Module 7: Pathological gambling

Question 1

To be diagnosed with a gambling disorder, one has to meet four of the following criteria during the past year (9) + indicate which ones correspond to substance abuse disorder criteria (6)

Answer 1

1.Need to gamble with increasing amount of money to achieve the desired excitement
2.Restless or irritable when trying to cut down or stop gambling
3.Repeated unsuccessful efforts to control, cut back on or stop gambling
4.Frequent thoughts about gambling (such as reliving past gambling experiences, planning the next gambling venture, thinking of ways to get money to gamble)
5.Often gambling when feeling distressed
6.After losing money gambling, often returning to get even (referred to as “chasing” one’s losses)
7.Lying to conceal gambling activity
8.Jeopardizing or losing a significant relationship, job or educational/career opportunity because of gambling
9.Relying on others to help with money problems caused by gambling

Question 2

General info on gambling from module background (4)

Answer 2

1. 87% of Dutch population has gambled in their lives (but only a few people will develop a pathological tendency)
2. most people who gamble do so on fruit machines
3. pathological gamblers report more mental disorders and substance abuse
4. living in a disadvantaged neighborhood and physical proximity is predictive of the development of pathological gambling

Question 3

Although many gamblers suffer from low rates of engagement and high dropout rates, what has been shown to reduce gambling related problems? (3)

Answer 3

CBT, both in a group and individual format

+ MI can be used to increase treatment engagement and completion
+ Gambler’s anonymous

Question 4

List the most important components of CBT for gambling disorder (6)

Answer 4

• Focus on the clients’ request for help and their motivation to achieve their goal.
• Psycho-education on the nature and characteristics of pathological gambling.
• Functional analysis to identify both the triggering and sustaining factors of gambling. These factors largely determine treatment interventions and their sequence (such as learning self-control mechanisms, training skills, etc.).
• Exerting ‘stimulus control’ to stop gambling and regain control over the behaviour in the short term (e.g., reducing availability of money, banning them from access to casinos or a gambling hall, using a filter to prevent online gambling, and transferring their finances to a significant other. Also includes increasing the rewarding value of alternative, pleasurable activities.
• Challenging “gambling illusions” or irrational thoughts.
• Relapse prevention, to identify high-risk situations for relapse, (social pressure, negative emotions, and interpersonal conflict), + provide appropriate strategies for dealing with problematic situations.

Question 5

Obesity general information

Answer 5

1. 30% of the world’s population is overweight or obese
2. 2.2 billion adults and children worldwide have health problems due to an excessively high BMI
3. (according to experts) unhealthy eating habits and low physical activity are main causes of this increase

Question 6

What do some neuroscience studies claim regarding ‘food addiction’?

Answer 6

They show support to the fact that overeating and obesity are associated with the same brain areas as drug addiction.

Question 7

What is meant by our environment being ‘obesogenic’?

Answer 7

We are surrounded by tasty, high-calorie foods which promote an unhealthy excessive diet.

Question 8

Physical effects of being overweight and obesity (4)

Answer 8

Physical:
* increased risk of cardiovascular diseases
* diabetes
* joint complaints
* certain types of cancer

! there can also be psychological complaints (due to cultural norms and stigmatization)

Question 9

How do evolutionary theories look at food addiction?

Answer 9

Due to our evolutionary focus on fatty and sweet food, we have networks in the brain that regulate motivation and food-seeking

• a prominent brain region is the nucleus accumbens

Question 10

Similarities between obese people and addicted people + why has this idea been controversial

Answer 10

Similarities:
* behavior appears compulsive - continued despite negative consequences

Controversial:
* food doesn’t have the same psychoactive effects as some drugs
* some researchers believe that only those with a binge eating disorder (not those that are obese) meet the characteristics of an addiction

Question 11

Brief history of the evolution of gambling into an addiction

Answer 11

• 1960: compulsive gambler
• 1980: pathological gambling - added to DSM-III as ‘impulse control disorder’ based on exp. by Robert Custer
• 1994: new diagnostic criteria similar to substance abuse in DSM-IV “impulse control disorders not elsewhere classified”

–> discussion starting around whether gambling is a real addiction
* 2013: gambling renamed gambling disorder and moves to “substance related and addictive disorders” in the DSM-5

Question 12

What may be the risk of defining addiction only in DSM-5 criteria?

