UO Addictive Behaviors: Disordered Gambling

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2/11/14 | Julie Hynes

2/11/14 | Julie Hynes

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  • 1. GAMBLING Julie Hynes, Sr. Community Health Analyst Lane County Public Health SAPP 407 | University of Oregon | Feb. 2014
  • 2. OVERVIEW • History & trends   • Defining the issue: problem gambling • Gambling & the brain • Addiction & mental health connections • Addressing the issue
  • 3. POTENTIAL
  • 4. DEFINITION: ______ something of value RISKING in the hopes of obtaining _________________ something of greater value. Source: American Psychiatric Association ‐ DSM‐5 (2013). 
  • 5. How quickly things are changing Source: insidefacebook.com
  • 6. Source: WSJ.com 2/11/14
  • 7. GAMING & GAMBLING: PARALLELS Stimulate dopamine Play for similar reasons (escape, relax,  stimulate, etc.) Potential for addiction?
  • 8. Anything can be a bet… (especially online!) Sources: linemakers.sportingnews.com, bovada.lv
  • 9. What are the 2 states that DON’T have legalized gambling?
  • 10. AVAILABILITY OF LEGAL GAMBLING IN U.S., 2014
  • 11. Nine tribal casinos opened 1994 - 2004 Video poker began Horsetrack 1931 Lottery approved 1984 1992
  • 12. Image sources: Oregon Lottery, Hynes
  • 13. Image sources: Oregon Lottery, Hynes
  • 14. ELECTRONIC GAMBLING: “Video Poker/Slots/Line Games” 7 $ out of every Photo source: Daniel Berman. $10 lottery dollars Source: Oregon Health Authority  (2012; ibid)
  • 15. Photo:  Hynes
  • 16. Photo:  Daniel Berman
  • 17. 1 in 175 1 in 175,000 1 in 175 million 1 in 175 billion
  • 18. 1 in 175 Million (174,233,510) Odds of getting struck by lightning: 1 in 280,000
  • 19. Let’s say there is 1 RED popcorn kernel in this bag of 10,000 pieces of popcorn ….you’d have a better  chance of reaching in and  grabbing the one red kernel  of popcorn in this bag than  you would of winning  $100 on a powerball ticket
  • 20. So…if your lucky numbers have “almost” come up in the last 5 drawings, are your chances better, worse, or the same?
  • 21. Sports bets Lottery tickets Video & online Bingo & raffles
  • 22. Gambling Treatment Clients Gamblers' Preferences Video lottery   & online gambling Electronic Gambling 89% Cards 6% Other 5%
  • 23. Research shows about what percentage of Oregon adults have a gambling problem? 0.1% 11.2% 1.2% 2.7%
  • 24. 2.7% of Oregon adults (1 in 37 people) have a gambling problem.
  • 25. Behind every story… there’s a story…
  • 26. Definitions PATHOLOGICAL: Persistent and recurrent  maladaptive gambling  behavior...results in the    LOSS OF CONTROL over      gambling. (DSM‐IV)
  • 27. New language
  • 28. GAMBLING DOESN’T START BY BEING A PROBLEM.
  • 29. It’s a No Gambling Recreational Experimentation “Continuum” At-Risk Problem Pathological “GAMBLING DISORDER” Sources: 1. Moore (2006). 2. Volberg, Hedberg, & Moore (2008). 3.  Shaffer & Hall (2001). 4. Northwest Survey & Data  Services (2007). 5. Moore (2001). 
  • 30. This is the first  generation of  widely available  electronic  gambling.  We really don’t  know the effects  yet. 5.6% college age (18‐24) 4% teens (13‐17) 2½ % all adults (18+)
  • 31. The new DSM-5 (May 2013) defines pathological gambling as a “behavioral addiction,” the first of its kind.
  • 32. SIMILAR BEHAVIORAL CONDITIONS, like internet and Binge eating, aren’t yet in the category of “behavioral addiction.” (It is thought They might be soon.)
  • 33. IS IT AN “ADDICTION” 1. Solidly established, problematic pattern of a  pleasurable & reinforcing behavior 2. Physiological/psychological components of  behavior pattern that create dependence 3. Interaction of these components in an  individual which makes person resistant to  change Definition of addiction from Diclemente, 2003
  • 34. IS SOMEONE YOU KNOW… • Gambling to escape problems • "Chasing" losses with more gambling • Lying to family and others about the extent of gambling • Committing crimes to finance gambling • Jeopardizing or losing relationships, jobs, education because of gambling • Relying on others to bail him or her out relieve a desperate financial situation caused by gambling
  • 35. EXAMPLES REAL LIFE‐ in the news
  • 36. http://www.oregonlive.com/portland/index.ssf/2013/06/former_postal_service_worker_s.html
  • 37. Register‐Guard, 5/13/11
  • 38. But really, the consequences are  usually much more than crime and  being in the news…
  • 39. THE STORIES GO ON. …each problem gambler affects an average of 6‐12 others.
