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.     

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.     

Correlates of Depressive Symptom Severity in Problem and Pathological Gamblers in Couple Relationships

Problem and pathological gamblers (PPG) often suffer from depressive symptoms. Gambling problems have negative consequences on multiple aspects of gamblers’ lives, including family and marital relationships. The objectives of the current study were to (1) replicate the results of studies that have suggested a stronger and more significant relationship between gambling and depression in PPG than in non-problem gamblers (NPG) and (2) explore specific correlates of depressive symptom severity in PPG in couple relationships. Variables demonstrated to be significantly correlated with depressive symptoms in the general population were selected. It was hypothesized that gender, age, gambler’s mean annual income, perceived poverty, employment status, clinical status (i.e., problem or pathological gambler versus non-problem gambler), trait anxiety, alcoholism, problem-solving skills, and dyadic adjustment would be significant predictors of depressive symptoms. Sixty-seven PPG were recruited, primarily from an addiction treatment center; 40 NPG were recruited, primarily through the media. Results revealed that PPG reported significantly greater depressive symptoms than did NPG. Further, elevated trait anxiety and poor dyadic adjustment were demonstrated to be significant and specific correlates of depressive symptom severity in PPG. These findings contribute to the literature on depressive symptomatology in PPG in relationships, and highlight the importance of the influence of the couple relationship on PPG.     

Metacognition in Pathological Gambling and Its Relationship with Anxious and Depressive Symptomatology

Gambling disorder is associated with elevated comorbidity with depressive and anxious disorders, and one variable that might help in the understanding of this association is metacognition. In the present study, the relationship between gambling and metacognition and the mediating role of metacognition in the relationship between gambling and depressive and anxious symptomatology were assessed. The sample comprised 124 pathological gamblers from centers that assist pathological gamblers and 204 participants from the general population. The results showed that pathological gamblers had higher levels of depressive and anxious symptomatology. Additionally, pathological gamblers had higher scores for positive beliefs about worry, negative beliefs of uncontrollability and danger, and beliefs about the need to control thoughts; these factors were also positively correlated with depressive and anxious symptomatology. Metacognition also fully mediated the association between gambling and depressive and anxious symptomatology. These results suggest that metacognition could contribute to explaining gambling disorder and the symptomatology associated with it.     

Psychological Distress as an Indicator of Co-Occurring Psychopathology among Treatment-Seeking Disordered Gamblers

Disordered gamblers frequently present with concurrent anxiety, depressive, personality, and substance use disorders, which may complicate treatment. Although there is a need for a thorough assessment, some questionnaires may prove lengthy for clients and clinicians. Thus, there is a need for brief screens for identifying co-occurring psychopathology. The present study sought to examine whether a brief, self-report measure of psychological distress could indicate the presence of co-occurring psychopathology among an outpatient sample of disordered gamblers. At intake, 69 participants completed self-report measures of distress and gambling symptomatology, a personality inventory, and a structured interview for the diagnostic criteria for disordered gambling. Gamblers with greater elevations of psychological distress evidenced greater severity of gambling pathology. Clinically significant elevations were present for symptoms of depression, deviancy, and anxiety, but not substance abuse. Greater scores of psychological distress significantly predicted elevations of depression, deviancy, and anxiety. Sensitivity and specificity were evaluated and the findings supported that an average psychological distress score of 16 corresponded with the presence of co-occurring psychopathology. Clinicians treating disordered gamblers should consider screening for co-occurring psychopathology with brief, self-report measures of psychological distress.     

