VIENNA, Austria — Pathological gamblers may have abnormally increased reward expectancy, making them "overoptimistic with regard to gambling outcomes," new research shows.
Investigators at the Amsterdam Institute for Addiction Research, in the Netherlands, used functional magnetic resonance imaging (fMRI) to assess brain activity in 15 participants with gambling problems and 16 without. They found that those with a gambling addiction had significantly more activation in the brain's reward areas than those without.
"When the brain responds to a higher degree to potential rewards, it may trigger increased propensity to gamble," coinvestigator Anna E. Goudriaan, PhD, told attendees here at the 25th European College of Neuropsychopharmacology (ECNP) Congress.
Dr. Goudriaan noted that this condition will be reclassified and will fall under "addiction and related disorders" in the upcoming Diagnostic and Statistical Manual of Disorders, Fifth Edition.
"This is a huge change because pathological gambling will be the first non-substance-related addiction to be put into this category."
During the same panel discussion, John E. Grant, MD, from the Department of Psychiatry and Behavioral Neuroscience at the University of Chicago, Illinois, said that clinicians should start screening all patients for this disorder.
"We already ask patients if they're smoking, drinking, or using drugs. And it's very simple to ask if there are other behaviors they feel are out of control," Dr. Grant told Medscape Medical News.
"Of course, it's important that the clinician then have some answers for how to deal with it," he added.
According to Dr. Grant, addictive gambling behaviors affect 2% to 4% of the worldwide population, but fewer than 4% of these individuals seek treatment for their problem.
Because of this, session moderator Hans-Ulrich Wittchen, PhD, from the Institute of Clinical Psychology and Psychotherapy and the Center of Clinical Epidemiology and Longitudinal Studies at the Technical University of Dresden, Germany, noted that it is important to figure out "what goes wrong in our brains when gambling behavior becomes dysfunctional."
"Why would people continue gambling even after they've lost everything? As we've seen over the past 20 years, there's evidently been an increase in those who lose control over their gambling. So what is behind this?" asked Dr. Wittchen, who is also currently the vice-president of the ECNP and a member of the steering board of the European Brain Council.
"I believe pathological gambling is as damaging and as dramatic in its consequences as alcohol dependence or any other addictive disorder."
In Dr. Goudriaan's study, 31 people in the Netherlands underwent fMRI scans during a gambling game to assess brain activity when expecting monetary wins or losses.
When anticipating a win, the problem gamblers (n = 15) showed more activation in the bilateral ventral striatum, the bilateral ventromedial prefrontal cortex, and the left insula than did those without the disorder (n =16). When anticipating a loss, there were no between-group differences in either the left insula or the right amygdala.
"It was a new finding that people with gambling problems had a higher activation in the reward areas when expecting potential wins in comparison with persons without gambling problems," said Dr. Goudriaan.
"When the brain of problem gamblers was activated more during the expectation phase of gambling (before the outcome of the game), this was associated with a higher level of intense, urgent, or abnormal desire (craving) to take up gambling activities," she explained in a release.
The release further notes that the finding may have important implications for future treatments of the disorder.
"When thinking of neuromodulation, the possibility of stimulating the cognitive-control system by implementing high-frequency repeated Transcranial Magnetic Stimulation (rTMS), and thus diminishing the responsivity of the response system, may provide a new way of normalizing the abnormal neural mechanism...as an add-on treatment combined with cognitive behavioral therapy."
The researchers add that studies are currently being conducted to test whether rTMS can change reward-responsivity in patients who are alcohol dependent.
"I thought this was a very exciting study because it shows us some of the interesting changes that might be associated with this disorder when it becomes pathological," Dr. Wittchen, who was not involved with the research, told Medscape Medical News.
"To my point of view, it also signals to us where we can look to developing better therapies," he added.
No Approved Treatment
During the panel discussion, Dr. Grant told Congress attendees that most people with a gambling addiction do not seek treatment because they do not know that treatment exists. In addition, "many primary care physicians and counsellors do not know that there are evidence-based treatments."
Although no medication has received regulatory approval in any jurisdiction as a treatment for pathological gambling disorders, Dr. Grant said that pharmacological treatments are more effective than no treatment at all.
On the basis of previous research and clinical findings, some of these include the following:
Opioid receptor antagonists, such as naltrexone, which "should be considered a first-line medication," particularly for those with family histories of alcoholism or who have strong urges to gamble;
Glutamatergic medications, including N-acetylcysteine;
Catechol-O-methyl transferase (COMT) inhibitors, which are often used to treat Parkinson's disease; and
Serotonin reuptake inhibitors, especially in those with co-occurring anxiety disorders.
"What we learn when treating gambling can often apply to a range of other behaviors, including substance and alcohol addictions. The gambler's brain has not been destroyed by a substance. So it's a pure addicted brain in some ways," said Dr. Grant.
"But it's important to realize that these people aren't thinking about the consequences of their behaviors, such as how the behaviors will affect families or jobs. Some studies have shown we might be able to use medications, such as memantine, to improve impulsive decision-making."
Memantine antagonizes N-methyl-D-aspartate receptors and has been used to treat Alzheimer's disease in patients whose front part of the brain has atrophied. Problem gamblers have been found to have hypofrontality — reduced baseline activity of the prefrontal cortex.
"The upshot is that we can actually treat gambling addiction with medication, based on the neuroscience research that is being done in gambling and addictions, in general," said Dr. Grant.
During the question-and-answer session, Dr. Wittchen asked whether the presenters thought that "the huge wave of pathological gamblers in Europe" could in part be caused by the increased use of online gambling and online gaming.
Dr. Goudriaan noted that because the Internet can bring gambling into the home, "it makes it harder to refrain from it." In addition, sites such as those offering online poker are becoming increasingly popular with young people.
"In the Netherlands, online gambling is illegal. But there are international sites, so you can get around that. And for actual casinos, you can only enter when you are over 18. But again, the Internet lets young people gamble right at home. It's exposing them at a younger age," she said.
Dr. Grant added that he thinks being online for 8 or more hours a day gaming "is fundamentally no different from gambling in terms of the brain. It's all about immediacy of the reward."
"I think we're breeding a generation of incredibly impulsive people who don't take time to wait for things," he said.
He added that pathological gambling comes from the same place many other addictions come from.
"It's a reward-inhibition imbalance. It's not that there are a lot of new disorders out there. It's different manifestations of the same biological process."
No Quick Fix
After the session, Dr. Wittchen told Medscape Medical News that he still "isn't quite sure if the pharmacological approaches are the way to go."
"In a way, we have to reeducate the brain to build up new connections. So I believe drugs might be needed to open up this door for better therapy. But at the end, I think it comes down to changing behavior by cognitive behavioral methods. There is no quick fix."
Parts of Dr. Goudriaan's research were first reported April 15, 2012, in Biological Psychiatry.
25th European College of Neuropsychopharmacology (ECNP) Congress. Presented October 14, 2012.
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Cite this: Gambling Addiction Explained? - Medscape - Oct 30, 2012.