________________________________________________________________________ Behavioral Addictions
problem gambling are heterogeneous, and a problem-gambling typology was developed to help account for these differences and consists of three subcategories [10]:
[10]. Termed the “crack cocaine of gambling,” electronic gaming machines are considered the most hazardous form of gambling, because they incorporate features that promote gambling-related cognitive distortions to perpetuate gambling, including near-win (or near-miss) outcomes and “loss disguised as a win.” These features activate the sympathetic nervous system and reward-related neural circuitry, amplified further in disordered gamblers [99; 100]. “Losses disguised as wins” undermine the decision-making capacity of disordered gamblers already experiencing cognitive distortions, so they are less likely to make rational choices. Gamblers often misinterpret near-wins as evidence they are mastering the game, which fosters an illusion of control [10]. ASSOCIATED FEATURES Smoking status is associated with more severe gambling and psychiatric symptoms. Among patients seeking treatment for gambling disorder, daily smokers (compared with non-daily smokers) were more likely to have histories of substance use disorder treatment, more severe gambling, family and social problems, and more frequent psychiatric symptoms, especially anxiety-related symptoms [101; 102]. In a study of the associa- tion between smoking and gambling in adolescents, those with “at-risk/problem gambling” who smoked were more likely to report poor grades, lifetime use of cannabis and other drugs, current heavy alcohol use, depression, aggressive behaviors, and less likely participation in extracurricular activities [103]. Gambling disorder is associated with elevated rates of suicidal thoughts and behavior. Among non-treatment seeking subjects with subsyndromal gambling disorder, suicidality was identi- fied in 18.4% [104]. Suicidality is significantly associated with mood and anxiety disorders, higher nicotine consumption, and greater impairments in decision-making and cognitive flexibility [104]. PATHOPHYSIOLOGY Disordered gambling is associated with several cognitive impair- ments, including diminished reward sensitivity from reduced reward circuit activity, reduced ability to delay reward or learn from negative consequences, stronger physiologic responses to near-wins, and poor error monitoring. The neuropsychologic impact of near-wins is a key feature in developing and main- taining gambling addiction [10]. Subjects with gambling disorder have been compared to healthy controls in numerous neuropsychologic and neuroimaging studies. Brain structure abnormalities, and corresponding functional deficits, have been identified in individuals with gambling disorder in the insula (altered near-miss cognitive interpretation), ventral striatum (impaired reward-based cognitive flexibility), frontotemporolimbic circuits (impaired concentration, memory, executive functions), PFC (cognitive rigidity, impulsivity, compulsivity), dorsolateral PFC (risky decision-making), ventrolateral PFC (impaired reward-based cognitive flexibility), and orbitofrontal cortex (risky decisions, impairments in assessing future consequences, and reward-
• Behaviorally conditioned problem gamblers • Emotionally vulnerable problem gamblers • Antisocial, impulsive problem gamblers
COMORBIDITY Gambling disorder is highly comorbid with other mental health disorders, particularly substance use disorders, and shows a heritability rate of 50% to 60% [94]. Data published before widespread access to online gambling indicate that, com- pared with non-pathologic gamblers, pathologic gamblers show a six-fold greater risk for substance use, a four-fold greater risk for illicit substance use disorder, and a three-fold greater risk for mood disorders [95]. At-risk gamblers have higher rates of psychiatric comorbidity relative to the general population [96]. RISK FACTORS Many attributes of online gambling have led to assumptions that Internet gambling may facilitate earlier onset, more rapid progression, and greater consequences related to gambling disorder compared with off-line gambling [96]. Land-based gamblers, characterized as older, female, and more likely to be divorced, show greater use of electronic gambling machines and table games and greater problem gambling rates than online gamblers [96]. Mixed (off-line and online) gamblers, character- ized by younger age, less likely to be married, and more likely to consume alcohol and illicit drugs when gambling, show a propensity to greater involvement in gambling, sustaining higher losses and consequent harms [96]. Online gamblers, consistently identified as male, younger age, higher in educa- tion and income, and employed full-time, are significantly less likely to report gambling-related problems than other gambler subgroups [96]. Unlike other behavioral addictions, online gambling is not associated with greater risk of problem or disordered behaviors, which seems more likely to develop in gamblers who prefer offline gambling in casinos or other venues [97]. In contrast to expectations of greater gambling severity and psychopathology in lower income (vs. middle/higher income) groups, a robust positive relationship is found between alcohol use disorder and gambling disorder in middle/higher income (vs. lower income) groups [98]. Gamblers preferring rapid continuous forms in land-based venues can be motivated by emotional vulnerabilities to engage in low-skill games and may be more likely to bypass responsible gambling options to persist despite losses. Setting predetermined limits is more easily achieved with Internet gambling because registration before play is required [96]. In Australia in 2010, gambling generated $19 billion in rev- enue; 55% came from electronic gaming machines in clubs and hotels, and 40% of electronic gaming machine revenue came from problem gamblers (only 0.6% of the population)
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