The Role of Metacognition in Pathological Gambling: A Mediation Model

Pathological gambling involves multitudinous costs related to financial, legal, and public health care aspects, as well as to specific psychological disorders. Despite the overall evidence suggesting that comorbid disorders represent a risk factor for pathological gambling, there is scant evidence on the appropriate treatments for gamblers with such disorders. In this context, metacognitive therapy is an interesting approach because it considers psychological disorders as a result of the activation of perseverative cognitive processes and attentional strategies in response to inner events. Several studies report that metacognition is associated with different psychological problems. This study investigated the relationship among comorbid disorders, metacognition, and pathological gambling. 69 pathological gamblers at the first hospital admission and 58 controls drawn from general population (matched for age, gender, education) completed a battery of self report instruments: Symptom Checklist-90-R, Metacognition Questionnaire 30, South Oaks Gambling Scale. Compared to controls, pathological gamblers showed higher level of comorbid symptomatology and metacognition. Correlation analyses showed that: comorbid symptomatology and metacognition were positively and significantly correlated with pathological gambling; metacognition was positively and significantly associated with comorbid symptomatology. Mediation analysis indicated that dysfunctional metacognitive strategies could have an indirect effect on pathological gambling mediated by concurrent psychological disorders. These findings provide some implications for gambling treatment programs: pathological gamblers should be screened for psychiatric disorders, and metacognitive therapy could be considered a correct treatment of pathological gamblers. Metacognitive therapy might lead to the reduction of the pathological gambling by the diminishing of the concurrent psychological disorders.     

Treatment of Female Pathological Gambling: The Efficacy of a Cognitive-Behavioural Approach

Given that a substantial proportion of current pathological gamblers are female, it is evident that women are underrepresented in the treatment outcome literature. The current study was designed to redress the limited information on the treatment of female pathological gambling. Although the use of cognitive-behavioural therapy is the most highly recommended approach as ‘best practice’ for the treatment of pathological gambling, no attempt to date has been made to evaluate the efficacy of this approach for female pathological gambling. Nineteen female pathological gamblers with electronic gaming machine problems were treated with a cognitive-behavioural program. While pathological gamblers placed on a waiting list did not show significant improvement on gambling behaviour and psychological functioning measures, the female pathological gamblers showed significant improvement on these measures over the treatment period, and maintained this improvement at the 6-month follow-up evaluation. By the completion of the follow-up period, 89% of participants no longer met diagnostic criteria for pathological gambling. Although further scientific demonstration and replication are required, the outcomes of this study indicate that the therapy that is considered ‘best practice’ in the treatment of pathological gambling is effective for female pathological gambling.     

The effect of compliance-improving interventions on the cognitive-behavioural treatment of pathological gambling

This exploratory study investigated the effect of interventions designed to improve compliance and reduce dropout rates during the outpatient treatment of pathological gambling at a University-based gambling treatment clinic. Forty subjects (29 males, 11 females, mean age = 37.6) meeting DSM-IV criteria (APA, 1994) for pathological gambling were randomly assigned to either a cognitive-behavioural treatment or a cognitive-behavioural treatment combined with interventions designed to improve treatment compliance. Compliance was indicated by the completion of all treatment sessions. Outcome measures were DSM-IV criteria assessed by structured clinical interview, South Oaks Gambling Screen scores, and percentage of income gambled. Logistic regression analyses identified pretreatment characteristics predicting compliance and outcome. Compliance-improving interventions significantly reduced dropout rates, resulting in superior outcomes at posttreatment compared to the cognitive behavioural treatment alone. At 9-month follow-up, there was no difference in outcome between treatments, although both produced clinically significant change. Comorbid problem drinking, drug use, and problem gambling duration predicted poor compliance. Poor outcome was predicted by comorbid problem drinking. The clinical implications of these results are discussed in light of the exploratory nature of the study and the need for future research to address compliance, outcome, and comorbidity issues.     

Gambling Motives: Do They Explain Cognitive Distortions in Male Poker Gamblers?