  • 40. >70% 48% are current  tobacco users experience  suicidal ideation 10% 32% have current  alcohol  problems Source: Oregon Health Authority, 2012 actually attempt  suicide Have current  drug problems
  • 41. 10:49PM Jordan SAPP 5:11PM Hey man we r here @  starbucks on 13th c u soon running late sorry It’s been 2 more hrs.  U  coming or what? on my way … Never mind. We finished  the project. AGAIN. Sorry but  the group is done w/your  excuses.
  • 42. PROCESS of ADDICTION.
  • 43. Typical Phases of Problem Gambling LOSING WINNING HOPELESSNESS DESPERATION Source: Custer, R. & Rosenthal, M.
  • 44. Winning PHASE
  • 45. Losing PHASE I’ll get my money back in no time. My big win is just around the corner!
  • 46. Desperation PHASE
  • 47. Hopelessness PHASE
  • 48. THOUGHTS, FEELINGS, ANTICIPATION, FANTASY REALITY (Gambler’s Mind, “Gambling Time/ Gambling Money”) (Self with Others) “Real Time, Real Money” CRASH Guilt, Shame, Anger, Denial, Justification, Restless, Irritable, Depression, Panic or Numb, Suicidal Thoughts Dopamine PLANNING (Removing obstacles to gambling) GAMBLING (“Winning & Losing”) Serotonin Adrenaline Dopamine Source: http://www.oregon.gov/oha/amh/gambling/gear‐workbook.pdf
  • 49. WHAT CAN TRIGGER ACTION? Lots of things, but these are some key triggers.  People at risk should especially avoid gambling when: H ungry A ngry L onely Tired
  • 50. Comparison by Start gambling younger Start gambling at older age than men Tend to like games of strategy & “action” (poker, sports bets) Get addicted faster Less likely to seek help Games of choice: video slots More likely to be “escape” gamblers These comparisons are of course generalizations and do not by  any means reflect all male and female gamblers.
  • 51. Oregonians in gambling treatment, 2012: 32k $ IS THE AVERAGE HOUSEHOLD INCOME.  Range is from $0 to over $1million/year. 85% ARE WHITE .  4.4% Hispanic/Latino., 3.4% Asian.   People of color are under‐represented in treatment. 90% prefer ELECTRONIC GAMBLING.  24% HAVE COMMITTED CRIMES TO FINANCE  THEIR GAMBLING. Most crimes are “white collar”  Video (slots/poker/line games).  Cards 4.1%; scratch‐its 1.3%; sports 0.9%; (forgery, check fraud, embezzlement.) $! 27k $ IS THE AVERAGE INDIVIDUAL GAMBLING  DEBT.
  • 52. Comparison of “Action” and “Escape” Pathological Gamblers Action Escape Excitement, competition Relief, escape from stress “Skilled” forms of gambling  (sports/poker, etc) “Luck” forms of gambling  (lottery, slots, bingo) Early onset of gambling Later onset of gambling More likely to present  narcissistic or antisocial traits More likely to present depressive/dysthymic traits Source: Center for Substance Abuse Treatment, 2005. 
  • 53. CAUSES? (RISK FACTORS) • Trauma -stemming from abuse or neglect • Mental health issues • Substance use • Parental attitudes & behavior • Competitive family • Community norms/laws • Early initiation • Friends favorable toward gambling
  • 54. At what age is the brain considered fully developed?  18  21  25  16
  • 55. The brain is still developing until The PREFRONTAL CORTEX is the LAST PART to develop.
  • 56.  Depression/mood disorders   Narcissistic personality disorder  PTSD    Impulsivity  ADHD  Substance abuse   Alcohol abuse  Sources  Ledgerwood & Petry (2006). Kausch et al. (2006). Biddle et al. (2005). Oregon Health Authority (2010). The  WAGER (2002, February 12);  Specker, et al., (1995); Kim & Grant (2001)
  • 57. It’s really about the action, not the money! “ALMOST  WINNING”  causes  dopamine to  be activated  the same as  ACTUALLY  winning. People play  LONGER  when  machines  give them  NEAR  MISSES. Problem  gamblers are  more likely to  see their near  misses as  “NEAR WINS” For more info: see article  “The Almost Winning Addiction” in the readings.
