Treatment Utilization of Pathological Gamblers with and without PTSD

This paper represents the first study of treatment utilization among pathological gamblers with and without PTSD. Comorbidity of PG and PTSD is increasingly recognized as an important association, both in its rate and clinical severity. The sample comprised 106 adults from the community (35 with current PG; 36 with current PTSD, and 35 with BOTH). Four areas were addressed: current treatment utilization, lifetime treatment utilization, specific treatments utilized, and satisfaction with treatments. Results indicated that the presence of PTSD was associated with higher treatment utilization (for current utilization, PTSD was higher than PG; and for lifetime, PTSD and PTSD/PG were both higher than PG). Indeed, only a minority of the PG group had ever attended current or lifetime treatment, whereas the majority of PTSD and PTSD/PG had. Yet notably, those with PG who utilized current treatment had no less satisfaction, number of treatment types, nor number of days in treatment than the other two groups. For all three groups, the most common current treatments were individual therapy and psychiatric medications. Study strengths include a rigorously diagnosed sample; an extensive interview-based assessment of treatment utilization, and identification of both current and lifetime utilization. Limitations include the inability to explore change over time or test–retest reliability of responses.     

The Prevalence and Course of Pathological Gambling in the Mood Disorders

The objective of the current investigation was to examine the prevalence of pathological gambling (PG) in a psychiatric sample with a history of mood disorder, and the concurrent and longitudinal association of PG and mood disorder symptoms according to retrospective report. A total of 275 (100 male, 175 female) psychiatric outpatients in Ontario, Canada, with a lifetime diagnosis of a depressive (n = 138) or bipolar disorder (n = 137), completed the Canadian Problem Gambling Index, South Oaks Gambling Screen and Longitudinal Interval Follow-up Evaluation. Correlational and cross-lagged panel analyses evaluated the relation between PG and mood disorder symptom course. The prevalence of PG was elevated within patients with a mood disorder; there was no difference across diagnosis. Concurrent PG and mood disorder symptoms were positively correlated; however, longitudinal analyses revealed no evidence for an association between PG and mood disorder symptoms when symptom stability was taken into account. Despite the elevated prevalence of PG within mood disorders, and the concurrent association between PG and mood disorder symptoms, no direct association was found between these types of pathology. Prospective designs and intervening variables are required to advance understanding of the etiological associations between these disorders.     

Gambling disorder and suicidality within the UK: an analysis investigating mental health and gambling severity as risk factors to suicidality

Greater severities of gambling behaviour and poorer mental health have been identified in the literature as risk factors for suicidality within gambling disorder (GD) populations. This is the first known study within the UK to use empirical data, taken from a UK treatment clinic for GD (National Problem Gambling Clinic, UK) to explore the associations between current suicidality (thoughts and plans) and measures assessing gambling severity and mental health. Self-report data from 122 participants were collected during the intake process at the clinic through a variety of methods including the use of questionnaires and a standardized 90-minute interview with a psychologist. Reported suicidality was high (current suicidal thoughts [28.7%] and plans [6.6%]), yet only one measure of gambling severity (estimated total losses) was found to be inversely associated with suicidality. Indices of poorer mental health were found to have a greater association with suicidality than measures of gambling severity, and a logistic regression analysis identified depressive symptomology and a history of psychiatric disorder in the participants’ family as significant factors associated with suicidality. Overall, within GD populations, factors associated with poorer mental health rather than gambling severity are seemingly a greater risk factor in patients with suicidality.     

Rates and Correlates of Pathological Gambling Among VA Mental Health Service Users

