Thomas Litwicki Emergent Recovery Introduction to Problem Gambling: Diagnosis, Prevalence, Co-morbidity, Theory and I

1. Thomas Litwicki Emergent Recovery Introduction to Problem Gambling: Diagnosis, Prevalence, Co-morbidity, Theory and Interventions

2. Definition of Gambling • Placing something of value on an event that has a possibility of resulting in a larger, more beneficial outcome (Petry).

3. Gambling is a socially acceptable form of entertainment practiced by most adults and a increasingly significant number of youth. Increased Opportunity = Increased Prevalence of Gambling Problems. Correlation between Gambling Problems and Substance Use/Behavioral Health Disorders = Need for Clinicians to Screen for the Disorder, Have an Awareness of Symptomology, and Available Treatment Options.

4. Historical Context • Dice found in an Egyptian tomb (3000 B.C.E.) • Gaming board cut into a step of the Acropolis at Athens. • Hebrews divided the Promised Land through the drawing of lots. • Colony of Virginia financed through lotteries. • Early Universities (Harvard) funded through lotteries. • Prohibition by 1910 in U.S. – to include Nevada • 1968 – first lottery in New Hamshire. • Today – 38 state lotteries, 32 casino style gambling. • Legal in every state except Utah and Hawaii

5. Internet Gambling • Internet Gambling – 8 Billion (2006)

6. What is Problem Gambling? • Recognized psychiatric disorder • Involves an uncontrollable urge to gamble • Disrupts or destroys the gambler’s personal, family and work life • Involves emotional dependence, loss of control, and interference with normal functioning • For those who have the disorder it’s not about fun but the “need” to gamble

7. Pathological Gambling: DSM-IV Criteria • The essential feature of Pathological Gambling is persistent and recurrent maladaptive gambling behavior that disrupts personal, family, or vocational pursuits.

8. Pathological Gambling: DSM-IV Criteria • Preoccupation • Is preoccupied with gambling (e.g., reliving past gambling experiences, handicapping or planning the next venture, or thinking of ways to get money with which to gamble • Tolerance • Needs to gamble with increasing amounts of money in order to achieve the desired excitement • Withdrawal • Is restless or irritable when attempting to cut down or stop gambling

9. Pathological Gambling: DSM-IV Criteria • Escape • Gambles as a way of escaping from problems or relieving dysphoric mood (feelings of helplessness, guilt, anxiety or depression • Chasing • After losing money gambling, often returns another day in order to get even • Lying • Lies to family members, therapists, or others to conceal the extent of involvement with gambling

10. Pathological Gambling: DSM-IV Criteria • Loss of control • Has made repeated unsuccessful efforts to control, cut back, or stop gambling • Illegal acts • Has committed illegal acts (forgery, fraud, theft, or embezzlement) to finance gambling • Risked significant relationship • Has jeopardized or lost a significant relationship, job, education or career opportunity because of gambling • Bailout • Has relied on others to provide money to relieve a desperate financial situation caused by gambling

11. Rule Out The gambling behavior is not better accounted for by a Manic Episode.

12. Similarities and differences (substance abuse) • Differences • Fantasies of success • No biological test • Easier to hide • Unpredictable outcome • Gambling is not self-limiting • Similarities • Loss of Control • Preoccupation • Negative impact on major life areas • Tolerance • Withdrawal Symptoms

13. Differences continued • Behavior not attributable to intoxication • More intense sense of shame and guilt • Greater financial problems • Intensity of family anger • Less public awareness and acceptance

14. Types of problem gamblers • Escape • Later Onset • Dysthymia • Machine Games (Slots/VP) • Relief/Dissociation • No Winning Phase • Gender Bias? • Action • Early Onset • Narcissistic • Games of Skill • Competition/Power • Winning Phase • More likely to be male

15. Prevalence

16. Arizona Prevalence Rates • U.S. Range of Lifetime Gambling by state is 81% to 89%. • North America • (1.6%) 2.2 Million Adults with pathological gambling • 3.9% at risk for developing • Arizona is 89%. • 69% last year, • 23% monthly, • 10% weekly. • Problem Gambling - 2.3% Overall • Pathological .7%, Problem 1.6% 2003 Arizona Gambling Prevalence StudyQuestionnaire 2,750 AZ Residents Age 18 and older.

17. Arizona population characteristics • Between 14,600 and 38,000 Pathological Gamblers in AZ • Between 42,600 and 78,000 Problem Gamblers in AZ • Most likely male age 35 – 54. • Overrepresented Among Hispanic, Unemployed, and Disabled. • 70% Casino or Lottery. • 33% Horse, Dog, Sports, Private Games.

19. Gender Differences • Women • 32% of all pathological gamblers • Start later in life – 30 • Telescoping • Problem – Pathological in one year • Men = 4.5 years

20. Older Adults • Primarily gambling behavior to relieve boredom, be active, engage in social activity. • Primarily slots, bingo, lottery. • Three times more likely to gamble daily. • Nursing Home Survey • 23% engage in games onsite more than once a week.

21. Arizona Youth Survey • Survey of 8th, 10th, and 12th graders administered every 2 years • Based on the Communities that Care Risk and Protective Factor Framework • Also includes measures on: • Lifetime, 30-day, and age of onset of alcohol, tobacco, and other drugs • Antisocial Behavior • School Safety • Gambling

22. Sample • Random sample for the state, counties, and 10 largest cities in Arizona • Conducted to ensure the ability to generalize the results at the state level • Prior participating schools • Voluntary schools

23. Gambling Questions How often have you done the following for money, possessions, or anything of value: • Played a slot machine, poker machine, or other gambling machine? • Played the lottery or scratch off tickets? • Bet on sports? • Played cards? • Bought a raffle ticket? • Played bingo? • Gambled on the Internet? • Played a dice game? • Bet on a game of personal skill such as pool, darts, or bowling?

