Gustavo C. Medeiros

Gambling disorder in older adults: A cross-cultural perspective

INTRODUCTION Gambling disorder (GD) in older adults is significantly increasing and became an important public health issue in different countries. However, little is known regarding GD in older adults. The prevalence and acceptance of gambling vary among different cultures and this raises the question of how and to what extent culture affects older gamblers. The majority of the important studies regarding GD in older adults have been conducted mainly in Anglo-Saxon cultures and little information is available regarding GD in other cultures. The objective of this paper is to perform the first standardized cross-cultural comparison regarding older adults presenting GD. METHODS The total studied sample involved 170 subjects: 89 from the Brazilian (BR) sample and 81 from the American (US) sample. It consisted of 67 men and 103 women (average age=64.42, standard deviation=±3.86). They were evaluated for socio-demographics, gambling behavior variables and psychiatric antecedents. RESULTS Overall, there were significant differences between BR and US older adult gamblers in marital status, onset of gambling activity, onset of GD and urge scores. DISCUSSION This study showed that there are important differences in gambling course, gambling behavior and personal antecedents between two samples of older adults presenting GD from countries with different social-cultural background. It weakens the possibility of generalization of results found in Anglo-Saxon countries to other cultures and reinforces for the need for development of research on GD in older adults outside the Anglo-Saxon culture.

Electronic gaming machines and gambling disorder: A cross-cultural comparison between treatment-seeking subjects from Brazil and the United States.

AIMS The objective of this paper is to perform a cross-cultural comparison of gambling disorder (GD) due to electronic gaming machines (EGM), a form of gambling that may have a high addictive potential. Our goal is to investigate two treatment-seeking samples of adults collected in Brazil and the United States, countries with different socio-cultural backgrounds. This comparison may lead to a better understanding of cultural influences on GD. METHODS The total studied sample involved 733 treatment-seeking subjects: 353 men and 380 women (average age=45.80, standard deviation ±10.9). The Brazilian sample had 517 individuals and the American sample 216. Subjects were recruited by analogous strategies. RESULTS We found that the Brazilian sample was younger, predominantly male, less likely to be Caucasian, more likely to be partnered, tended to have a faster progression from recreational gambling to GD, and were more likely to endorse chasing losses. CONCLUSION This study demonstrated that there are significant differences between treatment-seeking samples of adults presenting GD due to EGM in Brazil and in the United States. These findings suggest that cultural aspects may have a relevant role in GD due to EGM.

Gambling disorder: Association between duration of illness, clinical, and neurocognitive variables

Background and aims Gambling disorder (GD) may have its onset in a wide range of ages, from adolescents to old adults. In addition, individuals with GD tend to seek treatment at different moments in their lives. As a result of these characteristics (variable age at onset and variable age at treatment seeking), we find subjects with diverse duration of illness (DOI) in clinical practice. DOI is an important but relatively understudied factor in GD. Our objective was to investigate clinical and neurocognitive characteristics associated with different DOI. Methods This study evaluated 448 adults diagnosed with GD. All assessments were completed prior to treatments being commenced. Results Our main results were: (a) there is a negative correlation between DOI and lag between first gambling and onset of GD; (b) lifetime history of alcohol use disorder (AUD) is associated with a longer duration of GD; (c) the presence of a first-degree relative with history of AUD is associated with a more extended course of GD; and (d) there is a negative correlation between DOI and quality of life. Discussion This study suggests that some important variables are associated with different DOI. Increasing treatment-seeking behavior, providing customized psychological interventions, and effectively managing AUD may decrease the high levels of chronicity in GD. Furthermore, research on GD such as phenomenological studies and clinical trials may consider the duration of GD in their methodology. DOI might be an important variable when analyzing treatment outcome and avoiding confounders.

Trichotillomania and its clinical relationship to depression and anxiety

Abstract Objective: Trichotillomania (TTM) is associated with high rates of co-occurring depression and anxiety disorders. What the co-occurrence of TTM, depression or anxiety disorders means clinically and cognitively, however, has garnered little research attention. Methods: About 530 adults with TTM were examined on a variety of clinical measures including symptom severity, psychosocial measures of functioning, psychiatric comorbidity and neurocognitive testing assessing motor inhibition and cognitive flexibility. Clinical features and cognitive functioning were compared between TTM patients with current comorbid major depressive disorder (MDD), a current anxiety disorder, both MDD and an anxiety disorder, or neither. Results: Of 530 participants, 58 (10.3%) had MDD only, 97 (18.3%) had an anxiety disorder only, 58 (10.3%) had both MDD and an anxiety disorder, and 317 (59.8%) had neither. For almost all clinical measures, those with MDD only reported worse symptoms than those with an anxiety disorder only, and the combination of MDD and an anxiety disorder reported the worst level of symptom severity. Conclusions: These results suggest that adults with TTM and co-occurring MDD and anxiety disorders exhibit unique clinical differences. The clinical differences may also have treatment implications.

