Clinical and Research Perspectives on Problem Gambling and ADHD

Helping partners in a
relationship
with a problem gamblerRory C. Reid, Ph.D., LCSW
Assistant Professor,
Neuropsychology
Clinical Research Psychologist
UCLA Gambling Studies Program
Department of Psychiatry
UCLA Gambling Studies Program
Clinical and Research Perspectives
on Problem Gambling and ADHD
Rory C. Reid, Ph.D., LCSW, ICGC-II
Assistant Professor, Research Psychologist
International Certified Gambling Counselor
Email: roryreid@ucla.edu

Summary and Suggestions
CALIFORNIA PROBLEM GAMBLING TRAINING SUMMIT MARCH 4-5, 2019
Let’s put the end of my presentation at the beginning so you
can have some ideas about clinical application for what I’m
going to share!

Where possible, work with ADHD gamblers in couples therapy or
group therapy to minimize attrition.
Provide ADHD gamblers with handouts to help with retention
(use handouts rather than emails).
Allow ADHD gamblers to write down some thoughts while you
do you clinical note at the end of session.
Point of performance interventions (e.g. interrupting, not paying
attention).
Ask more open ended questions for problem gamblers with
ADHD so they can think out loud with you

Be direct when communicating (don’t sugar coat it difficult
conversations). Example: your response to your partner right
now reflects a lack of empathy and is only focused on what you
need. Can I help by suggesting something else you might say?
Regular vigorous aerobic exercise can offset stress, restlessness,
and a vast array of other symptoms associated with ADHD.
Engage in aerobic exercise 3-5 times weekly sufficient that you
maintain 60-85% of your maximum target heart rate throughout
your workouts for 20 minutes or longer.
Interventions such as TMS or Neurofeedback may be helpful but
should be considered with caution.

Psychoeducation about ADHD:
Delivered from Distraction: Getting the Most out of
Life with Attention Deficit Disorder by Dr. Edward
Hallowell, M.D. and Dr. John J. Ratey, M.D. (ISBN:
0345442318)
The network for Children and Adults with
Attention-Deficit / Hyperactivity Disorder
(www.chadd.org) allows for membership
enrollment, information on their annual
conference, and links to regional chapters enabling
members to connect with others locally, and a
subscription to their magazine titled Attention.

Summary and Suggestions: Podcasts

Welcome to divorce counseling. The goal is to help you
divorce yourself from your relationship with problem
gambling and refocus your attention on your primary
relationship. (Resource: www.adhdmarriage.com)
This site has resources for
couples and professionals.
There is an online seminar,
webinars, and workshops for
couples.

Become familiar with effective interventions that target
stress coping strategies and affect regulation.
Use recourses that help with enhancing effective time
management and time estimation.

Mindfulness meditation has been shown
to enhance attention, increase stress
coping, and improve emotional regulation
in both problem gamblers and adults with
ADHD.
This book by Dr. Zylowska also has a
CD-ROM included with some mindfulness
exercises.
Four different studies have found
empirical support for mindfulness
applications for adult ADHD.

Summary and Suggestions: Medications

Problem Gambling and Adult ADHD
And now for my presentation…..

ADHD and Gambling Disorders

Parallels / Overlap with ADHD and Gambling Disorders
Preoccupation Hyperfocusing
Escape Distractibility / Daydreaming
Lying Lying
Loss of Control Impulse Control Problems
Risking Relationships
Chasing Behaviors
Lack of Future Directed
Thinking; Risk-Taking,
Excitement-Seeking
Bailouts Being Rescued
Gambling Disorders ADHD

Comparable Levels of Impulsivity
Clinical Levels of
Impulsivity
Gamblers 48.8%
Hypersexuals 48.0%
Meth Abusers 44.4%

Adult ADHD, Problem Gambling, and Impulsivity
UPPS-P Impulsive Behavior Scale
 Negative Urgency
 Positive Urgency
 Sensation Seeking
 Lack of Premeditation
 Lack of Perseverance

Negative Urgency: Items on this subscale measure the tendency
to act rashly in response to negative affective experiences or
impulsivity when experiencing unpleasant emotions (e.g. feeling
bad, upset, rejected etc…). A few items on this scale capture
difficulty resisting cravings and feelings. Several items inquire
about making impulsive decisions that are later regretted. Higher
scores reflect greater impulsivity in the wake of cravings or
uncomfortable emotions.
PG PG+ADHD
59% 69%