The rate and correlates of diagnosed pathological gambling (PG) among mental health patients in the Veterans Health Administration, the only national system of mental health care, have not been studied. Using fiscal year 2009 (FY2009) VA administrative data, a case–control study compared those with an ICD code of 312.31 (PG) versus those without. The analytic group was limited to 1,102,846 Veterans Affairs (VA) specialty mental health (MH) services users because 94.5% of all those diagnosed with PG in the U.S. VA health system received such services. Chi-square tests and logistic regression assessed associations between demographic and clinical factors and PG diagnosis. The past-year rate of PG diagnosis among veterans treated in specialty MH program was 0.2%, significantly lower than prevalence rates in other treatment samples and the general U.S population, suggesting under-diagnosis and/or a low-income sample. Being female, ages 40–74, and higher income increased the risk of PG diagnosis, as did past-year homelessness (Odds Ratio (OR) = 2.2), alcohol use disorders (OR = 2.8), bipolar disorder (OR = 2.1) and personality disorders (OR = 2.1). Depression, schizophrenia, and anxiety disorders other than PTSD, were also positively associated with PG diagnosis. Drug use disorder had no significant independent association with PG. PTSD, dementia, and living in isolated rural areas conferred reduced risk. More systematic screening and surveillance of PG among MH service users generally, and veterans with heavy alcohol use, severe mental illness, and homelessness specifically, appears warranted.     

Impulsivity and pathological gambling across depressive versus bipolar disorders

Impulsivity has been implicated in the development of pathological gambling (PG); sensation seeking and urgency in particular have predicted gambling pathology in undergraduate and psychiatric samples. In light of the relevance of both depressed and elevated mood to impulsivity and gambling, the components of impulsivity associated with PG across mood disorders warrants investigation. The aim of the current investigation was to examine the association between impulsivity and gambling pathology severity across depressive versus bipolar disorders. A total of 275 participants with lifetime depressive or bipolar disorder completed measures of impulsivity and gambling. Urgency was consistently associated with gambling pathology indicators; lack of perseverance was specifically associated with gambling pathology within participants with depressive disorders. Reckless action during negative mood is associated with gambling pathology across mood disorders, whereas difficulty remaining focused is associated with PG solely within depressive disorders. Impulsivity and affective comorbidity may inform current understanding of PG.     

Treatments for PTSD and Pathological Gambling: What Do Patients Want?

This study explored the treatment preferences of 106 people with posttraumatic stress disorder (PTSD), pathological gambling (PG), or both. It is the first know study of its type for this comorbidity. Sixteen different treatment types were rated, with a broad array of modalities including manualized psychotherapies, medication, self-help, alternative therapies, coaching, and self-guided treatments (use of books and computerized therapy). A consistent finding was that PTSD treatments were rated more highly than PG treatments, even among those with both disorders. Further, of the sixteen treatment types, the sample expressed numerous preferences for some over others. For example, among PG treatments, self-help was the highest-rated. Among PTSD treatments, psychotherapies were the highest-rated; and individual therapy was rated higher than group therapy. For both PG and PTSD, medications were rated lower than other treatment types. Non-standard treatments (i.e., computerized treatment, books, coaching, family therapy, alternative therapies) were generally rated lower than other types. Discussion includes implications for the design of treatments, as well as methodological limitations.     

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.     

Prevalence and Diagnostic Correlates of DSM-IV Pathological Gambling in Psychiatric Outpatients

Studies of the prevalence of pathological gambling (PG) in psychiatric and substance abusing patients suggest that the disorder is not rare. Most studies have been of substance abusers in treatment, and the rate of PG has been found to be several times higher than the rate found in community based epidemiological surveys. However, only one study has examined the prevalence of PG in a heterogeneous sample of patients, and this was a study of psychiatric inpatients. We are not aware of any prior study of the prevalence of PG in a psychiatric outpatient sample. In the present report from the Rhode Island Methods to Improve Diagnosis and Services (MIDAS) project we examined the current and lifetime prevalence of PG in 1,709 psychiatric outpatients interviewed with a semi-structured diagnostic interview that included a module to diagnose DSM-IV PG. Forty (2.3%) patients had a lifetime history of DSM-IV PG, all of whom had at least one other DSM-IV axis I disorder. Patients with PG had significantly more axis I disorders than patients without PG, and had significantly higher rates of bipolar disorder, social phobia, panic disorder with agoraphobia, alcohol use disorder, and other impulse control disorders. Possible reasons for the low prevalence of PG in our sample are discussed.     