Answer 12

There is a risk of overpathologizing -
tendency to diagnose normal human emotions, behaviors, or life challenges as symptoms of mental illness

e.g., from lecture is the study of addiction to ‘offline-friends’ (it found that 69% of people were addicted to offline friends

Question 13

Instead, how should we see addiction

Answer 13

as the interaction between
* symptoms
* brain mechanisms
* biology/genes —- * environments

Question 14

Similarities between GD and SUDs (4)

Answer 14

1. Both have a lot of comorbidity with other mental disorders
   (for GD most commonly AUD, Drug use disorder and nicotine dependence)
2. Both share vulnerabilities in genetics, male gender, age and neuropsychology
3. effective treatments look the same for both of them
4. they have a similar neuropsychological profile (more about it later)

Question 15

Gambling disorder in the DSM-5 is based on similarities with SUDs in which areas? (6)

Answer 15

• core symptoms
• comorbidities
• shared heritability / genetics
• effective treatments (CBT, nalmfene)
• functional neuroimaging
• neurocognitive profile

Question 16

Gambling disorder severity measures

Answer 16

• mild: 4-5 criteria met
• moderate: 6-7 criteria met
• severe: 8-9 criteria met

Question 17

Measuring gambling-related problems: questionnaires

Problem gambling severity index (3)

Answer 17

• 9 items, based on DSM criteria
• severity measure
• often used for general population

Question 18

Measuring gambling-related problems: questionnaires

South Oaks Gambling Screen (3)

Answer 18

• 16 items: DSM criteria + gambling specific questions (type, amount of € lost, parents)
• severity measure, often used for clinical population
• specific questions related to gambling experience that you ask when you know someone already gambles

Question 19

SUD vs GD

Neurotoxic effects in SUD unlike GD

Answer 19

On average comparing control brains and alcohol brains shows differences in ventricles –> there is brain damage when you use alcohol and this is true for other substances as well

Question 20

SUD vs GD

Gambling disorders can be a model for addiction without…

Answer 20

the confound of long term effects of drugs

–> you don’t need to think about whether cognitive deficits are a cause or consequence of addiction

this is because there are no neurotoxic effects of gambling on the brain

Question 21

How can gambling hijack the reward system and be addictive?

A) Reward uncertainty: Fiorillo et al. 2003

Answer 21

Method: monkeys learn that stimuli predict reward (lemonade) with different probabilities

when cs predicts the reward 100% of the time –> dopamine fires only at presentation of cs

when cs predicts the reward 50% of the time –> dopamine fires at onset of cs AND in the face of the reward

when cs predicts the reward 0% of the time –> dopamine fires only at presentation of the us (the reward)

Question 22

Difference of SUDs and GD, reinforcement and predictability of rewards

Answer 22

substances:
* direct reinforcing effects on dopamine system
* predictability: reward (the nice effect of drug is always delivered
(in terms of dopamine release in the brain, it always happens even after its predicted)

gambling:
* indirect reinforcement through money (/loss)
* unpredictable reinforcement rate –> reward uncertainty (remember the Fiorillo study with unpredictable rewards eliciting most dopamine release)

Question 23

What makes gambling addictive?: Machine design features

Reinforcement schedules

Answer 23

Skinner: people gamble because of the schedule of reinforcement that follows - variable/random ratio schedules

–> induces a gambler’s fallacy (a human design feature)

Variable ratio: you don’t know how many responses you need to make before a reward
- leads to the highest number of responses and lowest number of rewards

Question 24

What makes gambling addictive?: Machine design features

Timing and stakes

Answer 24

The shorter the time between bet and outcome, the more addictive
- In NL the time between bet and outcome must be 4s
- Lottery related problems are virtually nonexistent –> time between bet and outcome is long

Higher addiction potential with higher stakes
- Regulated in NL: max loss on slot machines is 40€ per hour –> quite high

Question 25

# What makes gambling addictive?: Machine design features Near-miss reinforcement without winning

Answer 25

reinforcement in the absence of winning creates a higher physiological response than actual winning which enhances motivation to gamble - e.g., the video in which you ALMOST won