Gambling behavior is partly the result of varied motivations leading individuals to participate in gambling activities. Specific motivational profiles are found in gamblers, and gambling motives are closely linked to the development of cognitive distortions. This cross-sectional study aimed to predict cognitive distortions from gambling motives in poker players. The population was recruited in online gambling forums. Participants reported gambling at least once a week. Data included sociodemographic characteristics, the South Oaks Gambling Screen, the Gambling Motives Questionnaire-Financial and the Gambling-Related Cognition Scale. This study was conducted on 259 male poker gamblers (aged 18–69 years, 14.3% probable pathological gamblers). Univariate analyses showed that cognitive distortions were independently predicted by overall gambling motives (34.8%) and problem gambling (22.4%) (p < .05). The multivariate model, including these two variables, explained 39.7% of cognitive distortions (p < .05). The results associated with the literature data highlight that cognitive distortions are a good discriminating factor of gambling problems, showing a close inter-relationship between gambling motives, cognitive distortions and the severity of gambling. These data are consistent with the following theoretical process model: gambling motives lead individuals to practice and repeat the gambling experience, which may lead them to develop cognitive distortions, which in turn favor problem gambling. This study opens up new research perspectives to understand better the mechanisms underlying gambling practice and has clinical implications in terms of prevention and treatment. For example, a coupled motivational and cognitive intervention focused on gambling motives/cognitive distortions could be beneficial for individuals with gambling problems.     

Examining DSM-IV Criteria for Pathological Gambling: Psychometric Properties and Evidence from Cognitive Biases

We examined the DSM-IV criteria for pathological gambling as assessed with the DSM-IV-based Diagnostic Interview for Gambling Severity (DIGS; Winters, Specker, & Stinchfield, 2002). We first analyzed the psychometric properties of the DIGS, and then assessed the extent to which performance on two judgment and decision-making tasks, the Georgia Gambling Task (Goodie, 2003) and the Iowa Gambling Task (Bechara, Damasio, Damasio, & Anderson, 1994), related to higher reports of gambling pathology. In a sample of frequent gamblers, we found strong psychometric support for the DSM-IV conception of pathological gambling as measured by the DIGS, predictive relationships between DIGS scores and all cognitive performance measures, and significant differences in performance measures between individuals with and without pathological gambling. Analyses using suggested revisions to the pathological gambling threshold (Stinchfield, 2003) revealed that individuals meeting four of the DSM-IV criteria aligned significantly more with pathological gamblers than with non-pathological gamblers, supporting the suggested change in the cutoff score from five to four symptoms. Discussion focuses on the validity of the DSM-IV criteria as assessed by the DIGS and the role of cognitive biases in pathological gambling.     

Description and pre-post evaluation of a telephone and Internet based treatment programme for pathological gambling in Norway: a pilot study

Although the effectiveness of treatments for pathological gamblers is gaining support, only 10% of pathological gamblers seek treatment. Providing treatment via the Internet may lower the thresholds for treatment seeking. A new telephone and Internet based treatment programme for pathological gamblers is presented in this article, along with a pre-post evaluation of the programme. The participants (N = 112) were problem gamblers who were either self-referred or referred by their general practitioner. Data from post-treatment and 3-month follow-up are evaluated. The results suggest that using Internet and telephone-assisted treatment interventions can significantly reduce symptoms of pathological gambling (measured by the South Oaks Gambling Screen – Revised). The intervention was also associated with improvement on cognitive distortions, measured by the Gamblers Belief Questionnaire, and general psychological distress and psychopathology as measured by the Symptom Checklist-90-Revised. Although Internet-based treatment programmes have been suggested to have advantages compared to traditional face-to-face therapy, research in this area is scarce. This pilot study contributes to the growing literature in this area, and provides tentative support for the effectiveness of Internet based treatment interventions for pathological gamblers.     

Psychological characteristics of volunteers in studies on gambling

Advertisements were published in local newspapers asking for volunteers to participate in a study on gambling. A battery of eleven questionnaires was mailed to the subjects assessing pathological gambling behavior, sociodemographic characteristics, motivation to gamble, erroneous perceptions about gambling, superstitious beliefs, depressive symptoms, social anxiety and avoidance, alcohol and drug abuse, problem-solving skills, and marital satisfaction. Subjects received $10 when they returned the questionnaires fully completed. Response rate was over 95%. Surprisingly, 29% of the respondents met the criterion for probable pathological gambling (score of 5 or more on the SOGS) and a further 16% were identified as potential pathological gamblers (scores of 3 or 4). The potential and probable pathological gamblers showed significant differences on motivational and cognitive variables related to gambling compared to those subjects who showed no signs of pathological gambling. The probable pathological gamblers reported significantly more signs of poor psychosocial functioning than the other two groups, including depressive symptoms, poor problem orientation, drug and alcohol abuse, and interpersonal conflict. The practical and theoretical implications of these results are discussed.     