Racial Discrimination, Post Traumatic Stress, and Gambling Problems among Urban Aboriginal Adults in Canada

Little is known about risk factors for problem gambling (PG) within the rapidly growing urban Aboriginal population in North America. Racial discrimination may be an important risk factor for PG given documented associations between racism and other forms of addictive behaviour. This study examined associations between racial discrimination and problem gambling among urban Aboriginal adults, and the extent to which this link was mediated by post traumatic stress. Data were collected via in-person surveys with a community-based sample of Aboriginal adults living in a mid-sized city in western Canada (N = 381) in 2010. Results indicate more than 80 % of respondents experienced discrimination due to Aboriginal race in the past year, with the majority reporting high levels of racism in that time period. Past year racial discrimination was a risk factor for 12-month problem gambling, gambling to escape, and post traumatic stress disorder (PTSD) symptoms in bootstrapped regression models adjusted for confounders and other forms of social trauma. Elevated PTSD symptoms among those experiencing high levels of racism partially explained the association between racism and the use of gambling to escape in statistical models. These findings are the first to suggest racial discrimination may be an important social determinant of problem gambling for Aboriginal peoples. Gambling may be a coping response that some Aboriginal adults use to escape the negative emotions associated with racist experiences. Results support the development of policies to reduce racism directed at Aboriginal peoples in urban areas, and enhanced services to help Aboriginal peoples cope with racist events.     

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.     

Subtyping Non-treatment-seeking Problem Gamblers Using the Pathways Model

This study examined whether distinct subgroups could be identified among a sample of non-treatment-seeking problem and pathological/disordered gamblers (PG) using Blaszczynski and Nower’s (Addiction 97:487–499, 2002) pathways model (N = 150, 50% female). We examined coping motives for gambling, childhood trauma, boredom proneness, risk-taking, impulsivity, attention-deficit/hyperactivity disorder (ADHD), and antisocial personality disorder as defining variables in a hierarchical cluster analysis to identify subgroups. Subgroup differences in gambling, psychiatric, and demographic variables were also assessed to establish concurrent validity. Consistent with the pathways model, our analyses identified three gambling subgroups: (1) behaviorally conditioned (BC), (2) emotionally vulnerable (EV), and (3) antisocial-impulsivist (AI) gamblers. BC gamblers (n = 47) reported the lowest levels of lifetime depression, anxiety, gambling severity, and interest in problem gambling treatment. EV gamblers (n = 53) reported the highest levels of childhood trauma, motivation to gamble to cope with negative emotions, gambling-related suicidal ideation, and family history of gambling problems. AI gamblers (n = 50) reported the highest levels of antisocial personality disorder and ADHD symptoms, as well as higher rates of impulsivity and risk-taking than EV gamblers. The findings provide evidence for the validity of the pathways model as a framework for conceptualizing PG subtypes in a non-treatment-seeking sample, and underscore the importance of tailoring treatment approaches to meet the respective clinical needs of these subtypes.     

Clinical Gender Differences Among Adult Pathological Gamblers Seeking Treatment

This study aimed to examine the gender-related differences in demographics, gambling measures, psychological functioning, and motivation for therapy in an outpatient sample of pathological gamblers seeking treatment. Participants in this multisite study included 103 adult outpatients (51 women and 52 men) meeting current DSM-IV-TR criteria for PG. Logistic regression was used to examine if gender was related together to categorical and continuous independent variables. Female gamblers were older than men and more likely to be divorced or widowed and to have a lower annual income. Women became more dependent on bingo and men on slot machines. Gambling motivation and the course of illness for both sexes were also different. Female gamblers were more anxious and with a poorer self-esteem than male gamblers and more affected by depressive symptoms; in turn, men were more impulsive and higher sensation seekers than women and more affected by drug/alcohol abuse. The 68.6% of female gamblers reported being victims of intimate partner violence. There were no gender differences about the motivation for treatment. Future research should examine gambling behaviors and psychological functioning and suggest treatment approaches to address specific goals according to these gender-related differences.     

