A systematic review and meta-analysis of cognitive-behavioural interventions to reduce problem gambling:
Pathological gambling has so far received scant attention in the psychiatric literature. Pathological gambling can adversely affect the individual, family and society, and also carries high rates of psychiatric comorbidity. Early identification and appropriate treatment can limit the long-term adverse consequences and improve outcome.
This article reviews assessment techniques and tools, and treatment strategies for pathological gambling. Gambling is a common, socially acceptable and legal leisure activity in most cultures across the world. It involves wagering something of value usually money on a game or event whose outcome is unpredictable and determined by chance Ladouceur et al The various types of gambling activities commonly available in the UK are the national lottery, scratch cards, internet gambling, casino games, sports betting, bingo, slot machines and private betting.
Results from the most recent British Gambling Prevalence Survey indicate that nearly three-quarters of the adult population had gambled in the previous year and that over half had gambled in the previous week Sproston et al For the large majority, gambling is a recreational activity with no adverse consequences. The wide array of choices available to the modern-day gambler, combined with the deregulation of gambling in the UK, is likely to result in an increase in the number of pathological gamblers and gambling-related problems Griffiths, As it is an important public health issue, associated with high rates of psychiatric comorbidity and wide-ranging personal, family and societal problems, it is crucial that mental health professionals become familiar with this disorder, its assessment and treatment.
Pathological gambling typically begins in early adolescence in males later in females and pokemon roulette codes a chronic, progressive course, punctuated by periods of abstinence and relapses. Although gambling is currently more common among men, the prevalence among women is on the increase. Women are usually older than men when they take up gamblingbut once started they develop gambling-related problems more rapidly.
In a meta-analysis of prevalence studies, Shaffer et al found the lifetime and past-year prevalence rates of pathological gambling in adults to be 1. The British Gambling Prevalence Survey Sproston et alestimated the prevalence of problem gambling in British adults to be 0. Adolescents roulette 18 red more vulnerable than adults to gambling and gambling-related problems. Although gambling is illegal for people under 18 years old, surveys have found that nearly three-quarters of adolescents had gambled in the previous year and that rates of problem and pathological gambling in adolescents were nearly twice those in adults.
Gambling in this group is strongly associated with alcohol and drug misuse and with depression, and there is some evidence linking early onset of gambling to more severe later gambling and more negative consequences. Other at-risk populations include minority ethnic groups, those from lower socio-economic groups, and those with mental health or substance misuse problems. Pathological gambling adversely affects the individual, the family and society.
Gamblers have been noted to report high rates of various psychosomatic disorders and psychiatric problems such as affective, anxiety, substance misuse and personality disorders. To fund their gambling, some resort to criminal activities, ranging from theft and prostitution to violent crime, with obvious legal consequences. Costs of gambling borne by society online gambling in turkey the cost of the crimes committed by gamblers and the various health and social care costs.
Research has consistently noted the very high rates of Axis I and Axis II comorbidity in pathological gamblers. People with problem or pathological gambling were many times more likely than the general population to report major psychiatric disorders: Depression is probably the most common psychiatric disorder comorbid with pathological gambling.
Two theories have been put forward to explain the relationship between gambling and depression. One is that gambling-related losses and other adverse consequences result in depression. Suicidal ideation, suicide attempts and completed suicides are much more common in pathological gamblers than in the general population. Severe gambling, large debts, coexisting psychiatric disorders and substance use have all been william hill wigton with an increased suicide risk.
In a retrospective chart review of pathological gamblers, Kausch noted that Other disorders commonly comorbid with pathological gambling are personality disorders, impulse-control disorders, anxiety disorders and attention-deficit hyperactivity disorder. A good assessment will help the clinician to formulate a comprehensive and effective treatment plan. Many gamblers feel ashamed and embarrassed to reveal the true extent of their problems.
It is good to ask the patient to describe in his or her own words the initiation, development and progression of the gambling behaviour in a chronological sequence. Features of tolerance, craving, withdrawal symptoms and other diagnostic criteria, if present, will readily confirm the diagnosis, but this forms only part of the assessment. Box 1 Summary of key aspects of assessment of the pathological gambler Full psychiatric history, including history of presenting complaints, and psychiatric, family, treatment, past and personal histories.
Previous attempts to cut back or quit gambling and treatments tried should inform the clinician in planning the current treatment type and setting. The clinician must evaluate the impact of gambling on work being late, absences, job losses, etc. Despite the high rates of psychiatric comorbidity in pathological gamblers, they often go unrecognised and untreated. A detailed psychiatric history-taking and mental state examination should establish whether there is comorbidity. Assessment of suicide risk past attempts at self-harm and ongoing suicidal thoughts and plans forms a crucial part of the overall assessment.
In addition to the clinical interview, several structured instruments have been developed for the screening, diagnosis and assessment of the severity of pathological gambling. More recently, many tools have been developed that attempt to assess gambling-related attitudes, beliefs, cognitions and urges.
These are useful in formulating specific treatments and in monitoring response to treatment. It may also be reasonable to use a combination of instruments to capture the complex, multidimensional aspects of gambling. A detailed discussion of the various aetiological models of pathological gambling is beyond the scope of this article.
Various theories have been postulated: To date, no single model fully explains the complex and heterogeneous nature of pathological gambling. The currently preferred approach to its aetiological understanding is eclectic, viewing pathological gambling as the result of a complex interaction between psychological, behavioural, cognitive and biological variables. Conceptualising pathological gambling as either an impulse-control disorder or an obsessive—compulsive-spectrum disorder implicates the serotonergic system in its aetiology.