Question 26

# What makes gambling addictive?: Machine design features Near misses in the brain

Answer 26

Brain imaging shows that despite the reality / net effect of a near miss/win is the same as a full loss (because you didn't actually win) it FEELS like an actual win great for casinos

Question 27

# What makes gambling addictive?: Machine design featrues Audiovisual stimuli

Answer 27

* sounds * lights * animations --> These stimuli related with a win or the anticipation of a win serve to increase arousal and reinforcement

Question 28

# What makes gambling addictive?: Machine design features Losses disguised as wins

Answer 28

Conditioned reinforcers contingent on betting masked losses - e.g., machine says you won money (8€) but you actually lost because you had to bet (30€) --> lost 28€

Question 29

# What makes gambling addictive?: Machine design features Summary of machine design features (5)

Answer 29

* Reinforcement schedules * Timing & stakes * Near-miss effect * Audiovisual stimuli * Losses disguised as wins

Question 30

# What makes some people more addicted?: Human design features Executive functions in pathological gambling: response inhibition

Answer 30

* Response inhibition measured by the Stop-Signal task was impaired * predicted of relapse at 1-year follow-up --> Gamblers show decreased prefrontal cortex activation during response inhibition

Question 31

# What makes some people more addicted?: Human design features Executive functions in pathological gambling: decision making (2)

Answer 31

1. PG is characterized by suboptimal decision making on the Iowa gambling task 2. There is a steeper delay discounting curve in pathological gamblers in the delay discouting task

Question 32

# What makes some people more addicted?: Human design features Meta-analysis on compulsivity related neurocognitive effects + limitations

Answer 32

* cognitive flexibility is reduced in gamblers * stroop task: PG show greater interference on incongruent trials limitations * research into impaired goal-directed/habitual control in gambling disorder is lacking * need for more systematic research taking comorbidity into account

Question 33

# What makes some people more addicted?: Human design features Cognitive distortions: gambler's fallacy

Answer 33

Thinking that a run of the same outcome increases the chance of the other outcome of occurring - Each is random - Higher gambling distortions -> more gambler's fallacy decisions At risk gamblers prefer slot machines that deliver more "clumpy" outcomes

Question 34

# What makes some people more addicted?: Human design features Cognitive distortions: Illusion of control

Answer 34

* Irrelevant features of a game creating a sense that one is developing some kind of skill over an outcome that is in fact determined by chance * e.g., choosing a lottery number, throwing dice --> gambler's are more prone to the illusion of control

Question 35

# What makes some people more addicted?: Human design features Cue reactivity

Answer 35

Gamblers show **increased activation** of the mesolimbic reward system during **cue reactivity**

Question 36

# What makes some people more addicted?: Human design features Reward anticipation + what is the phenomenon in line with?

Answer 36

Gamblers show **decreased activation** of the mesolimbic reward system **during reward anticipation** in line with reward deficiency syndrome: those less sensitive to rewards --> more likely to develop an addiction

Question 37

# What makes some people more addicted?: Human design features Monetary rewards are a special type of reward. Does it also generalize to erotic pictures?

Answer 37

Gamblers: **higher** activation to monetary cue than erotic Controls: **Same** activation to erotic cues and monetary ones !!!! Both signals lower in gamblers --> indicative of a general reward deficiency

Question 38

# What makes some people more addicted?: Human design features Distorted reward processing during gambling

Answer 38

Gamblers show **decreased** activation of the mesolimbic reward system after **winning** in a card game - even when they play a gambling related game

Question 39

# What makes some people more addicted?: Human design features Near misses

Answer 39

Gamblers show **increased** activation of the mesolimbic reward system after **near-misses**

Question 40

# What makes some people more addicted?: Human design features Reward anticipation during gambling

Answer 40

Gamblers show **increased** activation of the mesolimbic reward system during the **anticipation of a gambling outocme** - With general monetary rewards this effect was not observed. Only when the reward is from a game of **chance** (aka. when the predictability of the reward is uncertain) - This is in line with the anticipation graph showed earlier where dopamine was released at onset of cue AND in anticipation to reward when reward was unpredictable

Question 41

# why is gambling addictive to some but not others: Yücel et al's model 1. Habit formation (beginning, machine design)

Answer 41

the process of developing a habit engrained in stimulus-response associations acquired through reinforcement learning