Gambling Type,Substance Abuse,Health and Psychosocial Correlates of Male and Female Problem Gamblers in a Nationally Representative French Sample

Many studies carried out on treatment-seeking problem gamblers (PG) have reported high levels of comorbid substance use disorders, and mental and physical health problems. Nevertheless, general population studies are still sparse, most of them have been carried out in the United States or Canada, and gender differences have not always been considered. Thus, the aim of this study was to describe the type of games, and psychological and physical correlates in male and female PG in a nationally representative French sample. The total sample studied involved 25,647 subjects aged 15–85 years, including 333 PG and 25,314 non-problem gamblers (NPG). Data were extracted from a large survey of a representative sample of the French general population. They were evaluated for sociodemographic variables, gambling behavior, type of gambling activity, substance use, psychological distress, body mass index, chronic disease, and lack of sleep. Overall, there were significant differences between PG and NPG in gender, age, education, employment and marital status, substance use disorders (alcohol, tobacco, cannabis, cocaine and heroin), psychological distress, obesity, lack of sleep and type of gambling activity. Although male and female PG had different profiles, the gambling type, especially strategic games, appeared as an important variable in the relationship between gender and problem gambling. This research underlines the importance of considering gender differences and gambling type in the study of gambling disorders. Identifying specific factors in the relationship between gender, gambling type and gambling problems may help improve clinical interventions and health promotion strategies.     

An Exploratory Study of Clinical Measures Associated with Subsyndromal Pathological Gambling in Patients with Binge Eating Disorder

Both binge eating disorder (BED) and pathological gambling (PG) are characterized by impairments in impulse control. Subsyndromal levels of PG have been associated with measures of adverse health. The nature and significance of PG features in individuals with BED is unknown. Ninety-four patients with BED (28 men and 66 women) were classified by gambling group based on inclusionary criteria for Diagnostic and Statistical Manual-IV (DSM-IV) PG and compared on a range of behavioral, psychological and eating disorder (ED) psychopathology variables. One individual (1.1% of the sample) met criteria for PG, although 18.7% of patients with BED displayed one or more DSM-IV criteria for PG, hereafter referred to as problem gambling features. Men were more likely than women to have problem gambling features. BED patients with problem gambling features were distinguished by lower self-esteem and greater substance problem use. After controlling for gender, findings of reduced self-esteem and increased substance problem use among patients with problem gambling features remained significant. In patients with BED, problem gambling features are associated with a number of heightened clinical problems.     

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.     

Violence and hostility among families of Vietnam veterans with combat-related posttraumatic stress disorder

The current study provides a portrait of emotional-behavioral functioning within a small sample of Vietnam veterans with combat-related posttraumatic stress disorder (PTSD), their partners, and older adolescent and adult children. Veterans, their partners and children reported moderate-low to moderate-high levels of violent behavior. In addition, partner and veteran hostility scores were elevated relative to gender and age matched norms. Partners also reported heightened levels of psychological maltreatment by veterans. Veterans' combat exposure was positively correlated with hostility and violent behavior among children but unrelated to partner variables. Veterans' reports of PTSD symptoms were positively associated with reports of hostility and violence among children, and hostility and general psychological distress among partners. Veterans' violent behavior was also positively correlated with children's violent behavior, but did not yield significant correlations with other child or partner variables. Findings are discussed in relation to prior work and directions for future research are addressed.     

Gambling in a National U.S. Veteran Population: Prevalence,Socio-demographics,and Psychiatric Comorbidities

This study aimed to examine associations between gambling level and clinically relevant measures, including psychiatric disorders and suicidality, in a nationally representative sample of U.S. veterans. Data on 3157 U.S. veterans were analyzed from the National Health and Resilience in Veterans Study. Chi square tests and analyses of variance were used to assess associations between gambling level, and demographic, military, and personality characteristics. Multinomial logistic regressions using stepwise selection were used to identify independent correlates of recreational gambling and at-risk/problem gambling (ARPG). A significant proportion of U.S. veterans engage in gambling activities, with 35.1% gambling recreationally and 2.2% screening positive for ARPG. ARPG was associated with greater prevalence of substance use, anxiety, and depressive disorders, as well as with a history of physical trauma or sexual trauma, having sought mental health treatment (particularly from the Veterans Administration), and minority group status. A similar pattern was found associated with recreational gambling, although the magnitudes of association were lower relative to ARPG. Younger age, self-identifying as black, being retired, and trauma burden were associated with increased odds of ARPG, whereas older age, being single, non-white Hispanic, being retired or not having a job, screening positive for alcohol- and drug-use disorders, and trauma burden were associated with increased odds of recreational gambling. More than a third of U.S. veterans gamble recreationally, with a significant minority (2.2%) screening positive for ARPG. Both recreational and ARPG were associated with elevated trauma burden and psychiatric comorbidities. These findings underscore the importance of routine screening and monitoring of gambling severity, and interventions for ARPG in this population.     