Adaptive and Maladaptive Coping Strategies in Adult Pathological Gamblers and Their Mediating Role with Anxious-Depressive Symptomatology

Coping plays a central role in the appearance and persistence of pathological gambling. Anxious and depressive symptomatology also influence pathological gambling and are related to coping. This study aimed to analyze pathological gamblers’ coping strategies and styles, as well as associated anxious and depressive symptomatology. The study sample included 167 male pathological gamblers (mean age = 39.29 years) and 107 non-gamblers (mean age = 33.43 years). Measures of gambling, coping, and anxious and depressive symptomatology were used. Results showed that pathological gamblers’ scored higher in all the maladaptive coping strategies, problem- and emotion-focused disengagement, and disengagement subscales. These subscales also correlated with pathological gambling, and anxious and depressive symptomatology. Pathological gamblers also scored higher in emotional expression and emotion-focused engagement, with no differences in the rest of the adaptive coping strategies. Coping was also found to predict pathological gambling and anxious and depressive symptomatology. It was found that coping mediated the relationship between pathological gambling and anxious symptomatology when controlling for the effect of age. Specifically, social withdrawal and disengagement stood out as mediators. These results provide practical information for use in clinical settings with people diagnosed with pathological gambling.     

Does gambling type moderate the links between problem gambling,emotion regulation,anxiety, depression and gambling motives

The aim of this study is to assess the link between emotion regulation, depression, anxiety and gambling motives among a population of regular gamblers, distinguishing between strategic and chance game players. We recruited 287 regular gamblers online, including both problem (PG) and non-problem gamblers (NPG). All participants completed online questionnaires to screen for problem gambling (SOGS) and to assess emotion regulation (ERQ), anxiety and depression (HADS) and gambling motives (GMQ-F). In this sample, 33.4% of participants were PG. PG scored significantly higher than NPG on the GMQ-F (except for the social subscale) and HADS, but not in ERQ. Gamblers who played both strategic and chance games displayed more frequent and severe gambling problems and had higher depression and anxiety scores than those playing only strategic games. Overall, enhancement and financial motives and depression significantly predicted PG. Finally, the study found that gambling type moderates the relationship between problem gambling and expressive suppression, depression and gambling motives. The results show the intricate relationship between gambling motives and psychiatric symptoms (in particular, depression) in PG. Mixed and strategic gamblers share common motives, but coping, financial and enhancement were stronger among PG. Finally, they emphasize the differences between different types of gamblers.     

The role of subjective mood states in the maintenance of fruit machine gambling behaviour

Explanations involving the etiology of pathological gambling have tended to emphasize psychosocial factors. However, the possibility that psychobiological factors are important should not be ruled out. Two currently researched psychobiological approaches to gambling involve the role of (i) arousal and (ii) depression. A study analyzing the subjective mood variables of 60 gamblers (44 males and 16 females; mean age 23.4 years) using self report measures was carried out in an attempt to identify which mood states are critical to gambling maintenance. Results indicated that regular and pathological gamblers experienced more depressive moods before playing and that regular and pathological gamblers experienced significantly more excitement during gambling than non regular gamblers. These results are discussed in relation to contemporary literature regarding the roles of arousal and depression in the maintenance of gambling behaviour.The author would like to thank the UK Economic and Social Research Council for funding this research through a research studentship. The author would also like to thank Henry Lesieur and the anonymous reviewers for their constructive advice and criticism in the revisions of this paper.     

A Preliminary Investigation of Abstinence and Controlled Gambling as Self-Selected Goals of Treatment for Female Pathological Gambling

The current study aimed to provide a preliminary evaluation of the differential efficacy of a cognitive-behavioural treatment program for female pathological gamblers delivered with the goals of abstinence or controlled gambling. The findings were based on the comparison of pathological gamblers selecting abstinence and pathological gamblers selecting controlled gambling on measures of gambling behaviour and psychological functioning. The findings revealed that pathological gamblers selecting controlled gambling displayed comparable levels of improvement to those displayed by gamblers selecting abstinence. Using a treatment completer approach, 89% of the gamblers selecting abstinence compared with 82% selecting controlled gambling no longer satisfied the diagnostic criteria for pathological gambling by the completion of the 6-month follow-up period. Although further scientific demonstration is required, the findings of this study provide preliminary support for the practice of offering controlled gambling as an alternative goal in the treatment of pathological gambling.     

