Uncovering the different subtypes of Problem Gamblers: An empirical testing of the Pathways Model and its clinical impl

1. Uncovering the different subtypes of Problem Gamblers: An empirical testing of the Pathways Model and its clinical implications Gupta, Blaszczynski, Nower, Derevensky, & Faregh March 11, 2010 Sacramento, California

2. Context After many years of researching and working with teens, it became evident that not all were similar in their presentation and etiology. Their gambling behaviors may have been similar, but distinct sub-types of people were emerging.

3. In order to better understand… Apply a theoretical framework to represent a complex phenomenon Measure this phenomenon with identifiable and measurable units of information A scientific approach will never reflect the true depth of human behavior, but it may reflect enough so that we may advance the current state of knowledge

4. Background Jacobs’ General Theory of Addictions (1989) postulates that all addictions are a “…dependant state acquired over time by a predisposed person in an attempt to relieve a chronic stress condition” Under/ Overactive physiological resting state Psychological characteristics such as low self-esteem

5. Pathwaysmodel Blaszczynski’s model is based on the premise that there exist different typologies of gamblers and that it is counter productive to merge distinctly different types of people into a single heterogeneous group.

6. Nower & Blaszczynski (2004) Proposed that the Pathways model can also serve as: “…an effective template for the development of early intervention, prevention, & targeted clinical management strategies for adolescent and young adult gamblers.”

7. The Pathways model proposes that there are a minimum of three subgroups of problem and pathological gamblers with distinct clinical features and etiological processes. This theoretical model is based on the premise that there exist different typologies of gamblers and that it is counter-productive to merge distinctly different types of people into a single heterogeneous group

8. Pathway 1- Behaviorally conditioned youth problem gamblers. These youth develop gambling problems as a result of conditioning rather than impaired control. They are characterized by an absence of premorbid psychopathology. Anxiety can surface as a consequence of gambling problems.

9. Pathway 2- Emotionally-Vulnerable Youth Problem Gamblers These young gamblers present with premorbid depression and/or anxiety, low self-esteem, poor coping, a history of familial neglect or abuse, and present with other adverse behaviors.

10. Pathway 3- Antisocial Impulsivist Youth Problem Gamblers These young gamblers present with premorbid psychopathology suggestive of neurochemical dysfunctions. They share many things in common with Pathways 2 individuals, but they are distinct in their features of impulsivity and antisocial personality disorder which impair their overall psychosocial functioning.

11. “Science may be described as the art of systematic over-simplification.”-Sir Karl Raymund Popper Testing a model empirically is a very complex undertaking. This study is the first to attempt to do so, and should be considered exploratory in nature. This study is limited by its cross-sectional nature and needs replication.

12. The sample 1133 students from Ontario and Quebec schools All English speaking 49.5% male, 50.5% female Grades 7 through 12

13. Gambling severity Non-gamblers 19.3% (n= 214) Social gamblers 70.4% (n= 779) At-Risk gamblers 7.2% (n= 80) PPG 3% (n= 33)

14. Instruments DSM-IV-MR-J GAQ Millon Adolescent Clinical Inventory (MACI) Conners-Wells self report scale Erroneous cognitions questions

15. MACI description 160 item self-report inventory designed specifically for assessing adolescent personality characteristics and clinical syndromes. “It is useful in the evaluation of troubled adolescents, and it may be used for developing treatment plans and as an outcome measure.” -p. 1 manual

16. The MACI measures 12 personality patterns 8 expressed concerns 7 clinical syndromes Reliability Internal consistency alpha coefficients range from 0.73 to 0.91 Test-retest obtained a median stability coefficient of 0.82

17. Plan of Analysis

18. An empirical classification of homogeneous subgroups by distinctive traits through 8 MACI variables*, making use of Latent Class Analysis (LCA) * 9 variables selected based on Pathways Model postulates

19. Problem gamblers were composed of at-risk and ppg youth. • Step-wise mixture modelling technique in Mplus 5.21. • Global fit indices for model parsimony and fit (BIC and AIC), overall classification soundness (entropy), the Vuong-Lo-Mendell-Rubin Likelihood ratio, the Lo-Mendell-Rubin Adjusted LRT test, and the bootstrapped parametric likelihood ratio tests for the K-1 models.

