Behavioral Addictions _ _______________________________________________________________________
based cognitive flexibility) [105; 106]. Neurochemical systems implicated in gambling disorder pathophysiology include dopaminergic, glutamatergic, serotonergic, noradrenergic, and opioidergic systems [106]. In one study of gambling disorder and control subjects, reactiv- ity to gambling cues was imaged by fMRI. In gambling disorder subjects, gambling cues reliably induced craving to gamble and increased neural reactivity in the anterior cingulate cortex and insula [107]. Craving level was strongly linked to: • Hyper-connectivity between the nucleus accumbens and insula • Hypo-connectivity between the nucleus accumbens and medial PFC Gambling cues activated brain responses in reward-related cir- cuits. The intensity of cue reactivity (as craving) was influenced by impaired PFC control over the limbic system. As gambling abstinence increased, craving elicited by the gambling cues decreased. Gray’s theory provides a framework to understand behavioral addictions in terms of the sensitivity of brain systems to pun- ishment and reward [46]. Patients with gambling disorder with higher reward sensitivity have been found more likely to drop- out from treatment than those with lower reward sensitivity. In a community sample of gamblers, high reward sensitivity was associated with greater gambling frequency and social motives for gambling. Disordered gamblers in therapy are commonly urged to sever their ties with people and places that may trig- ger a relapse; when confronted by this, patients with stronger social bonds to gambling may terminate treatment. This is even more likely in early-stage gambling disorder, in which the patient attains the sought-after immediate reward and has not yet experienced distress or consequences [46]. DIAGNOSIS According to the DSM-5-TR, gambling disorder is categorized as a substance-related or addictive disorder. Diagnosis of gambling disorder requires four or more of the following [11]: • Often preoccupied with gambling • Need to gamble with increasing amounts of money to achieve excitement • Repeated unsuccessful efforts to reduce or stop gam- bling • Restlessness or irritability when trying to reduce or stop gambling • Gambles in response to negative moods • Chases losses • Lies to others to conceal the extent of gambling • Jeopardizes relationships, career, or educational oppor- tunities because of gambling • Relies on others to escape negative financial conse- quences of gambling (i.e., “bailouts”)
The exclusion of illegal activity from the DSM-5-TR criteria was not an endorsement to downplay its relevance. The presence of illegal behavior in patients with gambling disorder is directly linked to more severe pathologic outcomes and resistance to treatment; specific and more intensive treatment may be required for these patients [108]. In differential diagnosis, it is important to rule out medication side effects when new-onset disordered gambling symptoms follow initiation of dopaminergic medication in Parkinson disease [11]. Gambling disorder is included in the International Classification of Disease, Eleventh Revision (ICD-11), published in 2018 [109]. TREATMENT Despite serious psychosocial and financial consequences, most disordered gamblers do not seek treatment or may seek treat- ment only after being pressured by family members. Patient motivation and treatment adherence importantly contribute to successful treatment outcome for patients with gambling disorder [110]. Prominent barriers to seeking help for gambling problems include wanting to handle the problem by oneself, shame/ embarrassment/stigma, unwillingness to admit the problem, and issues with treatment itself. Unwillingness to admit to the problem may be more prevalent than reported. Other barri- ers include a lack of knowledge about treatment options and practical issues involving treatment attendance [111]. A main challenge in gambling disorder treatment is the high patient dropout, ranging from 43% to 80% depending on treatment modality and setting [110]. Identifying factors that improve treatment engagement is important. One study found patients receiving antidepressants plus group CBT had the longest treatment retention, regardless of gambling disorder severity or demographic factors. Given the limited benefit of antidepressants in gambling disorder, this finding was unex- pected but suggests using multiple treatment modalities may reduce patient dropout [110]. Psychological Interventions Many disordered gamblers can trace the course of their disease to an early win, followed by increasing gambling frequency and expenditure. Even early wins of $100 to $500 can increase excitement about gambling, distort self-perceptions of skill or expected returns, and strengthen irrational beliefs about gambling (e.g., illusion of control) [112; 113]. Many errone- ous beliefs and inaccurate perceptions are rewarded, learned, or become habitual during disordered gambling, and several cognitive distortions are emblematic of gambling disorder, including [71; 114]: • The gambler’s fallacy (i.e., belief that a string of losses must predict an imminent win) • The availability heuristic (i.e., selective recall of wins over losses)
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