24. 2010 AYS Results • 63,784 Valid Results • 372 Schools • Representative State and County Samples

25. % of Youth Reporting Past 30 Day Substance Use

26. % of Students Reporting Gambling in the Past Year

27. Age of Initiation • How old were you when you first gambled or bet? • Average age of all students who answer question: • 12.1 years (2008) • 12.1 years (2010)

28. Co-morbidity

29. Co-occurring disorders • In the problem gambling treatment population, 70 percent of participants reported using illicit drugs and 24 percent reported drugs had been a problem at least once in their life (Toneatto, 2002). • Iowa (Shaffer et al., 2002) found 23% of gamblers had been treated for substance abuse. • A review of 520 problem gamblers receiving gambling treatment in Nebraska revealed that 45% had received mental health or substance abuse services in the six months prior to gambling treatment, and 43% of those were receiving outpatient substance abuse treatment (Christensen, 2001).

30. Substance Abuse • 7 times more likely to have substance abuse concerns • Lifetime Level 2 – 15.01% • Lifetime Level 3 – 14.23% Shafer, Hall, Vanderbilt (1999)

31. Past 30 Day Substance Use (youth)

32. Antisocial Behavior (youth)

33. Nixon, Petry Criminal behavior

34. Age and TxHistory(prison)

35. Crime and mental health (prison)

36. Problem Activity (prison)

37. Interventions For Problem Gambling

38. Screening and Assessment • South Oaks Gambling Screen 16 Questions • NORC DSM IV Screen For Problem Gambling Up to 34 Questions

39. Assessment • DSM IV Criteria • Mental Health History • Medical History • Medications • Substance Use/Dependence • Relationships – Past/Present • History of Suicide and Harm to Others • Gambling History • Financial History – Current Debts • Religion/Spirituality • Culture

40. Why do people gamble too much? • Behavioral Theories • Positive Reinforcement – variable reward schedule. • Negative Reinforcement • Initiating but not completing a habitual behavior leads to uncomfortable states of arousal. Chasing until you win. • Vicarious Learning • Imitate behaviors that are followed by reinforcers.

41. Why do people gamble too much? • Cognitive Theories • Thinking Errors • Superstition – Luck • Interpretive Bias Win = skill Loss = fluke • Temporal Telescoping • Expecting wins sooner for self than others • Selective Memory – ignore losses • Illusory Correlations • I won because of X • Sunk-cost Effect: Willingness to engage in behavior because of money or time already in behavior.

42. Why do people gamble too much? • Dispositional Theories • Personality Factors increase risk • Extroversion • Neuroses • Impulsivity • Low ego strength • Over or under arousal

43. Why do people gamble too much? • Neurobiological Systems • Differing reinforcement sensitivity • Serotonin • Possible impact on impulse control • 2 out of 3 studies found low levels • Dopamine Imbalance • Rewarding and reinforcing behaviors

44. Treatment Engagement • 8% of Level 3 gamblers get treatment (NRC, 1999) • Why don’t they come into treatment? • 80% wished to handle problem on their own. • 50% embarrassment • Other • Gambling not perceived as a problem • Unaware treatment is available • Unable to share problems with others • Concern over stigma • Only a minority of patients identified cost of treatment as a barrier.

45. Natural Recovery • Lifetime v. Last Year • 40% of persons with pathological gambling in lifetime, do not meet criteria for pathological gambling in the last year (Higins, 1999). • 36% to 46% Level 3 gamblers considered in recovery (NRC, 1999). • Why did they Stop? • Financial loss and emotional pain.

46. Evidence Based Practice • Motivational Interviewing/MET • Motivational interviewing is a goal directed, client-centered counseling style for eliciting behavior change by helping clients to explore and resolve ambivalence. • Miller, Rollnik (1991) • 3 Randomized Clinical Trials

47. Promising MAT Approaches • Managing Cravings • Naltrexone – Opioid receptor antagonist • Inhibits dopamine release and blocks the effect of endogenous endorphines (not as rewarding) • Better than placebo in short term pathological gambling treatment. • Increased outcome for those with unusually strong urges. • Antidepressents • Inhibits serotonin reuptake • Fluvoxamine • Mood Stabilizers

48. Promising Behavioral Approaches • 12 Step • Loss of Control • Solution - spiritual and character renewal • Cognitive Behavioral • Thinking = Emotions = Behaviors • Solution – modify thinking • CRA • Skill Building – refusal skills • Reward Positive Behavior – Social Events • Contingency Management • Variable Reward Schedules

49. Peer Mutual Aid Groups • Gamblers Anonymous • Stuart and Brown (1988) followed 232 GA attendees • 7.5% received 1 year pin • 25% only attended 1 meeting • 75% attended 10 or fewer • SMART Recovery • Christian Recovery Groups • Bi-polar and Depression Peer Support Groups

50. Arizona Office of Problem Gambling missionis to provide and support effective problem gambling prevention, treatment, and education programs throughout Arizona visionis a sustainable continuum of services that reduces to a minimum level the impact of problem gambling in Arizona 100% of funding comes from gambling revenues: Tribal gaming + Lottery funds