December 14, 2009 (Los Angeles, California) — Social or problem gamblers who may not meet the full Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition) (DSM-IV) criteria for pathological gambling may nevertheless demonstrate heightened impulsivity traits that can serve as red flags for a potential escalation into gambling addiction, according to new research presented here at the American Academy of Addiction Psychiatry 20th Annual Meeting & Symposium.
Furthermore, researchers say, screening for these traits may help prevent more serious gambling problems.
In assessing potential problem gamblers, clinicians may wind up categorizing patients either as pathological or not and fail to consider important signs of impulsivity that may not add up to pathological gambling on their own but are clues to possible future issues, said Timothy Fong, MD, assistant clinical professor of psychiatry at the UCLA Neuropsychiatric Institute and Hospital in Los Angeles, California.
"In medical school, we’re taught to put things in categories, such as certain things cause cancer, but the world isn’t like that," he said. "A patient may not have met the full criteria for pathological gambling, but they’re still incurring harm, so where do they fit?"
Comparing impulsivity performance across the spectrum of the DSM-IV with impulsivity scores on screening measures might help offer a clearer picture of a natural course of problem gambling, said Dr. Fong.
"We wanted to find out what things would look like if this was a dimensional construct instead of categorical,” he said. "Would the measures of impulsivity and neurodysfunctions still exist on a spectrum, or would we see wide variance?"
The researchers recruited 144 social, problem, and pathological gamblers and enrolled them based on criteria of having gambled at least once in the previous 2 weeks and having no co-occurring psychiatric or addictive disorders.
The subjects underwent a battery of neurocognitive tests to measure impulsivity, including a combination of self-report inventories and computerized assessments. The tests included a delayed discounting screening, which measures behavior economics and presents scenarios in which, for example, subjects are offered a choice of receiving money immediately or receiving a greater amount at a future date.
"This measures temporal sensitivity, with the choice of smaller immediate rewards indicating an impulsive personality," Dr. Fong said.
Other tests included the Barratt Impulsiveness Scale, a self-importance questionnaire measuring how patients think, act, and plan; the NEO Personality Inventory, a personality questionnaire with a subscale for impulsivity; and Conner’s Continuous Performance Test.
The impulsivity test results were then divided into a categorical perspective of the subjects’ gambling, according to DSM-IV criteria, with social gamblers (n = 18) having zero DSM criteria, problem gamblers (n = 49) having 1 to 4 DSM-IV criteria, and pathological gamblers (n = 77) having 5 or more criteria.
For each of the tests, with the exception of Conner’s Continuous Performance Tests, the impulsivity test results showed a positive correlation with the number of DSM-IV criteria for pathological gambling, according to Pearson and Spearman correlation coefficients.
For the NEO Personality Inventory (n = 124), the correlations were Pearson R = 0.38 (P = 1.5e – 05) and Spearman R = 0.35 (P = 8.1e – 05). For the Barratt Impulsiveness Scale (n = 135), the correlations were Pearson R = 0.51 (P = 2.4e – 10) and Spearman R = 0.51 (P = 2.2e – 10). For the delayed discounting task (n = 118), the correlations were Pearson R = 0.34 (P = 2e – 04) and Spearman R = 0.33 (P = .00032).
"For each, there was a nice, clean relationship — the higher the DSM-IV criteria, the higher the impulsivity measures," Dr. Fong said. "It’s clear that the more people have impulsive measures, the more likely they will have higher DSM scores [for compulsive gambling]."
The findings indicate that the symptoms of potential problem gamblers may be detected on a dimensional reading that demonstrates a natural course of problem gambling.
In an ongoing clinical trial, Dr. Fong’s team is looking at the full range of impulsivity measures among pathological gamblers and the potential of cognitive behavioral therapy to treat the condition.
"We’re linking the measures of impulsivity and neurocognition before, during, and post treatment to see if and how these measures change," he said.
Screening Worth the Effort
In the meantime, clinicians can use existing screening tools, such as the delayed discounting measure, to spot the signs of problem gambling and provide early intervention.
"If a patient’s delayed discounting is extremely high, for instance, you can start treatment, and if after treatment the measure goes back down, then you now have an effective marker and a way of showing that their gambling can probably also be reduced," Dr. Fong said.
With impulsivity also lying at the root of other addictions, the screening measures can offer key information for preventing a slide into any number of addictive behaviors.
"We use screening measures all the time for alcohol use or drugs or smoking, but I think the task for us as clinicians is to move forward and use screening measures for impulsivity at intake," said Dr. Fong.
According to Dr. Fong, when a patient scores high on basic measures of impulsivity, that should serve as a red flag to clinicians that they need to screen for other addictive disorders, such as gambling, sex, or video games.
The study’s findings help justify the use of impulsivity tests and suggest to clinicians that their efforts in screening for such measures could be well rewarded, added Steven Bakti, MD, a professor of psychiatry and behavioral sciences at Upstate Medical University in Syracuse, New York.
“I thought the report by Dr. Fong provided information that could and eventually should be adopted by clinicians seeking useful tests to measure the severity of the cognitive impairments that could underlie some of the pathology involved in gambling and other addictive disorders,” he said.
"These measures are also highly promising ways to attempt to predict clinical outcome and response to treatment, as well as to sequentially measure response to treatment."
The study was funded by the National Institute on Drug Abuse K23 Career Development Award. Dr. Fong discloses that he has received research support from the National Institute on Drug Abuse, OPG, Ortho-McNeil, and the Annenberg Foundation. He is on the speaker's bureaus for Pfizer, Rickitt Benckiser, Forest, and Lilly. Dr. Bakti has disclosed no relevant financial relationships.
American Academy of Addiction Psychiatry (AAAP) 20th Annual Meeting & Symposium. Presented December 6, 2009.
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