20. Results

21. A 4 class solution: optimal * Sample size adjusted

22. Classes and control group for 8 MACI variables (mean scores*) Variable C1 C2 C3 C4 Control group (N=924) Self-demeaning 19.3 29.5 90.0 56.1 45.623 Family discord 36.8 76.5 77.8 61.3 59.15 Childhood abuse 9.9 25.9 70.6 32.6 28.51 SAP** 19.5 84.7 73.2 39.5 43.53 Impulsivity 31.5 73.7 72.3 46.9 47.67 Anxious feeling 63.9 30.4 55.8 64.5 59.76 Depressive affect 35.4 30.7 99.1 73.1 59.87 Suicidal tendency 8.4 13.9 78.5 30.7 26.19 *A mean MACI score of > 60 reflects clinical range ** Substance abuse propensity

23. Class descriptions

24. Class 1: Anxious feelings (minimally significant) Class 2: Impulsive, prone to abusing substances (poor coping/ impulsive nature), reported family discord Class 3: Impulsive, prone to abusing substances, reported family discord, childhood abuse*, self-demeaning (very significant), depressive affect (very significant), suicidal tendency Class 4: Anxious feelings, depressive affect, family discord (minimally significant) * Self-demeaning, suicidal tendencies, and high depressive affect linked to childhood abuse only

25. Additionalfindings Problem gamblers are more likely to fall into class 3 (distinguished by childhood abuse, and combination of impulsivity and mood disorder) than any other class No significance in endorsement rates of DSM-IV-MR-J items between classes No significant differences in types of gambling activities and rates of play between classes

26. How do our 4 classes match up with the pathways model?

27. Three of our classes align very nicely with the 3 proposed pathways in the PM Pathway 1= latent class 1 Pathway 2= latent class 4. However, unlike those in PM, those experiencing childhood abuse are in a class of their own. Pathway 3= latent class 3

28. There is one meaningful difference: • our data points to a 4th class of people who are impulsive, prone to other addictions, but do not experience depressive/anxious symptoms (our latent class 2). • Based on our clinical experience with youth, we often treated gamblers who were either primarily impulsive OR depressive/anxious, so the addition of the 4th class makes a lot of sense, as the Pathways \model does not account for a unique subset of problem gamblers who are primarily impulsive but not depressed.

29. What does this tell us? Blaszczynski was onto something. Nower and Blaszczynski were also warranted in their belief that this pathways model could apply to youth.

30. Should the theory be modified? Replication studies are necessary, with different methodologies and larger subject pools, before any modifications or additions to the Pathways Model are warranted. Having said that, further exploration into the validity of a 4th pathway is warranted at this time.

31. Conclusions • Strong support for the premise that not all problem gamblers are the same

32. Implications Assessment on intake of gamblers in treatment should be extensive (clinical syndromes, history of abuse, impulsivity, personality concerns). Treatment should be tailored to these etiological factors and co-morbid disorders.

33. Implications • Treatment providers must be proficient in treating mood & impulse control disorders, and co-morbid addictions. Furthermore, it is important to be comfortable working with a family systems approach as well as in dealing with underlying contributing issues such as childhood abuse. • Therefore, an eclectic training is ideal so that treatment can be properly tailored to each of the 4 subgroups of problem gamblers.

34. Therapy: Class 1 • Cognitive restructuring of erroneous beliefs pertaining to gambling participation. • Financial counselling. Outcome excellent.

35. Therapy: Class 2 • Impulse control management is primary focus. Environmental and emotional triggers need to be identified and client is taught more effective ways of coping. Family systems approach would be helpful as well. Cognitive restructuring, financial counselling and management of budget skills. Anticipated outcome good, but relapse risk is high due to impulsive style.

36. Therapy: Class 3 • Primary focus on mood disorder and underlying cause of childhood abuse. Focus also on making them feel better about themselves and be less self-demeaning, self-destructive. Secondary focus on triggers and impulse control issues. Minimal focus on cognitive restructuring until primary mood and underlying issues dealt with. Anticipated outcome: guarded. Risk of relapse high.

37. Those experiencing childhood abuse are going to require a more comprehensive approach psycho-therapeutic approach and lengthy treatment protocol. Abuse leads to self-demeaning thought patterns, depression, and self-harming behaviours.

38. Therapy: Class 4 • Treatment of mood disorders is primary focus. Family systems approach, and financial counselling also useful. Cognitive restructuring may be necessary but minimal. Outcome good, lower risk of relapse if depression/anxiety under control.

39. Pharmacotherapy may be indicated for those experiencing underlying impulsivity, depression, and/or anxiety disorder. Grant et al. have proposed the benefits of SRIs, mood stabilizers, and Naltrexone for the treatment of problem gamblers.

40. Common therapeutic threads across subtypes • Focus on gradually cutting down gambling involvement (time, money, frequency). Requesting immediate abstinence will result in elevated treatment dropout rates. (Best achieved by establishing a baseline rate and working from there.)

41. Restructuring free time: Most temptation occurs when faced with free time. Help them plan and organize their time on a weekly basis.

42. Replace the gambling with other activities. Encourage a balanced lifestyle (i.e., exercise, taking on a hobby)

43. Involve others as supports, such as significant other, friends, relatives. (Support groups, such as GA can be useful in conjunction with therapy, especially when other supports are unavailable.)