Association between duration of untreated bipolar disorder and clinical outcome: data from a Brazilian sample

Objective: Bipolar disorder (BD) is often left untreated for long periods, and this delay in treatment correlates with unfavorable prognosis. The present study sought to assess the magnitude of duration of untreated bipolar disorder (DUB) in Brazil. We hypothesized that DUB would be longer in Brazil than in developed countries, and would be associated with poor clinical outcomes. Methods: One hundred and fifty-two psychiatric outpatients were evaluated for BD diagnosis, demographics, DUB, and clinical outcomes. Results: The mean age and mean DUB were, respectively, 38.9±10.8 and 10.4±9.8 years. An extended DUB was associated with early onset of BD (p < 0.001), depression as first mood episode (p = 0.04), and presence of BD in a first-degree relative (p = 0.012). Additionally, a longer DUB was associated with poorer clinical outcomes, such as elevated rates of rapid cycling (p = 0.004) and anxiety disorders (p = 0.016), as well as lower levels of current full remission (p = 0.021). Conclusion: As DUB may be a modifiable variable, better medical education regarding mental health, more structured medical services, and population-wide psychoeducation might reduce the time between onset and proper management of BD, thus improving outcome.

Anxiety, Gambling Activity, and Neurocognition: A Dimensional Approach to a Non-Treatment-Seeking Sample

Background and aims Previous analyses have highlighted significant associations between gambling disorder (GD)/subsyndromal GD and increased rates of anxiety symptoms and anxiety disorders relative to the general population. However, less is known about how anxiety symptoms influence the clinical presentation of gambling problems. The objective of this study was to evaluate the association between anxiety symptoms, gambling activity, and neurocognition across the spectrum of gambling behavior. Methods The sample consisted of 143 non-treatment-seeking young adults (aged 18–29 years), in which 63 individuals (44.1%) were classified as recreational gamblers, 47 (32.9%) as having subsyndromal GD, and 33 (23.1%) met criteria for GD. Results The main findings were: (a) there was a positive correlation between anxiety severity and gambling severity measured by the number of DSM-5 GD criteria met; (b) there was a positive correlation between anxiety severity and attentional impulsiveness; (c) subjects with suicidality presented higher levels of anxiety; and (d) the severity of anxiety symptoms was negatively correlated with the quality of life. Discussion and conclusions This study suggests that anxiety may be associated with relevant clinical variables in the broad spectrum of gambling activity. Therefore, proper management of anxiety symptoms might improve the clinical presentation of gamblers in different areas.

A cross-cultural clinical comparison between subjects with obsessive-compulsive disorder from the United States and Brazil

Although OCD is a global problem, the literature comparing, in a direct and standardized way, the manifestations across countries is scarce. Therefore, questions remain as to whether some important clinical findings are replicable worldwide, especially in the developing world. The objective of this study was to perform a clinical comparison of OCD patients recruited in the United States (U.S.) and Brazil. Our sample consisted of 1187 adult, treatment-seeking OCD outpatients from the U.S. (n=236) and Brazil (n=951). With regards to the demographics, U.S. participants with OCD were older, more likely to identify as Caucasian, had achieved a higher educational level, and were less likely to be partnered when compared to Brazilians. Concerning the clinical variables, after controlling for demographics the two samples presented largely similar profiles. Brazilian participants with OCD, however, endorsed significantly greater rates of generalized anxiety disorder and post-traumatic stress disorder, whereas U.S. subjects were significantly more likely to endorse a lifetime history of addiction (alcohol-use and substance-use disorders). This is the largest direct cross-cultural comparison to date in the OCD field. Our results provide much needed insight regarding the development of culture-sensitive treatments.

Impulsive aggression in Brazil: losing opportunities to intervene

High rates of violence are widespread in Brazil. In 2012 alone, an average of 154 homicides were committed per day in the country. Furthermore, approximately 50% of all injuries suffered by women are due to physical aggression; verbal aggression against females is also a common occurrence in Brazil. In the city of São Paulo alone, the Military Police receive up to 70 calls per day for severe road-rage incidents, which often result in physical injuries or even death. Despite the prevalence of these problems, there is a large gap in the current psychiatric understanding of aggressive behaviors in Brazil. Aggression can be classified either as pathologic or as incidental/situational, as is the case in defensive responses. Pathologic aggression is divided into two types: premeditated aggression and impulsive aggression (IA). Premeditated aggression is characterized by planning prior to the aggressive act and is classically associated with antisocial personality disorder. Conversely, IA is characterized by unplanned outbursts, and the aggressor’s empathic capacity is usually preserved. Negative feelings such as guilt, sadness, and regret often follow the outbursts. IA is also characterized by a significantly different neurobiology and phenomenology in comparison with premeditated aggression. Intermittent explosive disorder (IED) is the paradigmatic disorder of IA. Typical patients with IED present with recurrent and problematic aggressive behaviors, including both verbal and physical aggression, as well as destruction of property. IED is associated with substantial distress, difficulties in social and professional functioning, and monetary and legal problems. Studies of the U.S. population have estimated the lifetime prevalence of IED as 5 to 7%, and found that most of these individuals do not seek treatment. However, to the best of our knowledge, no study has addressed IED in Brazil. In this letter, we report the case of a patient with high levels of IA and a formal diagnosis of IED according to DSM-5 criteria. A 30-year-old male presented with repetitive aggressive behaviors evident since late adolescence. The patient sought treatment voluntarily after having verbally and physically assaulted his last three girlfriends, which precipitated the end of the relationships as well as legal issues. The patient described his IA as follows: ‘‘When I become angry, I just don’t think’’, and reported that, when irritated, he ‘‘does things blindly’’. Other notable incidents of IA included having broken more than 10 cell phones and intentionally crashing his car into other drivers on several occasions due to perceived ‘‘disrespect’’ while in traffic. The patient also noted that he had lost his job after an intense argument with his boss due to a minor issue. The patient reported feelings of deep regret and guilt after his outbursts of anger. He began individual cognitive behavioral therapy (CBT) in June 2013, but despite improvement, still experienced some relapses. After starting fluoxetine in February 2014, he acknowledged further improvements in