Positive Urgency: Several items on this subscale measures the
tendency to exhibit diminished control in the wake of positive
emotions (e.g. excited, happy) leading to impulsive behavior that
may cause problems or negative consequences. One item queries
respondents about giving into “cravings” or overindulging when
they are happy. Another item reflects “going overboard” when
feeling overjoyed. Higher scores reflect more impulsive behavior in
response to positive emotional experiences.
PG PG+ADHD
53% 72%

Sensation Seeking: Items on this subscale measure tendencies to
engage in excitement-seeking, novelty, or thrilling experiences.
Many of the items on this scale tap into desires to pursue what
some may consider risky/extreme sports (e.g. skydiving, speeding,
scuba diving) or simply enjoyment from taking risks. Higher scores
are associated with greater sensation-seeking behaviors and have
been linked to greater propensity for risk-taking.
PG PG+ADHD
9% 26%

Lack of Premeditation: This subscale taps into future directed
thinking about consequences prior to making decisions. Higher
scores on this factor suggest individuals are careless in their
choices, acting without purposefully thinking about the
ramifications of decisions or weighing the advantages or
disadvantages of their actions.
PG PG+ADHD
33% 67%

Lack of Perseverance: Items on this subscale capture diligence,
persistence, and the ability to follow tasks through completion.
One item appears to capture sustained attention “I concentrate
easily.” Higher scores reflect tendencies to quit prematurely,
become distracted, difficulties with task completion and are
positively correlated with boredom proneness and
procrastination.
PG PG+ADHD
20% 56%

Adult ADHD & Problem Gambling
Problem gamblers with adult ADHD encounter unique
challenges above those common among problem gamblers
including more problems with alcohol/drug abuse, higher
levels of impulsivity, earlier age for first gambling activities,
onset of gambling problems, and higher severity of gambling
problems. They pawned more items to obtain money for
gambling, were more likely to have debt, had significantly
higher rates of bankruptcy and domestic violence arising
from conflict with family members about their gambling.
However, groups did not differ significantly on their time
spent gambling prior to treatment, their win-to-loss ratio,
and a number of other gambling-related consequences.
Reid, Campos, Selochan, & Fong, 2019

Why ADHD and Problem Gambling
 Current studies suggest that the prevalence of adult ADHD in
problem gamblers is ~ 10 – 20%.
 Perhaps the more relevant question is why are individuals with
ADHD at increased risk for a variety of addictive behaviors, in
particular:
Alcohol and Drug
Addictions (19% - 33%)
Hypersexual Behavior
Sex Addiction (23% to 28%)

What Do We Know about ADHD and Gambling Disorders?
Common Challenges with ADHD:
 Social rejection, loneliness
 Academic underachievement
 Emotional dysregulation
 Difficulties with task-completion
 Poor-self concept, shame
 Diminished identity-formation
 Relationship difficulties
 Attrition from college
 Poor work performance
Increased tendency to ESCAPE,
disconnect, numb out, etc…

Underlying / Associated Features of Gambling Problems and ADHD
Loneliness
Shame
Substance
Abuse
Inattention
Depression
Anxiety
Fear
ImpulsiveSelf-Esteem
Conflict
Hypersensitive

Adult ADHD, Problem Gambling, and Loneliness
GamblingLonlieness
Anxiety

ADHD and Boredom Proneness

Boredom is about a Lack of Awareness

BOREDOM
When Eating Your Own Poo Sounds Like Fun
What to do with Boredom?

Positive
Comfortable
Good
Pleasant
Awkward
Uncomfortable
Bad
Unpleasant
Emotionally avoidant people become numb and detached
from both good and bad feelings. True, they’ve avoided pain
and negative emotion, but they’ve also diminished or
extinguished their ability to feel positive emotions.
Pornography
Gambling
Sex
Food
Drugs / Alcohol
Bandwidth of Positive Emotions
Emotional Avoidance
The Paradox of Emotional Avoidance

Contrast Creates Opportunities for Comparison and Appreciation

Neuroscience Findings
Just a Few Thoughts
about ADHD and the Brain

Conflict Monitoring and Resolution
Difficulties with Sustained Attention and
Inhibition of Competing Stimuli

An Attention Model of Gambling Addictions continued
Attentional Model of Gambling Addictions
SignalStrength
Work
Target Distractor
Gambling
Attentive Condition
Work
Target Distractor
Gambling
Inattentive Condition

Motivation and Reward
Deficits in the Dopamine Reward
Pathway in Adults with ADHD