Disordered Gambling Prevalence: Methodological Innovations in a General Danish Population Survey

We study Danish adult gambling behavior with an emphasis on discovering patterns relevant to public health forecasting and economic welfare assessment of policy. Methodological innovations include measurement of formative in addition to reflective constructs, estimation of prospective risk for developing gambling disorder rather than risk of being falsely negatively diagnosed, analysis with attention to sample weights and correction for sample selection bias, estimation of the impact of trigger questions on prevalence estimates and sample characteristics, and distinguishing between total and marginal effects of risk-indicating factors. The most significant novelty in our design is that nobody was excluded on the basis of their response to a ‘trigger’ or ‘gateway’ question about previous gambling history. Our sample consists of 8405 adult Danes. We administered the Focal Adult Gambling Screen to all subjects and estimate prospective risk for disordered gambling. We find that 87.6% of the population is indicated for no detectable risk, 5.4% is indicated for early risk, 1.7% is indicated for intermediate risk, 2.6% is indicated for advanced risk, and 2.6% is indicated for disordered gambling. Correcting for sample weights and controlling for sample selection has a significant effect on prevalence rates. Although these estimates of the ‘at risk’ fraction of the population are significantly higher than conventionally reported, we infer a significant decrease in overall prevalence rates of detectable risk with these corrections, since gambling behavior is positively correlated with the decision to participate in gambling surveys. We also find that imposing a threshold gambling history leads to underestimation of the prevalence of gambling problems.     

Prevalence of Problem and Pathological Gambling in Parkinson’s Disease

Pathological gambling (PG) has been identified in patients with Parkinson’s disease (PD) treated with dopamine agonists suggesting that dysregulation of brain dopaminergic activity may contribute to the development of gambling problems. The current study was undertaken to further establish the prevalence of problem and PG in patients with PD, identify any clinical correlates, and determine if psychiatric or substance use co-morbidity contributes to the increased prevalence of problem and PG. A cross-sectional survey of 140 serially recruited moderate to severe PD patients was undertaken utilizing the Canadian Problem Gambling Index, Alcohol Use Disorders Identification Test, Drug Abuse Screening Test, Beck Depression Inventory, Beck Anxiety Inventory, and Mini-Mental State Exam augmented by chart review, completed over an 8 month period. The 12 month prevalence of problem and PG in PD was 9.3% compared to 1.6% in the general population within a comparably aged sample. The increased prevalence of problem and PG in the PD group was related to dopamine agonist use and younger age, but not co-morbidity. Most subjects with problem and PG reported their gambling increased after being diagnosed with PD and starting treatment. The results suggest that brain dopaminergic activity is involved in the underlying neurobiology of problem and PG.     

The association between comorbidity and outcome in pathological gambling: a prospective follow-up of recent quitters

A naturalistic sample of pathological gamblers (N = 101) who recently quit gambling was followed prospectively for a year (follow-up rate 80%). Lifetime mood disorders were identified in 61% of participants and 73% and 48% had lifetime alcohol use and drug use disorders, respectively. Current prevalence rates, however, were much lower. Current mood disorders were found for 20% and 7% had a current alcohol disorder and 7% a current drug use disorder. Age of onset for substance use disorders was earlier than gambling disorders but mood disorders were equally likely to predate or follow gambling disorders. Lifetime mood disorder was associated with a longer time to achieve 3 months of stable abstinence. Participants who were currently in treatment or attending Gamblers Anonymous and the small number of participants with current alcohol disorders were also more likely to achieve abstinence earlier. The results underscore the importance of increasing our understanding of the role of comorbid disorders in the recovery process from gambling problems.