  • 58. Neurotransmitter “PGs” = problem gamblers | Neurotransmitters are brain chemicals that  transmit nerve impulses. Dopamine is known as the brain’s “reward system.” Neurotransmitter Role in Relation to Gambling Serotonin  Serotonin --  risk taking Behavior Initiation/Cessation Norepinephrine PGs Arousal,levels -   NE Excitement Opioids Pleasure, Urges Gambling -   β-endorphin Dopamine PGs -   dopamine response Reward, Reinforcement Dopamine: most studied neurotransmitter in problem gambling
  • 59. Gambling & Dopamine It’s not about the money – it’s about the action of the game and the hope of  winning.   Dopamine not released when expecting a loss. Flooded with dopamine when expecting a win! Source: Brain Briefings (2007, October), Society for Neuroscience, Washington, DC
  • 60. Sources: Tonneato, T. (1999). Cognitive psychopathology of problem gambling. Subst Use Misuse. Sep;34(11):1 Anecdotal reports from problem gamblers in treatment and recovery.
  • 61. COGNITIVE Distortions Superstition Lucky #’s Favorite shirt “My” machine Image source: Anheuser‐Busch Rituals/habits that are believed to affect the outcome.
  • 62. COGNITIVE Distortions Biased Evaluation Attributing wins to one’s special skill or luck, while losses are blamed on external circumstances. Example (win): “Yeah buddy! I was just waiting on my  card. I know this game inside and out.” Example (loss): “I would’ve won if that idiot didn’t get  lucky and draw an ace.”
  • 63. COGNITIVE Distortions Selective Memory Forgetting about losses, only remembering wins. Image source: Anheuser‐Busch
  • 64. COGNITIVE Distortions Gambler’s Fallacy Failure to see each event as independent. Examples: • Trying to see patterns in coin flips. • “This slot machine is DUE to hit!”
  • 65. THIS …those are other ways our minds trick us. We are wired to see patterns in things.
  • 66. Reflect: cognitive distortion Have you ever experienced a cognitive distortion? What was the experience like?
  • 67. VULNERABLE POPULATIONS Older adults • Substance abuse  history College students Ethnic minorities • Mental health  history Incarcerated  • Youth persons • Military & veterans • Women • • • •
  • 68. The “Addiction” Connection Similarities? Differences?
  • 69. The “Addiction” Connection Similarities? • • • • • • • • • • • Loss of control Denial Depression/mood swings Progressive Tolerance Use as an escape Preoccupation Similar “highs” Self‐help groups Family involvement Use of rituals Differences?  Defining “use” (gambling)  Behavior not attributable to       chemical ingestion No biological test More intense sense of shame  and guilt (anecdotal) Unpredictable outcome Fantasies of success /quitting is  giving up hope Easier to hide
  • 70. Effects of Problem Gambling on Children • Prone to abuse and/or neglect • Child endangerment may increase • Higher levels of tobacco,  alcohol, drug use, and overeating than  peers • Higher risk of pathological gambling  • Suffer effects from lack of financial  stability
  • 71. “The earlier people begin gambling, the more likely they are to experience problems from gambling.” - National Academy of Sciences
  • 72. Not Your Uncle’s Gambling Research on: Youth gambling still under-studied & under the radar
  • 73. •Amygdala active   •Fight or flight, emotion •Decision-making altered •More vulnerable to risk‐ taking & impulsive  behaviors Source: Ramoski, S., Nystrom, R. (2007).  “The adolescent brain is especially sensitive to the effects of dopamine.
  • 74. RISK FACTORS FOR YOUTH • Single‐parent household • Started gambling before  8th grade (early  • Gambling on  initiation) cards/sports • Being male, older teen • Parents who gamble‐‐ youth twice as likely to  • Lower household  be at‐risk gamblers &  income four times as likely to be  • Competitive problem gamblers • Having lost more than  $50 in a single month Source: Volberg, et al (2008; bid).
  • 75. Gambling & Oregon Teens Six in 10 Oregon (63 percent) have gambled 46 percent gambled in the past year 3 percent gamble weekly or more  Six percent problem gamblers or at risk Preferred games in order: Free Internet gambling-type games Cards (poker) Sports bets Games of personal skill Source: Volberg, et al (2008; bid).