Question 42

# why is gambling addictive to some but not others: Yücel et al's model 2). Problem gambling

Answer 42

Gambling behavior that is associated with some level of negative consequences and possible difficulties of self-control

Question 43

# why is gambling addictive to some but not others: Yücel et al's model 3). Addiction and gambling disorder (pathology, human design features)

Answer 43

Persistent and recurrent problematic gambling leading to clinically significant impairment or distress often with alterations in brain processes involved in reward, motivation, memory and goal-driven action

Question 44

Subtypes/first pathway: Behaviorally conditioned (4)

Answer 44

* little psychopathology * driven by social influences * cognitive distortions * availability, accessibility and early engagement in gambling --> play a key role in the development of their gambling problems

Question 45

Subtypes/second pathway: Emotional vulnerability (6) the emotionally vulnerable gambler

Answer 45

* Depressive/anxiety * low impulse * regulate dysphoric feelings * sensation seeking * risk taking * substance use

Question 46

Subtypes: Antisocial & impulsive (6)

Answer 46

* high impulsive * sensation seeking * enhance positive feelings * ADHD * antisocial behavior * substance abuse ON TOP OF THE CHARACTERISTIC IN THE SECOND PATHWAY

Question 47

GD in DSM-5 due to its similarities with SUD in (5)

Answer 47

* core symptoms * comorbidities * genetic vulnerabilities * effective treatments (CBT, nalmfene) * similar brain function distortions ad neurocognitive profiles

Question 48

Internet gaming disorder is under consideration to be included into the DSM, but eating, sex, exercise, shopping and tanning are not. Why (2)?

Answer 48

* data are inconclusive * consistent terminology and methodology are needed

Question 49

Discussion about including IGD in ICD-11

Answer 49

Asian countries put enormous pressure on WHO to go through with it: * higher prevalence * more stigma about addiction --> may have caused overestimation? * but there is again a risk of overpathologizing behavior

Question 50

Important factors for classification of future behavioral addictions (5)

Answer 50

* assessment behaviors * prevalence rates * psychiatric comorbidities * demographic and biological risk factors * promising treatment approaches

Question 51

What is the review of Clark about? (4)

Answer 51

1. Gambling affects how people think and by studying those effects (using brain scans) we might learn more about what maes people vulnerable to addiction in general 2. How a behavior can become addictive in the absence of exogenous drug stimulation by looking at: - nondrug vs. drug reward potency - mental distortions in the processing of chance --> important especially in gambling

Question 52

Why was Gambling Disorder reclassified in the DSM-5? (4)

Answer 52

Due to significant scientific evidence demonstrating similarities with substance use disorders in: * symptom profile * comorbidities * heritability * brain changes

Question 53

GD and SUD's are similar in symptom profile, what does this consist of? (3)

Answer 53

1. tolerance 2. craving 3. withdrawal

Question 54

What is the difference between neurotoxicity and neuroadaptive changes, and which is more likely in behavioral addiction?

Answer 54

Neurotoxicity refers to actively damaging effects on the brain, potentially causing cell atrophy, often associated with chronic drug exposure. Because we cannot infer actual cell atrophy from structural neuroimaging, we should be referring to neurotoxicity as neuroadaptive changes.

Question 55

What is impulsivity, and why is it considered a shared marker for addictive disorders?

Answer 55

multifactorial trait characterized by unplanned responding and hasty decision making that may be unduly risky or nelect negative consequences --> because studies show that it reflects the predisposition to develop a range of addictive disorders

Question 56

How do fMRI studies of reward processing in gambling disorder show inconsistent results regarding brain activity?

Answer 56

some reporting hypoactivity and others, hyperactivity in key brain regions involved in reward processing in individuals with gambling disorder Conclusion: signs of structural brain changes can be detected in gambling disorder but they are minor compared to most substance addictions

Question 57

What is the key finding from PET studies of dopamine D2 receptor binding in gambling disorder compared to drug addictions?

Answer 57

Drug addictions: D2 receptor binding is a robust effect Gambling disorder: studies fail to detect significant differences compared to healthy controls

Question 58

According to the updated Redish model, what two added features are critical for understanding gambling addiction?