Impulsivity and Stress Response in Pathological Gamblers During the Trier Social Stress Test

Gambling has been associated with increased sympathetic nervous system output and stimulation of the hypothalamic–pituitary–adrenal axis. However it is unclear how these systems are affected in pathological gambling. This study aimed to investigate the effect of the Trier Social Stress Test (TSST) on cortisol and on cardiac interbeat intervals in relation to impulsivity, in a sample of male pathological gamblers compared to healthy controls. In addition, we investigated the correlation between the TSST, duration of the disorder and impulsivity. A total of 35 pathological gamblers and 30 healthy controls, ranging from 19 to 58 years old and all male, participated in this study. Stress response was measured during and after the TSST by salivary cortisol and cardiac interbeat intervals; impulsivity was assessed with the Barratt Impulsiveness Scale (BIS-11). Exposure to the TSST produced a significant increase in salivary cortisol and interbeat intervals in both groups, without differences between groups. We found a negative correlation between baseline cortisol and duration of pathological gambling indicating that the longer the duration of the disorder the lower the baseline cortisol levels. Additionally, we found a main effect of impulsivity across groups on interbeat interval during the TSST, indicating an association between impulsivity and the intensity of the neurovegetative stress response during the TSST. Involvement of the hypothalamic–pituitary–adrenal axis in pathological gambling was confirmed together with evidence of a correlation between length of the disorder and diminished baseline cortisol levels. Impulsivity emerged as a personality trait expressed by pathological gamblers; however the neurovegetative response to the TSST, although associated with impulsivity, appeared to be independent of the presence of pathological 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 Gamblers: Inpatients’ versus Outpatients’ Characteristics

Several researchers and clinicians have questioned the advantages and disadvantages of inpatient and outpatient treatment for people suffering from pathological gambling. This study compares the characteristics of pathological gamblers seeking inpatient and outpatient treatment. A total of 233 pathological gamblers (inpatients = 134, outpatients = 99) participated in the study. Results show that inpatients have more severe gambling problems than those receiving outpatient services. Similar results were obtained on most other related variables such as anxiety, depression, alcohol consumption, and comorbidity. These results are discussed in terms of the costs and benefits of these two treatment modalities.     

Treatment Goal Selection for Female Pathological Gambling: A Comparison of Abstinence and Controlled Gambling

The current study was an exploratory investigation of the selection of controlled gambling as a goal of treatment for female pathological gambling. Specifically, it aimed to explore: 1) the popularity of controlled gambling as a goal of treatment; 2) the reasons pathological gamblers select abstinence and controlled gambling as goals of treatment; and 3) the characteristics of pathological gamblers attracted to abstinence and controlled gambling. The sample comprised 85 female pathological gamblers attending a cognitive-behavioural treatment program for pathological gambling. The selection of controlled gambling by one-third (34%) of the sample suggests that, at least in the Australian context, controlled gambling is a relatively popular goal of treatment for female pathological gamblers. In this study, the only differences between treatment-seeking female pathological gamblers selecting abstinence and controlled gambling were that those selecting controlled gambling were older and were less likely to endorse the belief that problematic gambling is a disease or affliction that can only be overcome by lifelong abstinence. Further research investigating the characteristics of pathological gamblers associated with controlled gambling as both a goal and outcome of treatment is required in order to ensure that treatment-seeking pathological gamblers can make an informed decision regarding their goal selection.     

Anxiety and social stress related to adolescent gambling behaviour

Abstract

This study examined the relationship between anxiety, social stress, and gambling behaviour among 1,044 high school students in grades 7 to 11. Adolescents completed questionnaires concerning their state, trait, and generalised anxiety, social stress, and gambling behaviour. Results reveal that adolescent probable pathological gamblers report more state anxiety, trait anxiety, and higher levels of social stress compared to non‐gamblers, social gamblers, and gamblers at‐risk for serious problems. Gamblers with high state and trait anxiety engaged in more severe gambling behaviours, greater substance abuse, reported different reasons for gambling, and endorsed more dissociation items. The results provide additional support for Jacobs’ (1986) General Theory of Addictions. The implications for treatment and prevention programs are discussed.     