  • 76. Lane County 2012 Student Wellness Survey (SWS) 2012 Gambling, Substance Use and Mental Health  among Oregon Youth 50% Percentage 40% 6th 30% 11th 20% 10% 0% Gambling Alcohol Binge Marijuana Cigarettes Depression Psych Alcohol distress Source: http://oregon.pridesurveys.com/esds.php?year=2011 n=55,611 students (18,885 6th grade; 21,368 8th grade; 15,358 11th grade)  8th
  • 77. Used alcohol in the past month 100% 90% 80% 70% Percentage 60% 50% Did not gamble 40% Gambled 30% 20% 10% 0% Grade 6 Grade 8 Available at: www.preventionlane.org/sws.htm Grade 11
  • 78. Binge drank in the last 30 days 50% 45% 40% Percentage 35% 30% Did not gamble Gambled 25% 20% 15% 10% 5% 0% Grade 6 Grade 8 Available at: www.preventionlane.org/sws.htm Grade 11
  • 79. Smoked cigarettes in the past month 50% 45% 40% Percentage 35% 30% Did not gamble Gambled 25% 20% 15% 10% 5% 0% Grade 6 Grade 8 Available at: www.preventionlane.org/sws.htm Grade 11
  • 80. Used marijuana in the past month 50% 45% 40% Percentage 35% 30% 25% Did not gamble 20% Gambled 15% 10% 5% 0% Grade 6 Grade 8 Available at: www.preventionlane.org/sws.htm Grade 11
  • 81. Percentage Skipped school one or more days in the past month 50% 45% 40% 35% 30% 25% 20% 15% 10% 5% 0% Did not gamble Gambled Grade 6 Grade 8 Available at: www.preventionlane.org/sws.htm Grade 11
  • 82. Percent of youth who attempted suicide in the past year 30% Percentage 25% 20% Did not gamble 15% 10% 11.3% 7.2% 5% 9.0% 5.0% 0% Grade 8 Available at: www.preventionlane.org/sws.htm Grade 11 Gambled
  • 83. Percent of youth that attempted suicide in the past year 30% Percentage 25% 21.0% 18.6% 20% 15% 10% 10.1% Did not bet/gamble more than wanted to 8.0% Bet/gambled more than wanted to 5% 0% Grade 8 Grade 11
  • 84. Conclusion? Teens who gamble are  smoked up, toked up,  drunk emo delinquents.
  • 85. Conclusion? Teens who gamble are  smoked up, toked up,  drunk emo delinquents.
  • 86. Conclusion: Problem Gambling is ONE COMPONENT of Problem Behaviors delinquency sexual behavior Problem depression Behaviors gambling substance use
  • 87. Identification & Treatment
  • 88. Online: click here Source: Written by Robert L. Custer, M.D; retrieved from Council on Compulsive Gambling of New Jersey, Inc..
  • 89. Intervention Helpline  541.741.7107: emergence Or 24/7: 1.877.MY.LIMIT Referred to provider for  assessment Family members come in;  later bring gambler in
  • 90. A Simple Screen: Lie-Bet Tool (Johnson et al., 1988) 1.Have you ever felt the need to bet more and more money? 2.Have you ever had to lie to people  important to you about how much you  gambled? Valid and reliable for ruling out pathological gambling behavior Response to ONE or both indicates referral for longer assessment useful in screening to determine whether a longer tool (e.g., SOGS, DSM‐IV)  should be used in diagnostics
  • 91. Assessment Tools SOGS DSM
  • 92. DSM Criteria Revisited 1. 2. 3. 4. 5. Preoccupation with gambling Increases amount of money gambled Unsuccessfully tries to quit Restless or irritable when trying to cut down/stop Gambles as an escape 6. 7. 8. 9. “Chases” losses Lies to others to conceal gambling Has jeopardized relationships Relies on others to bail him/her out Gambling Disorder = Four or more of above, AND: The gambling behavior is not better accounted for by a Manic Episode.