Answer 58

1. The "big win" hypothesis (early major payouts as significant positive prediction errors that reinforce learning and gambling in the future) 2. The asymmetry in temporal-difference learning where financial losses don't trigger simple unlearning but may promote "state splitting" or hindsight bias --> explaining losses away in a manner that doesn't hurt the player's belief in his or her ability to win

Question 59

law of small numbers

Answer 59

the concept that is often the psychological account of the gambler's fallacy - people expect small fragments from a distribution to be representative of the distribution itself

Question 60

What is the proposed role of the insula region in gambling-related cognitive distortions?

Answer 60

proposed to play a causal role in gambling-related cognitive distortions like the response to near misses and the gambler's fallacy. Its function in interoception, or awareness of bodily states, may be relevant given the physiological arousal associated with gambling.

Question 61

how does the three-system model incorporate the insula

Answer 61

the insula represents a gateway between the subcortical reward system and the prefrontal system responsible for decision making and inhibitory control

Question 62

"slippery slope" concern

Answer 62

Avoiding pathologizing everyday passions - requires significant impact on daily functioning

Question 63

What is needed for considering candidate disorders?

Answer 63

detailed neural and behavioral analyses

Question 64

Behaviors that are capable of being addictive may be limited by

Answer 64

psychological properties like choice uncertainty or cognitive distortions

Question 65

# candidate disorders: Obesity and binge eating

Answer 65

* parallel with drug self-administration in animals * reduced D2 binding * addiction may be best adapted for binge eating subgroup = bias towards immediate gratification despite long-term negative consequences

Question 66

# Candidate disorders: what do obesity and binge eating NOT involve

Answer 66

1. distortions in prediction-error signaling 2. processing of chance

Question 67

# Candidate disorders: Compulsive shopping

Answer 67

Link to neurobiology of drug addiction seen in Parkinson's disease Dopamine agonists increase gain-related prediction-error signals in the ventral striatum and heighten risk taking to gain prospects in this subgroup. Very little neuroscientific research outside of Parkinson's Unclear if parallels exist in processing choice uncertainty and psychological distortions.

Question 68

# Candidate disorders: Internet gaming disorder: neurobiological/cognitive data (5)

Answer 68

* striatal dopamine release during gaming * reduced striatal D2 binding * cue reactivity * trait impulsivity * cognitive impairments

Question 69

# Candidate disorders: Internet gaming disorder: Extension of Redish model

Answer 69

Bivalent outcomes, uncertain environment, variable-ratio reinforcement schedule. Skill dimension exists but rewards remain unpredictable. Overlapping reinforcement schedules.

Question 70

# Candidate disorders: Internet gaming disorder: unique features of MMORPG's

Answer 70

* avatars * multiplayer component * game continues online --> fosters checking/counterfactual thoughts

Question 71

According to Fletcher, what is one major problem with applying the term "food addiction" to human eating behaviors?

Answer 71

lack of a discovered addictive substance in food that exerts a direct pharmacological effect on the brain comparable to addictive drugs.

Question 72

What scale is commonly used to measure characteristics thought to be common to substance and food addiction, according to the text?

Answer 72

The Yale Food Addiction Scale (YFAS) is commonly used to measure characteristics thought to be common to substance and food addiction

Question 73

Fletcher argues that studies showing addiction-like patterns in rats fed palatable food regimens have limitations. What is one key limitation he mentions regarding their translation to humans?

Answer 73

carefully controlled regimens of intermittent availability, which may not translate well to the constant and plentiful food environment most humans inhabit

Question 74

According to Kenny, what is the primary characteristic of substance use disorders (SUDs) that he believes is analogous or homologous to the struggles of some overweight individuals?

Answer 74

Kenny suggests that combinations of macronutrients, particularly in palatable high-calorie foods that do not occur naturally, may deliver a supraphysiological punch to brain motivation circuits.

Question 75

Kenny suggests that even lean individuals can suffer from patterns of dysregulated eating. What shared features with SUDs does he mention in this context?

Answer 75

He states that these patterns share many features with SUDs, including difficulty controlling food intake despite negative consequences and experiencing feelings of deprivation during abstinence.

Question 76

What type of food items does Kenny suggest may be particularly problematic, not necessarily due to a single ingredient, but due to their composition?

Answer 76

combinations of macronutrients, particularly in palatable high-calorie foods that do not occur naturally, may deliver a supraphysiological punch to brain motivation circuits.