Effectiveness of a Self Help Cognitive Behavioural Treatment Program for Problem Gamblers: A Randomised Controlled Trial

The study aimed to strengthen the scarce literature on self-help treatments for Problem Gambling (PG) by comparing the effectiveness of a Self-Help Cognitive Behavioral Treatment (SHCBT) program (n = 23) with a 6-week Waitlist condition (n = 32) in problem gamblers. Participants were community volunteers with gambling problems and were randomly allocated to the Waitlist and treatment conditions. Results showed significant improvements at post-treatment in gambling behaviors including frequency of gambling, average amount gambled per day and PG symptoms as well as a number of gambling correlates including psychological states (e.g., depression, anxiety and stress), gambling cognitions, gambling urges, gambling related self-efficacy, satisfaction with life, and quality of life among those who completed the SHCBT program, when compared with the waitlist condition. The effect size (partial η ²) ranged from .25 to .57 for all assessed outcomes that showed significant improvement from pre- to post-treatment. It was concluded that a self-help CBT program can be beneficial for treating community problem gamblers.     

Plasma endorphin levels in pathological gambling

Despite its formal definition as a disorder of impulse control, pathological gambling has come under the generic label of addictive disorders with subjective excitement and physiological arousal as the major motivating factor. Individual differences in autonomic/cortical arousability in interaction with irregular schedules of reinforcement have been postulated to be important determinant factors in the pathogenesis of pathological gambling (Anderson & Brown, 1984). Mood disturbances and cross-addictions are frequently observed in pathological gamblers seeking treatment and the behavior has also been conceptualized as a defense against depression and anxiety. Recently the role of endorphins has been implicated in mood disturbances associated with psychiatric states and in addictive processes; the latter through their euphorogenic or reward-transmitting properties in accordance with operant and classical conditioning principles. The hypothesis that the etiology or maintenance of gambling behavior is related to endorphin activity was investigated in this study. Using radioimmunoassay techniques, baseline B-endorphin plasma levels were measured in a sample of 39 pathological gamblers seeking treatment and 16 male and 19 female non-gambling healthy control subjects. In addition, B-endorphin reactivity to gambling activity was measured in a subgroup of 13 horse-race gamblers.Diagnostic and Statistical Manual III criteria for diagnosis were used. Written consent was obtained. Blood samples were drawn at the same time of day for each subject. The experimental procedure consisted of taking baseline blood samples at 11 a.m. following which subjects were instructed to place a bet sufficient to excite them on a horse-race. A subsequent blood sample was taken at 2 p.m., five minutes after subjects listened to the race broadcast on radio. Heart rate measures and a visual analogue scale rating excitement, tension and urge to gamble were also administered immediately before and after the race broadcast. Results showed that as a group pathological gamblers did not differ from controls on baseline B-endorphin levels. But differentiating gamblers according to type of gambling activity revealed horserace addicts to have significantly lower baseline levels as compared to poker-machine players and controls. This finding provides empirical evidence for the hypothesis that distinct subgroups of gamblers exist and raises the corollary that different etiological factors may characterize each subgroup. That B-endorphin levels did not increase in response to gambling was explained by the failure of the relatively small bet size to generate high arousal.This paper was presented at the Sixth National Conference on Gambling and Risk Taking, held at Atlantic City, New Jersey, December 9 to 12, 1984.     

Family,marital, and occupational satisfaction for recovering pathological gamblers

This paper describes the efforts of a private gambling treatment program to conduct a retrospective study of pathological gamblers treated in a publicly supported residential program. The Johns Hopkins Center for Pathological Gambling treated approximately 100 pathological gamblers nationwide from 1979 to 1983 in its residential component. Twenty-six gamblers were assessed regarding their recovery status with specific focus on family, marital status and occupational satisfaction. It was hypothesized that the more satisfied patients would display lower frequencies of gambling and that gambling frequency was dependent upon the level of satisfaction. Thirty-one percent of these gamblers reported abstinence. Regression analyses indicated that the recovery of pathological gamblers as measured by frequency of gambling is significantly influenced by job satisfaction, and moderately influenced by marital status and family life satisfaction. Consequently, these factors should be addressed by mental health professionals in research and treatment of pathological gambling.     

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.     

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.     

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.