Henrietta Bowden-Jones

Impulsivity and cognitive distortions in pathological gamblers attending the UK National Problem Gambling Clinic: a preliminary report

Background Pathological gambling (PG) is a form of behavioural addiction that has been associated with elevated impulsivity and also cognitive distortions in the processing of chance, probability and skill. We sought to assess the relationship between the level of cognitive distortions and state and trait measures of impulsivity in treatment-seeking pathological gamblers. Method Thirty pathological gamblers attending the National Problem Gambling Clinic, the first National Health Service clinic for gambling problems in the UK, were compared with 30 healthy controls in a case-control design. Cognitive distortions were assessed using the Gambling-Related Cognitions Scale (GRCS). Trait impulsivity was assessed using the UPPS-P, which includes scales of urgency, the tendency to be impulsive in positive or negative mood states. Delay discounting rates were taken as a state measure of impulsive choice. Results Pathological gamblers had elevated impulsivity on several UPPS-P subscales but effect sizes were largest (Cohens d>1.4) for positive and negative urgency. The pathological gamblers also displayed higher levels of gambling distortions, and elevated preference for immediate rewards, compared to controls. Within the pathological gamblers, there was a strong relationship between the preference for immediate rewards and the level of cognitive distortions (R2=0.41). Conclusions Impulsive choice in the gamblers was correlated with the level of gambling distortions, and we hypothesize that an impulsive decision-making style may increase the acceptance of erroneous beliefs during gambling play.

Striatal dopamine D2/D3 receptor binding in pathological gambling is correlated with mood-related impulsivity

Pathological gambling (PG) is a behavioural addiction associated with elevated impulsivity and suspected dopamine dysregulation. Reduced striatal dopamine D2/D3 receptor availability has been reported in drug addiction, and may constitute a premorbid vulnerability marker for addictive disorders. The aim of the present study was to assess striatal dopamine D2/D3 receptor availability in PG, and its association with trait impulsivity. Males with PG (n = 9) and male healthy controls (n = 9) underwent [11C]-raclopride positron emission tomography imaging and completed the UPPS-P impulsivity scale. There was no significant difference between groups in striatal dopamine D2/D3 receptor availability, in contrast to previous reports in drug addiction. However, mood-related impulsivity (‘Urgency’) was negatively correlated with [11C]-raclopride binding potentials in the PG group. The absence of a group difference in striatal dopamine binding implies a distinction between behavioural addictions and drug addictions. Nevertheless, our data indicate heterogeneity in dopamine receptor availability in disordered gambling, such that individuals with high mood-related impulsivity may show differential benefits from dopamine-based medications.

Decision making, impulsivity, and addictions: do Parkinson's disease patients jump to conclusions?

Links between impulsive‐compulsive behaviors (ICBs) in treated Parkinsons disease (PD), behavioral addictions, and substance abuse have been postulated, but no direct comparisons have been carried out so far. We directly compared patients with PD with and without ICBs with illicit drug abusers, pathological gamblers, and age‐matched healthy controls using the beads task, a test of reflection impulsivity, and a working memory task. We found that all patients with PD made more impulsive and irrational choices than the control group. PD patients who had an ICB showed similar behavior to illicit substance abusers, whereas patients without ICBs more closely resembled pathological gamblers. In contrast, we found no difference in working memory performance within the PD groups. However, PD patients without ICBs remembered distractors significantly less than all other patients during working memory tests. We were able to correctly classify 96% of the PD patients with respect to whether or not they had an ICB by analyzing three trials of the 80/20 loss condition of the beads task with a negative prediction value of 92.3%, and we propose that this task may prove to be a powerful screening tool to detect an ICB in PD. Our results also suggest that intact cortical processing and less distractibility in PD patients without ICBs may protect them from developing behavioral addictions.

Pathological gambling in Parkinson's disease--a review of the literature.