Question 77

Both authors agree that the term "addiction" is problematic in this context. What do they suggest about the term itself?

Answer 77

Both authors agree that the term "addiction" is too imprecise and loaded to convey proper meaning, contributing to confusion and misinterpretation.

Question 78

According to the "How to move the field forward" section, what is one core principle that a scientific strategy to explore food addiction should adopt?

Answer 78

One core principle is to begin by using insights from the drug addiction literature to focus and sharpen scientific questions relating to obesity, rather than assuming overeating is a form of addiction

Question 79

The article mentions the use of choice procedures in animal models. What specific kind of maladaptive behavior in the context of drug addiction might these procedures help us understand in the context of food?

Answer 79

These procedures, which assess choices between natural rewards and drug rewards, may help us understand long-lasting shifts in dietary preferences toward highly rewarding energy-dense food items.

Question 80

What do initial results from large-scale genome-wide association studies (GWAS) suggest about the common variant genetic architectures of substance use and obesity, according to the text?

Answer 80

Initial results from GWAS suggest that the common variant genetic architectures of substance use and obesity are largely distinct from one another

Question 81

According to the DSM-5 classification, how is gambling disorder categorized and what is the significance of this categorization?

Answer 81

gambling disorder is classified as the first behavioral addiction under the category of Substance-Related and Addictive Disorders. This is significant because it acknowledges the many similarities between GD and substance-related addictions and suggests that other behavioral addictions could be classified similarly.

Question 82

What are some of the key similarities in symptom profiles between gambling disorder and substance-related disorders as noted in the text? (4)

Answer 82

overlap in criteria such as * preoccupation with the activity, * needing to increase the amount or frequency to obtain desired excitement (tolerance) * feeling restless or irritable when unable to engage (withdrawal) * jeopardizing important aspects of life due to the behavior.

Question 83

What specific criterion included in the DSM-5 for Substance Use Disorders is not explicitly listed as a criterion for Gambling Disorder?

Answer 83

craving

Question 84

Briefly describe the multifactorial biopsychosocial model as it applies to the development of gambling disorder.

Answer 84

The model explains the development of gambling disorder as a complex interaction between biological, psychological, and social factors. Genetic vulnerability, neurobiological predispositions, personality traits, environmental accessibility, and early engagement in gambling all play a role.

Question 85

Explain the concept of "cognitive misperceptions" in the context of gambling disorder and provide an example from the text.

Answer 85

abnormal or irrational thoughts about gambling. An example given is the "illusion of control," which is the mistaken belief that one's attention or effort can influence the outcome of a chance-based gambling game.

Question 86

How is impulsivity characterized in the study of both gambling disorder and substance use disorders, and what different measurement approaches are mentioned?

Answer 86

* seen as a multifaceted construct in both disorders. * measured by self-report questionnaires (like BIS-11 or UPPS) and behavioral tasks (like motor impulsivity, choice impulsivity, and cognitive impulsivity). * It is considered both a vulnerability factor and a characteristic of the disorders.

Question 87

What is delay discounting and how do studies suggest it is similar or different between gambling disorder and substance use disorders?

Answer 87

tendency to choose an immediate, smaller reward over a larger, delayed reward. Studies suggest that higher delay discounting is present in both GD and SUDs, and a meta-analysis indicated comparable levels of delay discounting across both categories.

Question 88

Describe the general findings regarding attentional bias in individuals with gambling disorder when confronted with gambling-related cues.

Answer 88

disordered gamblers show attentional bias towards gambling-related stimuli, meaning they pay higher attention to these cues. This has been measured using tasks like the Stroop task and dot-probe task. --> similar to SUDs

Question 89

What is the significance of "near misses" in gambling disorder according to the text?

Answer 89

they activate reward circuitry similarly to real wins, albeit to a lesser extent. They are associated with an increased desire to continue gambling and may play a role in developing loss of control.

Question 90

How might novel interventions like neuromodulation and cognitive training, currently being investigated for SUDs, be relevant for treating gambling disorder?

Answer 90

due to similarities in underlying mechanisms like impulsivity, craving, and abnormalities in fronto-striatal brain functions. These interventions could target cognitive control, reduce craving, or improve skills needed for therapy.