The Development of an Internet-Based Treatment for Problem Gamblers and Concerned Significant Others: A Pilot Randomized Controlled Trial

Problem gambling creates significant harm for the gambler and for concerned significant others (CSOs). While several studies have investigated the effects of individual cognitive behavioral therapy (CBT) for problem gambling, less is known about the effects of involving CSOs in treatment. Behavioral couples therapy (BCT) has shown promising results when working with substance use disorders by involving both the user and a CSO. This pilot study investigated BCT for problem gambling, as well as the feasibility of performing a larger scale randomized controlled trial. 36 participants, 18 gamblers and 18 CSOs, were randomized to either BCT or individual CBT for the gambler. Both interventions were Internet-delivered self-help interventions with therapist support. Both groups of gamblers improved on all outcome measures, but there were no differences between the groups. The CSOs in the BCT group lowered their scores on anxiety and depression more than the CSOs of those randomized to the individual CBT group did. The implications of the results and the feasibility of the trial are discussed.     

Experiences and Perceptions of Problem Gamblers on Cognitive and Exposure Therapies When Taking Part in a Randomised Controlled Trial: A Qualitative Study

In South Australia (SA) problem gambling is mainly a result of the widespread availability of electronic gaming machines. A key treatment provider in SA offers free cognitive and behavioural therapy (CBT) to help-seeking problem gamblers. The CBT program focuses on the treatment of clients’ urge to gamble using exposure therapy (ET) and cognitive therapy (CT) to restructure erroneous gambling beliefs. The aim of this study was to explore treatment specific and non-specific effects for CT alone and ET alone using qualitative interviews. Interviewees were a sub-sample of participants from a randomised trial that investigated the relative efficacy of CT versus ET. Findings revealed that all interviewees gained benefit from their respective therapies and their comments did not appear to favour one therapy over another. Both treatment specific and treatment non-specific effects were well supported as playing a therapeutic role to recovery. Participants’ comments in both therapy groups suggested that symptom reduction was experienced on a gambling related urge–cognition continuum. In addition to symptom improvement from therapy-specific mechanisms, ET participants described a general acquisition of “rational thought” from their program of therapy and CT participants had “taken-over” their gambling urges. The findings also highlighted areas for further improvement including therapy drop-out.     

Illusion of control and gambling in children

This paper outlines a cognitive theory to explain persistent gambling behavior. The major thesis is that people who persist in gambling in the face of significant losses do so, in part, because they misattribute the locus of control of the outcome of gambles to themselves rather than a random environmental event. Stated differently, this implies that people who are involved in gambling situations and win, find ways to take responsibility for winning, and that people will seek to exert control and direction over future gambles as well. This explanation is not intended to totally supplant existing theoretical analyses of persistent gambling such as models of addictive processes, or psychodynamic motivations, but rather to add a cognitive process dimension. Indeed, the different models are not mutually exclusive. In all probability, parts of each are useful in explaining pathological gambling. This study suggests that more importance and more research is need in the cognitive area to fully understand pathological gambling.     

Gambling,Drinking and Quality of Life: Evidence from Macao and Australia

The investigation of the interface between psychological constructs, compulsive consumption of alcohol and pathological gambling is an important avenue for development of future initiatives in social marketing or prevention programs. This cross-cultural study attempts to bridge the gap in literature by providing an evaluation of the predictive ability of psychological variables such as gambling urge, gambling-related erroneous cognitions and comorbid alcohol consumption on pathological gambling behaviour and its impact on overall quality of life indicators. Participants consist of 445 Macao and Australian young adults (Mean age = 23 years). Results indicate that probable pathological gamblers as compared with non-gamblers reported significantly lower quality of life in all domains—physical health, psychological well-being, social relationships and environment. Adults who drank more alcohol and have stronger erroneous cognitions evidenced higher pathological gambling behavior. Our research model fits both cohorts and interestingly, erroneous gambling-related cognitions serve as a full mediator for the predictive relationship between gambling urge and pathological gambling in the Macao sample, but serve as a partial mediator in the Australian sample. Targeting erroneous cognitions in future social marketing or preventive campaigns should demonstrate to be an important strategy in reducing the effects of urge to gamble among at-risk individuals. Further implications for the industry, marketing and governmental strategies are discussed.     