Dopamine, Reward, and Motivation Pathways
Decreased activation of nucleus accumbens in ADHD in rewards
 Lower D2/D3 receptor availability
 Reward deficits with failure to delay
gratification, preference for small
immediate rewards over larger
delayed rewards
 Dopamine deficits linked to
symptoms of inattention (e.g. most
pronounced in tasks considered
boring, repetitive, uninteresting
 Higher risk / vulnerability for
addiction to intensify rewards

Dopamine, Reward, and Motivation Pathways
Lower dopamine receptivity availability in hypothalamic region
 Some evidence for co-occurring
hypothalamic pathology with
ADHD such as:
 Sleep disturbances
 Overweight or obesity issues
 Abnormal responses to stress

Sleep Deprivation and Negative Emotional Appraisals
Increased response to negative stimuli and loss of
functional connectivity with the MPFC. Thus, it may
be that a good nights sleep “resets” the brain to
cope with next-day emotional challenges by
maintaining integrity of the MPFC-amygdala circuit.

Adult ADHD and Stress Coping: STRESS = ESCAPE = GAMBLE
Resources
Demands
Appraisal
Adaptive Coping
Maladaptive Coping
Unhealthy Stress Coping
Healthy Stress Coping

How to Make Stress Your Friend: Dr. Kelly McGonigal
KELLY MCGONIGAL

Inattention and Time Estimation
An accurate estimation of how long something will take to complete
requires several aspects of attention.

Adult ADHD Self-Report Scale

Treatment of Adult ADHD and Gambling Disorders
Treatment

Mindfulness and ADHD

Mindfulness and ADHD?

ADHD and Mindfulness

Goodness of Fit for ADHD and Gambling Disorders
Gambling
Suffering
Cravings
Stress
ImpulsivityBoredom
Attention
Emotion

Mindfulness and Cravings / Urges
 Addictive cravings are powerful and can be intense
 Patients often get into a tug-of-war with cravings
 Patients often give special status to cravings
 Patients have an adversarial relationship with cravings
Cravings Gambling Consequences
Reorganize relationship with craving to co-exist: Neither
avoiding nor indulging, just being present in a non-
judgmental, curious manner.

Mindfulness and Gambling Disorders
Gambling
Mindfulness
DepressionAnxiety Stress Impulsivity

Shame
Rumination
Problem
Gambling
Self-
Compassion
Mediating Effects of Self-Compassion on Problem Gambling

Gambling Disorders and Mindfulness
Mechanisms:
 Increased tolerance for
uncomfortable feelings
 Increased stress coping
 Increased tolerance for
cravings
 Attenuates impulsivity

Being aware of mind wandering: This is the practice of
being attentive, alert, and aware of moments when your
thoughts wander from the target stimuli (e.g. breathing).
The more we practice being aware, the better we become
in being aware sooner when thoughts wander and thus we
are able to intervene in a more timely fashion. This
reduces the amount of time spend being unaware and
entertaining wandering thoughts. The moment we become
aware of wandering thoughts is a mindful moment.

Noticing where the mind has wandered: Mind
wandering can involve a variety of thoughts including
planning thoughts, worrying thoughts, temptations,
judging thoughts, making up stories in our minds,
daydreaming, self-critical thoughts, etc… The practice of
“noting” involves simply noticing where our mind has
wandered. We don’t judge mind wandering, it is neither
good nor bad. We simply just note the process with
openness and curiosity.

Letting go of tangential thoughts: Once we note
where the mind has wandered, we let go of the
wandering thoughts whatever they may be. This practice
of letting go is important, especially when our wandering
thoughts might lure us to follow them, or make up
narratives about them. We must remember, that mind
wandering is the antithesis of being mindful. The more
we practice letting go and refocusing our attention, the
more proficient we will become in our ability to “let go” in
real world situations.

Refocusing attention: This is the process of
refocusing our attention on being present, moment
by moment, and sustaining our attention on
whatever target stimuli we have chosen. It is this
practice of refocusing that we do again, and again
throughout the process of being mindful.

ADHD Treatments: Exercise
Regular vigorous aerobic exercise can
offset stress, restlessness, and a vast array
of other symptoms associated with ADHD,
anxiety, and dysregulated mood
disorders.3-4 In consultation with your
general physician, it is recommended that
you engage in aerobic exercise 3-5 times
weekly sufficient that you maintain 60-85%
of your maximum target heart rate
throughout your workouts.

Clinical and Research Perspectives on Problem Gambling and ADHD

ADHD Treatments: Computer Programs
 Lumosity
 CogMed

Treatments: Neurofeedback

Treatments: Transcranial Magnetic Stimulation (TMS)

Clinical and Research Perspectives on Problem Gambling and ADHD

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