Co-occurring Mental Illness and Problem Gambling

1. Co-occurring Mental Illness and Problem Gambling

2. The Victorian Statewide Problem Gambling and Mental Health Partnership Program 2009-2011

3. Partnerships

4. Our Mission: To increase knowledge and capacity within Victorian Area Mental Health services (VMHS) and Gamblers Help services (GHS) to provide optimal outcomes for clients who present with co-occurring Problem Gambling (PG) and mental illness (MI).

5. Main Aims: 1) Raise awareness…   (2) Enhance accessibility…  (3) Provide timely access…  (4) Increase knowledge and skill capacity… 

6. How are they different? What is gambling? What is Problem Gambling? Module 1

7. Gambling Module 1 “To stake money or risk anything of value on the outcome of something involving chance”. Dictionary.com website: http://dictionary.reference.com/browse/gamble

8. Defining “Problem Gambling” Module 1 Problem Gambling refers to the situation when a person’s gambling activity gives rise to harming the individual player, and/or his/her family, and may extend into the community. Victorian Casino & Gaming Authority (1998)

9. Impact of Gambling in Australia: Current finding and recommendations from the government

10. The Productivity Commission Inquiry Report – Gambling; February 2010

11. Key Points: Total recorded expenditure (losses) in Australia 2008-09: just over $19 billion (an average of $1500 per adult who gambled). The risks of problems are low for people who play lotteries and scratchies, but rise steeply with the frequency of gambling on table games, wagering and, especially gaming machines. The significant social cost of problem gambling is estimated to be at least $4.7 billion a year.

12. Most policy interest centres on people playing regularly on “pokies”. Around 600,000 Australians (4% of the adult population) play at least weekly. - Around 15% of these regular players are “problem gamblers”. Their share of total spending on machines is estimated to range around 40 per cent. There were 198,300 EGMs (pokies) in Australia in 2009. - Annual revenue per EGM was around $59,700 in 2008-09 with average revenue per venue $2.1 million. - Annual Losses per EGM player averaged around $3700 in NSW, $3100 in Vic and $1800 in Qld

13. Governments should work to establish stronger formal linkages between gambling counselling services and other health and community services, including by: Ensuring that health professionals and community services have information about problem gambling and referral pathways. Providing a one-item screening test, as part of other mental health diagnostics, for optional use by health professionals and counsellors, particularly those presenting with anxiety, depression, high drug and alcohol use. Providing dedicated funding to gambling help services to facilitate formal partnerships with mental health, alcohol and drugs, financial and family services.

14. Module 1 Understanding the Problem Gambler

15. DSM-IV definition of Pathological Gambling Module 1 In order to be diagnosed, an individual must have at least 5 (or more) of the following symptoms: - Impulse Disorder (312.31) Preoccupation. Preoccupied with reliving past gambling experiences, handicapping or planning the next venture, or thinking of ways to get money with which to gamble. Tolerance. As with drug tolerance the subject requires larger or more frequent wagers to experience the same “rush”. Withdrawal. Restlessness or irritability associated with attempts to cease or reduce gambling. Escape. The subject gambles to improve mood or escape problems. Chasing. The subject tries to win back gambling losses with more gambling.

16. DSM-IV definition of Pathological Gambling (cont) Module 1 Lying. The subject tries to hide the extent of his or her gambling by lying to family, friends, or therapists. Loss of control. The person has unsuccessfully attempted to reduce gambling. Illegal acts. The person has broken the law in order to obtain gambling money or recover gambling losses. This may include acts of theft, embezzlement, fraud, or forgery. Risked significant relationship. The person gambles despite risking or losing a relationship, job, or other significant opportunity. Bailout. The person turns to family, friends, or another third party for financial assistance as a result of gambling. The gambling behaviour is not better accounted for by a Manic Episode American Psychiatric Association (2000). Diagnostic and Statistical Manual of Mental Disorders: Fourth Edition. Washington DC: American Psychiatric Association.

17. Phases of Gambling Module 1 • Winning • Losing • Desperation • Hopelessness

18. Phases of Gambling Module 1 Desperation Presentation to service Winning Start gambling Treatment pathway Losing Hopelessness

19. Winning Phase Module 1 • Gambling episodes occur more frequently but still may be widely spaced apart. • Person experiences gambling episodes as positive and fun events. • Person starts to view gambling as an important behaviour in their lives. • An increased acceptance and rationalization of gambling.  • There may be a period without negative economic consequences. •  This phase may last for many years or can be quite brief to some or non-existent for others (especially for slot machine players).

20. Losing Phase Module 1 • Gambling episodes occur more frequently, and may be regular and habitual. • Chasing losses begins; wager size increases. • Gambling becomes a primary behaviour and replaces other hobbies and interests. Occupation and family may suffer from neglect. • Increased anxiety and depression resulting from financial pressures. Loans are often sought from banks or credit cards, then from family and friends. First “bail out” may occur. Starts to employ “creative financing” to hide losses. • Symptoms of pathological gambling begin to appear.