Discharge planning with pathological gamblers: An ongoing process

Criteria for a diagnosis of pathological gambling include gambling related disruption or damage in legal, financial, family, vocational and personal areas. Therefore, discharge planning with a pathological gambler is much more than a placement problem at the end of an inpatient treatment stay. In fact, discharge planning incorporates and continues a holistic treatment approach at the Cleveland Veterans Administration Medical Center, Brecksville Gambling Treatment Program. This paper discusses all areas of the gambler's life which have been disrupted and need to be considered when working on a discharge and recovery plan.     

Gambling-Related Cognitive Biases and Pathological Gambling Among Youths, Young Adults, and Mature Adults in Chinese Societies

This study investigated the extent to which gambling-related cognitive biases would associate with various levels of gambling pathology among 2,835 youths, 934 young adults, and 162 mature adults in Chinese societies. Results showed that gambling cognitive biases, especially biases in perceived inability to stop gambling and positive gambling expectancy, were salient correlates of pathological gambling across the three age cohorts. Analyses of variances on total cognitive biases also showed a gambling pathology main effect and an age cohort × gambling pathology 2-way interaction effect. It was noted that the probable pathological gambling group had greater cognitive biases than the probable problem gambling group, which in turn had greater cognitive biases than the non-problem gambling group. In the non-problem gambling group, mature adults had greater cognitive biases than youths and young adults, but this pattern was reversed in the probable problem gambling group. In the probable pathological gambling group, youths had greater cognitive biases than young and mature adults. Specific categories of cognitive biases also varied according to gender and gambling pathology. While men as compared to women in the non-problem and probable problem gambling groups reported a greater bias in their perceived inability to stop gambling, no significant gender difference in this bias was found in the probable pathological gambling group. Men generally had greater perceived gambling expectancy bias than women.     

Social Costs of Gambling in the Czech Republic 2012

Evidence about social costs of gambling is scarce and the methodology for their calculation has been a subject to strong criticism. We aimed to estimate social costs of gambling in the Czech Republic 2012. This retrospective, prevalence based cost of illness study builds on the revised methodology of Australian Productivity Commission. Social costs of gambling were estimated by combining epidemiological and economic data. Prevalence data on negative consequences of gambling were taken from existing national epidemiological studies. Economic data were taken from various national and international sources. Consequences of problem and pathological gambling only were taken into account. In 2012, the social costs of gambling in the Czech Republic were estimated to range between 541,619 and 619,608 thousands EUR. While personal and family costs accounted for 63% of all social costs, direct medical costs were estimated to range from 0.25 to 0.28% of all social costs only. This is the first study which estimates social costs of gambling in any of the Central and East European countries. It builds upon the solid evidence about prevalence of gambling related problems in the Czech Republic and satisfactorily reliable economic data. However, there is a number of limitations stemming from assumptions that were made, which suggest that the methodology for the calculation of the social costs of gambling needs further development.     

Differences in Cognitive Distortions Between Pathological and Non-Pathological Gamblers with Preferences for Chance or Skill Games

Cognitive distortions have been thought to play an important role in the development and maintenance of pathological gambling. The present study investigated whether severity of gambling problems and gamblers’ preference for chance or skill games were related to two sub-factors of cognitive distortions as measured by the Gamblers Belief Questionnaire: Luck/Perseverance, which reflects an individual’s perception that chance is favorable to him/her, and Illusion of Control, which reflects an individual’s perception that his/her behavior influences chance occurrences. Participants (N = 166) were recruited from a race track (n = 79), off-course betting facilities (n = 50) and from an online treatment program for problem gamblers (n = 49). Gambling severity was measured by the South Oaks Gambling Screen, and 73 were classified as pathological gamblers whereas 93 were classified as non-pathological gamblers. The present study supports previous proposals that cognitive distortions are core processes related to gambling behavior as pathological gamblers reported more cognitive distortions than did non-pathological gamblers. A preference for skill games was also associated with greater Illusion of Control compared to a preference for chance games. For gamblers preferring skill games there were no differences in Luck/Perseverance or Illusion of Control between pathological and non-pathological gamblers.     