The prevalence of pathological gambling is 3.4% to 6% in treated Parkinsons disease, which is higher than the background population rate. In this review we discuss current evidence to indicate that dopamine agonists are much more likely to trigger this behavior than either L‐dopa or selective monoamine oxidase B inhibitor monotherapy. New insights from recent behavioral and functional imaging studies and possible treatment approaches are also covered. A PubMed literature search using the terms “gambling” and “Parkinsons disease,” “impulse control disorder,” “impulsive compulsive behaviour,” “dopamine agonist,” of individual dopamine agonists, and of ongoing drug trials, using http://www.clinicaltrials.gov, was carried out for the period up to January 2011.

Pathological gambling: a neurobiological and clinical update

A proposed merging of pathological gambling with the drug addictions in the forthcoming DSM-5 prompts an overview of the neurobiological data showing similarities between these conditions, as well as an update on national trends in gambling behaviour and current treatment provision.

Blunted Endogenous Opioid Release Following an Oral Amphetamine Challenge in Pathological Gamblers

Pathological gambling is a psychiatric disorder and the first recognized behavioral addiction, with similarities to substance use disorders but without the confounding effects of drug-related brain changes. Pathophysiology within the opioid receptor system is increasingly recognized in substance dependence, with higher mu-opioid receptor (MOR) availability reported in alcohol, cocaine and opiate addiction. Impulsivity, a risk factor across the addictions, has also been found to be associated with higher MOR availability. The aim of this study was to characterize baseline MOR availability and endogenous opioid release in pathological gamblers (PG) using [11C]carfentanil PET with an oral amphetamine challenge. Fourteen PG and 15 healthy volunteers (HV) underwent two [11C]carfentanil PET scans, before and after an oral administration of 0.5 mg/kg of d-amphetamine. The change in [11C]carfentanil binding between baseline and post-amphetamine scans (ΔBPND) was assessed in 10 regions of interest (ROI). MOR availability did not differ between PG and HV groups. As seen previously, oral amphetamine challenge led to significant reductions in [11C]carfentanil BPND in 8/10 ROI in HV. PG demonstrated significant blunting of opioid release compared with HV. PG also showed blunted amphetamine-induced euphoria and alertness compared with HV. Exploratory analysis revealed that impulsivity positively correlated with caudate baseline BPND in PG only. This study provides the first evidence of blunted endogenous opioid release in PG. Our findings are consistent with growing evidence that dysregulation of endogenous opioids may have an important role in the pathophysiology of addictions.

Pathological gambling and the treatment of psychosis with aripiprazole: case reports

This paper details three case reports that suggest that pathological gambling activity may have been adversely modified following treatment for psychosis with the antipsychotic aripiprazole. These reports are discussed in the context of previous observations of the potential impact of aripiprazole on impulse control and the implications such observations could have for clinical practice and future research.

The benefits of using the UPPS model of impulsivity rather than the Big Five when assessing the relationship between personality and problem gambling

