible factorial structures. The impulsive antisocial factor was found to be associated with gambling behavior and indices of poor psychosocial functioning.     

Personality Disorders Among Pathological Gamblers

The objective of this study was to investigate the prevalence of DSM-III-R diagnostic categories of personality disorders in pathological gamblers and to highlight the possible association between such disorders, psychological distress and selected forms of gambling. The Personality Disorders Questionnaire-Revised and a battery of psychometric measures were administered to a sample of 82 consecutive admissions to a behavioral treatment program for gambling problems at an impulse control disorders research unit in Sydney, Australia. Seventy-three percent of subjects were male. The total sample reported having gambled a mean of 15 years of which, on average, the last 6.4 years were associated with problems. Results indicated that the majority of subjects met diagnostic criteria for at least one Personality Disorder (93%), with an average of 4.6 personality disorders per subject. The majority of gamblers evidenced personality disorders from the Cluster B grouping with particularly high rates of borderline, histrionic, and narcissistic personality disorders which were found to be associated with high levels of impulsivity and affective instability. Antisocial personality disorder and narcissistic personality disorder were both found to be possible mediators of the severity of the problem gambling behaviours.