  • 93. Treatment is Free. 24 hrs: 1877‐my‐limit Online: 1877mylimit.org
  • 94. TREATMENT OPTIONS IN OREGON Minimal intervention:  GEAR (Gambling  Education and Reduction) Outpatient treatment (44) Crisis respite (2) Residential treatment (1)
  • 95. EMERGENCE GAMBLING TREATMENT PROGRAM Treatment free for gamblers and loved ones 275 problem gamblers and family members treated last year Gender-specific Multimodal treatment  Individual sessions therapy Group sessions counseling Didactic lectures - Family - Recreational - Audiovisual educ. Suggest to explore 12‐step program
  • 96. • Only about 2% of Oregonians who need treatment  enroll  • Those enrolling who lived within a 50 mile radius  of a casino were significantly more likely to report  casino as their primary venue  • 30% enter treatment through the statewide  helpline
  • 97. THOUGHTS, FEELINGS, ANTICIPATION, FANTASY REALITY (Gambler’s Mind, “Gambling Time/ Gambling Money”) (Self with Others) “Real Time, Real Money” CRASH Guilt, Shame, Anger, Denial, Justification, Restless, Irritable, Depression, Panic or Numb, Suicidal Thoughts Dopamine PLANNING (Removing obstacles to gambling) GAMBLING (“Winning & Losing”) Serotonin Adrenaline Dopamine Source: http://www.oregon.gov/oha/amh/gambling/gear‐workbook.pdf
  • 98. DISRUPTING THE ACTION CYCLE • • • • • Barriers to Money Treatment Support Systems Accountability H.A.L.T. (hungry, angry, lonely, tired) Slide credit: Janese Olalde, MEd, CGAC, CADC
  • 99. FAMILY TREATMENT ISSUES • • • • • • • • Allow venting of rage and betrayal Education of compulsive gambling as an illness Family Groups Renew sense of hope Empowerment Seek support – treatment  GAM‐ANON DON’T KEEP SECRETS! Slide credit: Janese Olalde, MEd, CGAC, CADC
  • 100. Family Financial Issues • Create own avenue to financial stability  (employment or other) • Protect financial assets • Close joint accounts • Use automatic/electronic  deposits for gambler’s income • NO BAILOUTS!  Slide credit: Janese Olalde, MEd, CGAC, CADC
  • 101. Couple Issues in Therapy       Sequencing with individual work  Assess possibility of domestic violence Impact on partner and children  Role of money in the relationship  Deal with hurt, anger, mistrust Dealing with “unfolding truths” Slide credit: Janese Olalde, MEd, CGAC, CADC
  • 102. Promotion & Prevention
  • 103. Creating conditions in families,  schools, and communities that promote the wellbeing of people Emotional and behavioral health Physical health
  • 104. Awareness & communication of the problem is relatively low. 2012 Oregon Student Wellness Survey, Lane County (“Esd”) and Oregon;  available at http://oregon.pridesurveys.com/esds.php?year=2011
  • 105. Targeting Parental Attitudes Oregon parent/youth focus groups revealed: • All parents in the groups said their kids  didn’t gamble • All kids in the groups said they did gamble • Neither sees gambling as risky
  • 106. Targeting Parental Attitudes Most parents believe: • Youth gambling is harmless  • Youth who gamble are unlikely to have  problems in school • Youth gambling is not associated with alcohol  or drug use …and those beliefs are part of the problem
  • 107. Crashed cars “Scared straight” Boot camp One‐time activities
  • 108. Our efforts in Oregon have • Public awareness a focus on: • Policy • Support for in‐ school prevention  curriculum • Parent education
  • 109. Problem Gambling Advisory Committee • Meets monthly • Works on policy &  awareness issues • Comprised of  professionals &  community  members
  • 110. Various Methods
  • 111. ON THE RIGHT PATH
  • 112. KEY CHALLENGES IN THE FIELD • Youthful subject • Perception of  harmlessness • Stigma/shame • Industry
  • 113. IS IT “SOCIAL” OR PROBLEM GAMBLING? Social Gambler Problem Gambler Occasional Frequent, preoccupied Sticks w/ limits Plays w/needed $, borrows Hopes to win, expects to lose Hopes & expects to WIN Can take it or leave it Primary source of “fun”
  • 114. 10 TIPS FOR RESPONSIBLE GAMBLING 1. Gamble only if it's fun. 2. Think of the money you lose as the cost of  entertainment. 3. Set a dollar limit and stick to it. 4. Set a time limit and stick to it. 5. Accept losing as part of the game.
  • 115. 10 TIPS FOR RESPONSIBLE GAMBLING 6. Don't borrow money to gamble. 7. Don't let gambling interfere with family, friends,  or work. 8. Don't gamble to win back losses. 9. Don't use gambling as a way to cope with  emotional or physical pain. 10. Know the warning signs of problem gambling.
  • 116. SUMMARIZING THIS CONTENT • • • • • • We defined gambling & problem gambling We looked at trends We looked at connections with other issues We saw the effects on the brain We looked at how to address problem  gambling
  • 117. Under $100 $100‐$1,000 $1,000-$2,500 More than $2,500
  • 118. Problem gambling treatment  is ‘free’ in Oregon for  gamblers AND loved ones.
  • 119. The average problem gambler in Oregon gambling treatment owes $4,000 in gambling-related debts.
  • 120. The average problem gambler in  Oregon gambling treatment owes  $30,000 in  gambling‐related debts.
  • 121. preventionlane.org facebook.com/ preventionlane twitter.com/ preventionlane