Mental health of refugees: report of a successful case in Brazil.

Refugees have a substantially higher risk of developing a variety of mental disorders. Between 2000 and 2010, Brazil saw an 87% increase in the number of immigrants, a major portion of whom are refugees. However, there is little research and training focused on this subject, and it is given little importance. Recognition and proper treatment of mental health problems in this population are challenging due to differences in language and culture, in addition to the specific stressors associated with migration and resettlement. We present a case that exemplifies successful multidisciplinary treatment of a refugee that addressed the specific problems of this population. A 23-year-old black male born in the Democratic Republic of the Congo, the country with the world’s worst quality of life, arrived in Brazil after a series of traumatic events. He witnessed the kidnapping and murder of two friends and the violent execution of his parents, and was himself kidnapped and physically and sexually abused. He came to Brazil by ship, as a stowaway, in a precarious and clandestine journey. All the information given was corroborated by documentary evidence and by an investigation by the Federal Police. The patient was admitted to the Outpatient Transcultural Psychiatry Unit of Hospital das Clı́nicas da Faculdade de Medicina da Universidade de São Paulo with posttraumatic stress disorder (PTSD) and a major depressive episode, meeting both DSM-IV-TR and DSMV criteria. Personal and family neuropsychiatric history, blood tests, and brain magnetic resonance imaging were normal. During the first 3 months, treatment was essentially pharmacological. Two classes of antidepressants were trialed, at appropriate doses and for appropriate lengths of time; however, the patient experienced progressive worsening of symptoms. The patient also lacked psychosocial support, with no significant relational bonds, housing, income, legal recognition, employment, or familiarity with the Portuguese language. This is a common situation in the refugee population. With the help of Caritas Arquidiocesana, a Roman Catholic relief organization that provides support to refugees, and volunteers, we then pursued a multidisciplinary and comprehensive approach that included: case discussion in the hospital’s grand round for therapeutic planning; psychiatric follow-up; support psychotherapy for 6 months, followed by shorter cycles for management of exacerbations; legal aid to help the patient gain refugee status and obtain documents; an intensive Portuguese language course; educational support (including scholarships for a pre-college examination, free vocational Figure 1 Progression of symptoms and quality of life of a refugee patient. PTSD = posttraumatic stress disorder. Letters to the Editor 274

A cross-cultural study of gambling disorder: a comparison between women from Brazil and the United States

Objective: To perform a cross-cultural comparison of gambling disorder (GD) in women from Brazil and the United States, two countries with pronounced social and cultural differences. We hoped to produce insight into the impact of cultural influences on the presentation of GD in women, which may be useful for the development of culturally-sensitive interventions. Method: We assessed 681 women with GD: 406 from a Brazilian sample and 275 from a U.S. sample. We assessed demographic and gambling behavior variables in addition to co-occurring psychiatric disorders. Results: Fewer Brazilian participants were Caucasian (73.3 vs. 91.3%; p = 0.022). Also, Brazilian women had lower levels of education (59.9% with high school or less vs. 44.4%; p < 0.001), and were more likely to have a current partner (54.9 vs. 43.4%; p = 0.003). Brazilian gamblers also reported lower urge scores (6.6±4.3 vs. 11.6±2.4; p < 0.001) and higher chasing rates (89.1 vs. 80.0%; p = 0.002). Brazilian gamblers reported higher rates of bingo gambling (19.2 vs. 5.7%; p < 0.001), but lower rates of card game gambling (5.8 vs. 23.1%; p < 0.001). Finally, Brazilian gamblers were more likely to endorse a history of major depressive disorder (36.9 vs. 24.4%; p = 0.001). Conclusions: This study reinforces the need for further general cross-cultural research on GD and particularly for studies investigating how gender mediates these differences. Finally, the differences noted in this analysis suggest that the findings of predominantly Anglo-Saxon cultures may not be generalizable to other world populations.