Brunborg et al.’s recent paper [1] focuses on the relevance of personality factors associated with problem gambling (PG) in a study in which personality traits were examined along with subclinical gambling problems in a large-scale epidemiological sample. The study offers new insights into specific personality traits associated with PG, namely high neuroticism and low conscientiousness [1]. If these traits are indeed the most relevant personality dimensions linked to PG, then in our communicationwewould like to suggest using the UPPS model of impulsivity [2] as a more suitable framework to help us understand the relationship between personality and PG, rather than the Big Five model [3]. Based on the UPPS model [2,4], impulsivity is an umbrella construct reflected by four distinct dimensions: (i) negative urgency, defined as the tendency to act rashly while faced with intense negative emotional contexts (emotion-laden impulsivity); (ii) premeditation, defined as the tendency to take into account the consequences of an act before engaging in that act; (iii) perseverance, defined as the ability to remain focused on a task that may be boring and/or difficult; and (iv) sensation-seeking, considered as a tendency to enjoy and pursue activities that are exciting and openness to trying new experiences. In relation to the arguments developed in the current letter, it is important to emphasize that each factor has an analogue among the facets of the Big Five personality traits. Negative urgency is related strongly to neuroticism (and not to conscientiousness, as stated erroneously by Brunborg et al. [1]). Furthermore, according to Settles et al. [5], negative urgency explains variance in externalizing behaviours beyond that accounted for by other personality factors that correlate strongly with neuroticism. Moreover, it has been shown that urgency is the impulsivity facet that distinguishes more strongly between treatment-seeking pathological gamblers and matched control participants [6]. However, in comparison to neuroticism, negative urgency is a narrower construct that has been linked to specific executive and affective mechanisms (e.g. poor pre-potent response inhibition, heightened emotion reactivity) [7,8], allowing the development of more focused prevention and treatment strategies [9]. Premeditation and perseverance relate, respectively, to the ‘deliberation’ and ‘self-discipline’ facets of conscientiousness. These two UPPS components rely upon distinct underlying mechanisms [10], which are not linked identically to PG [11]. In fact, the lack of premeditation has been associated with poor decision-making abilities, which is an established hallmark of PG [12,13], whereas the lack of perseverance has been linked rather to attentional processes that are not necessary altered in PG. Accordingly, it is not surprising that low premeditation (but not low perseverance) is elevated in PG. It is thus likely that screening tools able to distinguish between premeditation and perseverance are more relevant in relation to the prevention and treatment of PG than measures capturing only a broad and multi-determined construct of conscientiousness (such as the one used in Brunborg et al. [1]). Finally, the construct of sensation-seeking (asmeasured by the UPPS) is probably more relevant in relation to PG than the broader construct of extraversion (measured by the Big Five and unrelated to PG in Brunborg et al. [1]). Indeed, although linked inconsistently to PG per se, a heightened level of sensation-seeking has been associated consistently with certain gambling preferences (e.g. gambling frequency, favoured types of games) [14,15], and thus constitutes relevant information when tailoring prevention efforts in gamblers (for example, in relation to specific game types).

Neural substrates of cue reactivity and craving in Gambling Disorder

Cue reactivity is an established procedure in addictions research for examining the subjective experience and neural basis of craving. This experiment sought to quantify cue-related brain responses in gambling disorder using personally tailored cues in conjunction with subjective craving, as well as a comparison with appetitive non-gambling stimuli. Participants with gambling disorder (n=19) attending treatment and 19 controls viewed personally tailored blocks of gambling-related cues, as well as neutral cues and highly appetitive (food) images during a functional magnetic resonance imaging (fMRI) scan performed ~2–3 h after a usual meal. fMRI analysis examined cue-related brain activity, cue-related changes in connectivity and associations with block-by-block craving ratings. Craving ratings in the participants with gambling disorder increased following gambling cues compared with non-gambling cues. fMRI analysis revealed group differences in left insula and anterior cingulate cortex, with the gambling disorder group showing greater reactivity to the gambling cues, but no differences to the food cues. In participants with gambling disorder, craving to gamble correlated positively with gambling cue-related activity in the bilateral insula and ventral striatum, and negatively with functional connectivity between the ventral striatum and the medial prefrontal cortex. Gambling cues, but not food cues, elicit increased brain responses in reward-related circuitry in individuals with gambling disorder (compared with controls), providing support for the incentive sensitization theory of addiction. Activity in the insula co-varied with craving intensity, and may be a target for interventions.

Gaming disorder: Its delineation as an important condition for diagnosis, management, and prevention

Online gaming has greatly increased in popularity in recent years, and with this has come a multiplicity of problems due to excessive involvement in gaming. Gaming disorder, both online and offline, has been defined for the first time in the draft of 11th revision of the International Classification of Diseases (ICD-11). National surveys have shown prevalence rates of gaming disorder/addiction of 10%–15% among young people in several Asian countries and of 1%–10% in their counterparts in some Western countries. Several diseases related to excessive gaming are now recognized, and clinics are being established to respond to individual, family, and community concerns, but many cases remain hidden. Gaming disorder shares many features with addictions due to psychoactive substances and with gambling disorder, and functional neuroimaging shows that similar areas of the brain are activated. Governments and health agencies worldwide are seeking for the effects of online gaming to be addressed, and for preventive approaches to be developed. Central to this effort is a need to delineate the nature of the problem, which is the purpose of the definitions in the draft of ICD-11.