There is also considerable neurobiological evidence to support serotonin 5-HT system dysfunction in pathological gambling. Hence, fluvoxamine, citalopram, paroxetine, sertraline and fluvoxetine have all been tried with some success in treatment trials for pathological gamblers. However, this study had a small sample size 5 of the 15 dropped no deposit games free money and was of relatively short duration 16 weeks.
However, Blanco et alin a larger and longer study 32 gamblers, 6 monthsfailed to demonstrate any significant superiority of fluvoxamine over placebo. In a study of 53 pathological gamblers, Kim et al noted paroxetine to be superior to placebo. Sertraline was no better than placebo in the treatment of pathological gambling in a double-blind, placebo-controlled study of 60 individuals Saiz-Ruiz et al It is also useful in reducing high-urge and craving states in people dependent on alcohol and heroin.
Hence, it is postulated that naltrexone could be used to reduce the rewarding and reinforcing properties of gambling behaviours and thus decrease the urge to gamble. Many participants reported significant adverse effects and many had elevated liver function tests, a particular concern with high-dose naltrexone treatment. Some researchers have conceptualised pathological gambling as a bipolar-spectrum disorder, because of shared characteristics such as impulsivity.
As the impulsive behaviours in mania are treated effectively with mood stabilisers, it has been suggested that these may also be effective in the treatment of pathological gambling. Case reports have shown lithium and carbamazepine to be effective in the treatment of the disorder. Pallanti et al evaluated the efficacy of lithium and valproate in a randomised single-blind study.
In all, 15 people on lithium and 16 on valproate completed the week trial. A more recent study of sustained-release lithium carbonate treatment of a sample of 40 pathological gamblers with bipolar affective disorder found significant improvements in gambling and affective instability in the treatment group compared with placebo Hollander et al Other drugs that have been used with some success in treating pathological gambling include olanzapine, bupropion, topiramate and nefazodone which is no longer licensed in the UK.
No drug has been approved for use in the UK or USA to treat pathological gambling and no clear guidelines are currently available. Trials have shown that selective serotonin reuptake inhibitors SSRIsnaltrexone and mood stabilisers are all effective, although none has demonstrated superiority over others. The existence of comorbidity might often help determine online ausmalen choice of drug. For example, choose an SSRI if there is coexisting obsessive—compulsive-spectrum disorder or depression; choose a mood stabiliser in the presence of comorbid bipolar disorder; and prefer naltrexone if pathological gambling is associated with other impulse-control disorders.
Doses of SSRIs and naltrexone required are often at the higher end of the therapeutic range and side-effects are therefore more common. As discontinuation studies are lacking, there is no clear evidence on how long to continue treatment: Although empirical evidence is lacking, a combination of pharmacological and psychological therapies might be the best option.
More robust studies looking at augmentation strategies, continuation and maintenance treatment and combined pharmacotherapy and psychotherapy are warranted. Behavioural theorists view gambling as a learned maladaptive behaviour that can be unlearned through behavioural treatments derived from both classical and operant learning theories.
Much of the early work in the s on evaluating behavioural treatments for pathological gambling focused on aversion therapy, which is no longer used. Seager found that 5 out of 14 gamblers were abstinent for 1—3 years after aversion treatment. Koller reported significant improvement in gambling behaviour in 8 out of 12 individuals given aversion treatment. However, some participants in the study also received other interventions, such as attending Gamblers Anonymous.
Other behavioural treatments that have been used successfully include imaginal desensitisation, imaginal relaxation, behavioural monitoring, covert sensitisation and spousal contingency contracting. McConaghy et al compared aversion therapy and imaginal desensitisation in 20 pathological gamblers and demonstrated both treatments to be effective.
They also noted that the imaginal desensitisation group had significantly lower levels of state and trait anxiety, and fewer gambling behaviours and urges at 1-year follow-up, compared with the aversion therapy group. This study had a relatively long-term follow-up 5. Although a range of behavioural treatments have been found to be effective in the treatment of pathological gambling, these days behavioural therapy is more often administered in conjunction with cognitive treatment, as a cognitive—behavioural treatment package.
Cognitive therapy attempts to correct these cognitive errors, which reduces the motivation to gamble. They also found that after treatment, gamblers had increased perception of control over the problem and better self-efficacy.
These positive effects were maintained at 1-year follow-up. Cognitive therapy has also been found to be effective when delivered in a group format to pathological gamblers. As already mentioned, in clinical practice cognitive therapy is often administered as part of a cognitive—behavioural package. Other treatments often incorporated in cognitive—behavioural packages include training in assertiveness, problem-solving, social skills, relapse prevention and relaxation.
Specific cognitive—behavioural treatment models have been developed and evaluated by Petry and Ladouceur kerby anderson gambling al Sylvain et al evaluated overview efficacy of cognitive—behavioural treatment in a sample of 29 male pathological gamblers. The treatment incorporated cognitive restructuring, problem-solving training, social skills training and relapse prevention. Results indicated statistically and clinically significant improvement on many outcome measures and the gains were maintained at 1-year follow-up.
In a randomised study, Echeburura et al compared four treatments: William hill advertising spend same research group also evaluated the efficacy of providing a relapse prevention treatment after a 6-week individual intervention Echeburua et al, Gamblers Anonymous is a self-help group modelled on Alcoholics Anonymous.Young Canadians today are growing up in a culture where gambling is legal, easily accessible – especially online – and generally presented as harmless. Casinos and Gambling. Welcome to the Casinos and Gambling topic! In this topic you may collaborate with your peers by participating in discussions, adding. Pathological gambling (PG) is a relatively common disorder associated with significant personal, familial, and social costs. The condition is currently classified as.