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Diagnostic considerations gambling use disorder
- 1. Leigh Falls Holman, Ph.D., LPCS, RPTS, NCC, CSC AMHCA Diplomate & CMHS Substance Abuse & Co- Occurring Disorders
- 2. Change diagnostic category from Substance- Related Disorders to Substance Use and Addictive Disorders The addition of Addictive Disorders indicate acceptance of process or behavioral addictions as a concept by the APA workgroup that worked on this category.
- 3. Acknowledges behavioral processes can activate the reward system and produce behavioral symptoms similar to SUDS. Includes Gambling Use Disorder as a diagnosis in Section II under the Substance-Related and Addictive Disorders category. Includes Internet Gaming Disorder (p. 795) in Section III. Other process addictions must be categorized under other diagnostic categories such as Feeding and Eating Disorders, Impulse Control Disorders, Obsessive Compulsive Disorders, and Sexual Disorders or Paraphilias.
- 4. Pre-occupation Tolerance Denial Progression Withdrawal
- 5. ◦ Clinically significant impairment or distress ◦ 4 or more criteria in 12 month period More money to achieve desired excitement (tolerance) Restless or irritable when tries to cut down/stop (withdrawal) Can’t control behavior (compulsion) Preoccupied with gambling (obsession) Gambles when feeling distressed (emotion regulation) Lies to conceal extent of gambling Impaired functioning Relies on others to provide money to continue gambling ◦ Not better explained by a manic episode
- 6. Episodic or Persistent Remission: ◦ Early: 3-12 months ◦ Sustained:Over 1 year Severity Level ◦ Mild: 4/5 Criteria (less in treatment) ◦ Moderate: 6/7 criteria ◦ Severe: 8/9 criteria
- 7. Distorted Thinking: ◦ Denial ◦ Superstitions ◦ Sense of power & control over the outcome of chance events ◦ Overconfidence “Some are impulsive, competitive, energetic, restless, and easily bored” (p. 587).
- 8. “May be overly concerned with the approval of others and may be generous to the point of extravagance when winning.” “Others may be depressed and lonely, and they gamble when feeling helpless, guilty, or depressed.” About 50% in treatment have suicidal ideation & about 17% have attempted suicide.
- 9. Prevalence ◦ Last 12 months .2%-.3% of the general population ◦ Lifetime prevalence rate gender & ethnicity Males: .6% Females: .2% African Am .9% Whites .4% Hispanics .3% ◦ More common among young & mid-life ◦ Risk & Prognostic Factors: Temperament Genetic Course Modifiers
- 10. Earlier onset: More common with males Often begin with family & friends Associated with impulsivity & substance abuse HS & college students who have the disorder may grow out of it Younger prefer sports betting Older: Machine/bingo gambling more likely Females: mid-late adult onset is typical more rapid development in females more likely than males to have depression, bipolar, & anxiety Low rate of treatment seeking in general <10%, but more older onset females present for treatment than other populations Frequency gambling can be more associated with the type of gambling than the severity of gambling. (scratch ticket vs. casino) Amount of money isn’t necessarily an indicator of a gambling problem.