21. Desperation Phase Module 1 • Increased depression, shame and guilt. • May sell possessions, float checks, engage in illegal acts, do things that they never would have considered before the addiction started. • Debt related anxiety often increases further. • Physical health and sleep patterns may be affected. • Isolation from family and friends may increase.

22. Hopelessness Phase Module 1 • 20% of pathological gamblers will attempt suicide, almost all pathological gamblers seriously consider suicide. • 60% will commit a criminal offense.  • 20% will appear before the judicial system. • Although a person in this phase essentially gives up, they may still seek or return to treatment. Adapted from material written by R. Custer, M.D., R. Rosenthal, M.D., L. Rugle, Ph.D. and S. Wexler.

23. Types of Problem Gamblers Module 1 • Action Problem Gambler • Escape Problem Gambler • Internet Problem Gambler

24. Action Problem Gambler Module 1 • Can be characterized as highly competitive, domineering, controlling, manipulative and egotistical.  • See themselves as friendly, sociable, gregarious and generous. They are energetic, assertive, persuasive and confident. • Usually have low self esteem. • May have started gambling at an early age, often in their teens, by placing small bets on sporting events or playing cards with friends or relatives. • Progress through the four phases of the disorder over a ten to thirty year time span.

25. Understanding the “Action” Module 1 • Typically gamble primarily at "skill" games such as poker or other card games; craps or other dice games; horse and dog racing and sports betting.  • Both legal and illegal sports betting is dominated by these gamblers.  • Gamble to beat other individuals or the "house" and often believe they can develop a system to achieve this goal. • During the desperation phase of the disease, many action gamblers often begin to gamble specifically for escape, medicating the pain they are feeling from the destruction created by their gambling with the narcotic-like effect of slot or, more likely, video poker machines. Adapted from material written by Don Hulen, AZCCG.

26. Escape Problem Gambler Module 1 • Typically play games that do not require high levels of skills or knowledge such as handicapping. • They tend to choose games such as slot machines, video poker, cherry masters, bingo, keno, pull tabs, etc. • May go into a "trance like" state and spend extensive amounts of time "lost" in their gambling.

27. Behind the “escape” Module 1 • Most have been nurturing, caring responsible people for most of their lives.  • Most are not egotistical, have no indications of narcissism and are not out-going. • They appear to be "normal" and have an almost exact opposite character profile than that of the action problem gambler. • During their lives, various psychological traumas have occurred and commonly suffer from undiagnosed PTSD • Frequently suppress those negative feelings and do not deal with them. As time goes by and the traumas increase, a single traumatic event may take place which causes situational or clinical depression.  • Are prone to use drugs, food, sex, alcohol or gambling as a way to self-medicate.

28. Internet Problem Gambler Module 1 • Internet gambling is the placing, receipt, or other transmission of a bet or wager which involves the use of the Internet. • This type of gambling is available 24-hours a day.  • The internet problem gambler can be more capable of concealing harmful activity from friends and loved ones. • Becoming more problematic in youth.

29. The Pathways Model Reference: Blaszczynski, A., & Nower, L. (2002). A pathways model of problem and pathological gambling. Addiction, 97, 487-499. Module 1

30. Theories of Gambling Module 1 The problem with the traditional models (psychodynamic, behavioural, cognitive etc) is that they share a faulty assumption that Problem Gamblers form a homogenous group, which they do not. Attached to this is that the theoretically derived treatments (associated with these schools of thoughts) can be applied effectively to all problem gamblers. The Pathways Model has tried to address this.

31. Pathways Model Module 1 Developed by Alex Blaszczynski in late 1990’s Professor of Psychology at the University of Sydney Most Useful way to bring together all of these aspects and conceptualize this client group.

32. Pathways 1 Module 1 Behaviourally Conditioned Problem Gamblers (‘Normal’ Gamblers) No Psychopathology present or pre-morbid to gambling issue There may be circumstantial depression or anxiety associated with the outcomes of gambling

33. Pathway 1 • Ecological Factors • Increased Availability • Increased Accessability Module 1 • Classical and Operant Conditioning • Arousal/Excitement • Subjective Excitement + Physiological Arousal • Cognitive Schemas • Irrational Beliefs + Illusion of Control • Habituation • Pattern of habitual gambling established • Chasing • Chasing wins, losses • Losing more than expected Problem/Pathological Gambling

34. Pathway 2: Module 1 Emotionally Vulnerable Problem Gamblers (Depressed Gambler) This group present with: Pre-morbid anxiety and/or depression A history of poor coping/problem solving skills Negative family background/development and life events

35. Ecological Factors Increased Availability Increased Accessibility Pathway 2 Module 1 • Emotional Vulnerability • Child Disturbance • Personality • Risk Taking, Boredom Proneness • Mood Disturbance • Depression • Anxiety • Poor coping/Problem Solving • Life Stresses • Substance Use Biological Vulnerability Biochemical Serotonergic Noradrenergic Dopaminergic Cortical EEG Differentials • Classical and Operant Conditioning • Arousal/Excitement • Subjective Excitement & Physiological Arousal • Cognitive Schemas • Irrational Beliefs, Illusion of Control, Biased Evaluation, Gambler’s Fallacy Habituation Pattern of Habitual Gambling Established Chasing Chasing wins, losses Losing more than expected Problem/Pathological Gambling

36. Pathway 3: Module 1 Antisocial Impulsivist Problem Gamblers (Chronic, Personality Disordered Gambler) This group are characterised by impulsivity, disordered personality and attention deficits which manifests in severe multiple maladaptive behaviours affecting their general level of functioning.