Impaired Probability Estimation and Decision-Making in Pathological Gambling Poker Players

Poker has gained tremendous popularity in recent years, increasing the risk for some individuals to develop pathological gambling. Here, we investigated cognitive biases in a computerized two-player poker task against a fictive opponent, among 12 pathological gambling poker players (PGP), 10 experienced poker players (ExP), and 11 inexperienced poker players (InP). Players were compared on probability estimation and decision-making with the hypothesis that ExP would have significantly lower cognitive biases than PGP and InP, and that the groups could be differentiated based on their cognitive bias styles. The results showed that ExP had a significantly lower average error margin in probability estimation than PGP and InP, and that PGP played hands with lower winning probability than ExP. Binomial logistic regression showed perfect differentiation (100%) between ExP and PGP, and 90.5% classification accuracy between ExP and InP. Multinomial logistic regression showed an overall classification accuracy of 23 out of 33 (69.7%) between the three groups. The classification accuracy of ExP was higher than that of PGP and InP due to the similarities in probability estimation and decision-making between PGP and InP. These impairments in probability estimation and decision-making of PGP may have implications for assessment and treatment of cognitive biases in pathological gambling poker players.     

The prevalence of problem and pathological gambling: A critical analysis

Prevalence of pathological gambling refers to the percentage of cases of pathological gambling occurring in the community at a given time. Prevalence studies conducted in different principalities throughout the world are reviewed, and it is found that none of them conforms to this definition of prevalence. The major error in all but the most recent surveys conducted is identified as the use of questions which ask whether gambling-related problems have ever occurred rather than whether they are currently occurring. This error will lead to an over-estimation of the prevalence of pathological gambling in society. The second major error identified in nearly all studies involves the accuracy of the screens being used to assess whether or not an individual is a pathological gambler. Concerns about the efficiency of the South Oaks Gambling Screen have not yet been satisfactorily resolved. None-the-less, the widespread use of the South Oaks Gambling Screen has made a valuable contribution to international comparisons of prevalence studies. Future work that explores the emerging relationship between levels of personal expenditure on gambling, types of gambling product and gambling-related problems are recommended.     

In Search of Executive Impairment in Pathological Gambling: A Neuropsychological Study on Non-treatment Seeking Gamblers

Pathological gambling is characterized by a persisting maladaptive and recurrent behavior with severe social and psychological consequences. There is evidence of strong comorbidity with psychiatric manifestations as well as cognitive mainly involving executive functions. This study aimed to investigate impairment in executive functions and working memory, and personality traits in a sample of Greek gamblers. Twenty-four men involved in various gambling activities were recruited from ecological settings as probable pathological gamblers. They were assessed with a comprehensive neuropsychological battery involving several executive tasks, the Zuckerman–Kuhlman Personality Questionnaire, the Hospital Anxiety Depression Scale, and the Difficulties in Emotion Regulation Scale. An age- and education-level matched group of 21 men without history of habitual gambling served as controls. As a group, gamblers displayed significantly lower scores on indices of inhibition, decision making and self-reported emotional awareness, and scored higher on impulsivity/sensation seeking personality traits. Notably, gamblers scored similarly or significantly higher on measures of verbal and visuospatial working memory, cognitive flexibility, processing speed, verbal fluency, and sustained attention. Overall, we argue that gamblers do present with specific cognitive deficits, but there is no evidence for a generalized executive impairment, and further stress the importance of investigating cognitive, personality, and psychiatric aspects of gambling on the basis of an ecologically valid sampling.     

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.     

The Relationship Between Anxiety, Smoking, and Gambling in Electronic Gaming Machine Players

Given higher reported rates of smoking in populations under treatment for problem gambling, in a sample of 81 Electronic Gaming Machine players, this study considered whether: 1) there were relationships between tobacco dependency and problem gambling, and 2) a common mechanism such as negative affect was involved. The untreated sample comprised eighty-one Electronic Gaming Machine players that completed the South Oaks Gambling Screen, the Tobacco Dependence Scale and the State-Trait Anxiety Inventory. There was a relationship between smoking status and scores on the South Oaks Gambling Screen, and negative affect contributed to both gambling problems and tobacco dependence. It was suggested that gambling problems and tobacco dependence have similar characteristics. The data has implications for treatment and anti-smoking legislation in gaming venues.