- 11. Poor general health & utilize medical services at a high rates ◦ Tachycardia & angina more common in GD population even when other substance use disorders are controlled for. Jeopardize or loss of important relationships Repeated lying to cover up the extent of gambling May request money used for gambling or to pay off gambling debts Employment/educational activities may be adversely impacted ◦ Absenteeism ◦ Poor work/school performance
- 12. Differential Diagnosis: ◦ Non-disordered gambling ◦ Manic Episode ◦ Personality Disorders ◦ Other Medical Conditions (e.g. Parkinson’s meds) Comorbidity ◦ Substance use disorders ◦ Depressive disorders ◦ Anxiety disorders ◦ Personality disorders
- 13. Genetics: research “suggests that the possession of the dopamine D2A1 allele receptor gene may result in deficits in the dopamine reward pathways” (Ashley & Boehlke, p. 56). Trauma History: Kausch et al. found 64.4% Cognitive Distortions (next slide) Accessibility: Gerstein et al. double risk if within 50 miles of a casino - controversial Co-morbid SUDs, mood, ADHD Criminal behavior, Bankruptcy Suicidal Thinking
Editor's Notes
- Leigh
- Leigh
- Gambling Disorder: Persistent and recurrent problematic gambling behavior leading to clinically significant impairment or distress, as indicated by the individual exhibiting four (or more) of the following in a 12-month period: Needs to gamble with increasing amounts of money in order to achieve the desired excitement. (tolerance) Is restless or irritable when attempting to cut down or stop gambling. (withdrawal) Has made repeated unsuccessful efforts to control, cut back, or stop gambling. (Loss of control/compulsion) Is often preoccupied with gambling (e.g., having persistent thoughts of relieving past gambling experiences, handicapping or planning the next venture, thinking of ways to get money with which to gamble). (obsession) Often gambles when feeling distressed (e.g., helpless, guilty, anxious, depressed). (emotion regulation) Impaired Functioning 6. After losing money gambling, often returns another day to get even (“chasing” one’s losses). 7. Lies to conceal the extent of involvement with gambling. (Criteria 8 and 9 are least endorsed – usually most severe cases) 8. Has jeopardized or lost a significant relationship, job, or educational or career opportunity because of gambling. 9. Relies on others to provide money to relieve desperate financial situations caused by gambling. B. The Gambling Behavior is not better explained by a manic episode.
- Episodic: Meets Diagnostic Criteria at more than one time point Symptoms subsiding between episodes for several months Or Persistent: Continuous symptoms for multiple years In Early Remission After diagnosis, none of the criteria have been met between 3 and 12 months or In Sustained Remission After diagnosis, none of the criteria met 1 year or longer Severity Level Mild: 4-5 criteria met Moderate:6/7 criteria met Severe:8/9 criteria met “Those presenting for treatment most often are at the moderate to severe level of severity” (p. 586).
- Prevalence – Last 12 months .2%-.3% in general population. Lifetime prevalence rate Males: .6% Females: .2% African Am.9% Whites.4% Hispanics.3% More common among young & mid-life Risk & Prognostic Factors Temperamental: Gambling beginning in childhood or early adolescence is associated with increased rates of gambling disorder. GD appears to aggregate with antisocial PD, depressive & bipolar disorders, and other substance use disorders (particularly alcohol) Genetic Can aggregate in families related to both genetic & environmental factors More frequent in monozygotic than dizygotic twins More frequent among first degree relatives of individuals with moderate-severe alcohol use disorder
- Development Earlier onset: more common with males Youth – often begin with family & friends associated with impulsivity & substance abuse HS & college students who have the disorder may grow out of it Younger prefer sports betting OlderMachine/bingo gambling more likely Females:mid-late adult onset is typical more rapid development in females more likely than males to have depression, bipolar, and anxiety Low rate of treatment seeking in general &lt;10%, but more older onset females present for treatment than other populations Course Modifiers Many individuals are likely to resolve gambling disorder problems over time Strong predictor of future gambling problems is prior gambling problems Frequency gambling can be more associated with the type of gambling than the severity of gambling. (scratch ticket vs. casino) Amount of money isn’t necessarily an indicator of a gambling problem.
- Differential Diagnosis: Non-disordered Gambling: Professional gambling – risks are limited & discipline is central Social gambling typically occurs with friends or colleagues & lasts for a limited period of time, with acceptable losses. Manic Episode: Loss of judgment associated with excessive gambling may occur during a manic episode. Only give GD if the behavior isn’t better explained by mania. Similarly, a person with GD may exhibit behavior consistent with mania when gambling but does not exhibit this behavior away from gambling. Personality Disorders: Antisocial PD & some other personality disorders may be more prone to GD. Full criteria for both disorders must be met in order to diagnose both. Other Medical Conditions: Determine if dopaminergic medications (i.e. for Parkinson’s disease) are resulting in experiencing urges to gamble. – don’t give GD if so Comorbidity: Poor general health Tachycardia & angina more common in GD population even when other substance use disorders are controlled for. Substance us disorders Depressive disorders Anxiety disorders Personality disorders