37. Pathway 3 Module 1 They engage in a wide range of behavioural problems (independent of their gambling) including: Substance abuse Suicidality Irritability Self Harm Low tolerance for boredom Criminal Behaviour

38. Ecological Factors Increased Availability Increased Accessibility Pathway 3 Module 1 • Emotional Vulnerability • Child Disturbance • Personality • Risk Taking, Boredom Proneness • Mood Disturbance • Depression • Anxiety • Poor coping/Problem Solving • Life Stresses • Substance Use Biological Vulnerability Biochemical Serotonergic Noradrenergic Dopaminergic Cortical EEG Differentials • Classical and Operant Conditioning • Arousal/Excitement • Subjective Excitement & Physiological Arousal • Cognitive Schemas • Irrational Beliefs, Illusion of Control, Biased Evaluation, Gambler’s Fallacy Habituation Pattern of Habitual Gambling Established Impulsive Traits Neuropsychological ADHD Impulsivity Chasing Chasing wins, losses Losing more than expected Problem/Pathological Gambling

39. What do these clients look like? Co-morbidity in practice Module 1 Pathway 1: These clients have a relatively ‘normal’ presentation with their only real issue being around gambling. You are unlikely to see these clients in your work as they do not have any underlying psychopathology.

40. What do these clients look like? Module 1 Pathway 2: These clients present with symptoms of Depression/Anxiety which they have had over a long period of time. In order to cope with these disorders they have begun to gamble. They will describe being able to ‘zone out’ when they are gambling which allows them to have a break from the symptoms they are experiencing.

41. What do these clients look like? Module 1 Pathway 3: These clients are the most complex and the most entrenched in their behavioural patterns. They usually have co-morbid personality disorders and require longer term treatment. For them, gambling is a symptom of their psychopathology, and due to their problems with impulsiveness it is very difficult for them to exert any control over their gambling.

42. Pathways 3 cont… Module 1 These clients will often present in crisis, and will drift in and out of counselling over time. When they are able to be engaged and their crises contained, these clients can experience positive outcomes.

43. Overview Module 2 • Understanding co-morbidity • Current research in co-morbidity and problem gambling

44. Common co-occurring illnesses in MI & PG: Module 2 • Depression + • Anxiety + • Substance abuse +

45. Statistics of co-morbidity amongst Problem Gamblers Module 2 Epidemiological data: • alcohol use disorder (44.5%-73.2%) • drug use disorder (23.3%-38.1%) • major depression (8.8%-37%,) • mania (3.1%- 22.8%) • generalized anxiety (7.7%- 11.2%) • panic disorder (3.3%- 23.3%) • agoraphobia (5.1%-13.3%) • phobia (10%-23.5%) • obsessive-compulsive disorder (3.9%-16.7%) Bland, Newman, & Stebelsky, 1993; Cunningham-Williams, Cottler, Compton,& Spitznagel, 1998; Petry, 2005

46. Co-morbidity and pathological gambling:Epidemiological data Module 2 43,093 US adults participated in face-to-face interviews in the 2001-2002 survey: 73.2% of pathological gamblers had an alcohol use disorder 38.1% had a drug use disorder 60.4% had nicotine dependence 49.6% had a mood disorder 41.3% had an anxiety disorder 60.8% had a personality disorder Petry et al (2005)

47. Anxiety disorders and Problem Gambling: Module 2 • Kessler et al 2008 found that 60.3 per cent of problem gamblers had an anxiety disorder (odds ratio = 3.1). • Petry et al (2005) reported the prevalence rate to be 41.3% with an odds ratio of 3.4. • The Victorian Department of Justice (2009) survey found 46.36% of problem gamblers reporting anxiety compared with 7.4% of non-problem gamblers.

48. Depression and Problem Gambling: Module 2 • Volberg et al (2006): 37% of problem gamblers in their general population survey also had experienced depression in the last year. • Kessler et al (2008): 38.6% of problem gamblers have co-morbid depression • Petry et al (2005): 36.99 % of problem gamblers have a major depressive disorder in their lifetime. • The Victorian Department of Justice (2009): over 50% of gamblers reporting past year depression.

49. Alcohol abuse and dependence and Problem Gambling Module 2 73.22% of problem gamblers have been found to have a co-morbid alcohol use disorder (Petry et al 2005). In Victoria, the Department of Justice (2009) reported that compared with non-problem gamblers, using the CAGE alcohol screen: • problem gamblers were significantly (4.3x) more likely to report signs of clinical alcohol abuse problem

50. Problem gambling in culturally and linguistically diverse (CALD) communities