Addiction & Mental Health Resources

Introduction

In this presentation, Dr. Luke Clark, Director of the Centre for Gambling Research at UBC, will consider the modern conceptualization of pathological gambling (or Gambling Disorder) as a behavioural addiction. After briefly reviewing diagnosis and prevalence, the talk will focus on the distorted styles of thinking that occur during gambling, and their neurobiological basis in terms of brain chemistry and the brain reward system. [Taken from YT Description]

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Gambling Lecture Review & Sources

Objectives of the Centre for Gambling Research at UBC

• To provide a focal point for research on gambling and problem gambling across the province
• To reduce the harms associated with problem gambling (e.g., treatment, prevention)
• Strengthening the scientific base for gambling policy

Gambling in British Columbia

To the best of my knowledge, I believe these statistics were taken from ‘Lower the Stakes: A Public Health Approach to Gambling in B.C.’, which relied upon Ipsos Reid: British Columbia Problem Gambling Prevalance Study.

• 73% of participants were involved in gambling in the last 12 months.
• The most popular forms of gambling were lottery, charity raffles, casinos, private games, and sports betting.
• The prevalance of problem gambling was 4.6%, with 0.9% being severe enough to receive a diagnosis.
• If we take a slightly looser definition of ‘moderate risk’ or ‘at risk gambling’, it’s about 4-5% of the population that is experiencing some of the harms associated with gambling.
• For problem gamblers, they typically engage in: internet gambling, electronic machines, poker, sports betting.
• Problem gamblers account for 26% of the total revenue in the gambling industry.

Pathological Gambling as The First Behavioural Addiction

• Gambling Disorder is the first recognized behavioural addiction in the DSM-5.
• The DSM-5 update removed ‘illegal acts’ as part of the diagnostic criteria.
• A diagnosis is made when 4 of the 9 features are present.
• The decision to move it into the addictions category was based evidence that problem gambling is similar to chemical addictions, such as including withdrawal symptoms and tolerance.
• Gambling addiction has comorbitity with other diagnoses, e.g., those seeking traetment have elevated levels of substance use disorders, especially nicotine and alcohol.
• Research into shared heritability shows a genetic component to the disorder.
• Effective treatments for chemical dependency are also being shown to help with gambling addiction, e.g., Naltrexone, an opioid antangonist, has been used to treat heroin and alcohol dependency, and is now being used for this disorder in clinical trials.
• There is also an overlap in neuroimaging / neurocognitive similarities, e.g., groups of people with problem gambling have similar profiles to groups with substance dependence.

A Public Health Approach To Gambling

• There are certain risk factors at the level of the gambler, the individual – e.g., personality traits such as impulsivity.
• There are psychological characteristics of the games, and we can think of this in terms of classical conditioning – e.g., the speed of the game, size of the rewards, the rate of the rewards.
• The modern games, however, also have more sophisticated features – e.g., Near-Misses, Gambler’s Fallacy, Illusory Control.
• This relationship between the game and the gambler is occurring within the gambling environment: what kinds of games exist, what games are legal, what games are widely accessible, can you access these games on the Internet and so on. This is where the gambling legislation becomes particularily relevant.

The British Situation

• The National Gambling Clinic (London, UK) offers a treatment program primarily focused on Cognitive Behavioural Therapy, supplemented with debt counselling and family therapy. Some of the clients engaged in research, undergoing a clinical and cognitive assessment. A portion of these clients then participated in more complex studies involving brain imaging.
• This study, by Bowden-Jones et al. (2022), is the largest of its kind that has ever been done in the UK. They compared a group of gamblers with a control group (e.g., those who do not gamble or only gamble recreationally at low levels)
• FINDINGS: participants were primarily male and the preferred form of gambling was electronic roulette. This type of gambling is more popular in the U.K. because they do not have much of a casino culture. This type of roulette is much faster than table roulette, and two of the features mentioned previously, the speed and stakes of the game, that underlie the risks of developing this addiction are being shown to be linked to these games.

Impulsive Decision-Making

• The Cambridge Gambling Task (CGT) is used to study decision-making.
• Results presented in this lecture show that the problem gambler is more likely than the healthy control to choose the unlikely colour; this is effectively an irrational decision. They also tend to place higher bets on those decisions.
• This profile was not limited to problem gamblers – it was also seen with alcohol dependence.
• Impulsive decision-making is a cognitive marker that seems to cut across addictions and is a risk factor that predates the onset of the addiction.

Dopamine

• Dopamine is targeted either directly or indirectly by all drugs of abuse.
• Dopamine receptor levels are reduced in the brain of patients with different forms of drug addiction.
• The main treatments for Parkinson’s aim to replenish the dopamine system, but there is a side effect of spontaneous gambling linked to some of the medications.
• One component of impulsivity is urgency, a mood-related impulsivity (e.g., doing impulsive things when you’re in a low mood or anxious state, or a when you’re feeling very high and euphoric).
• Gamblers with the highest levels of urgency show a reduction in dopamine receptor levels.

Opioid System

• Endogenous opioids, like endorphins, are involved in euphoria, and has an important role in analgesia.
• Problem gamblers show blunted opioid release across several brain regions, including the striatum and parts of the prefrontal cortex.
• There is a weaker opioid release in gamblers and they also show less euphoria as a subjective mood response to opiates (I believe the source is from Mick et al., 2014).

Functional Imaging of Gambling Tasks

• A study by Reuter et al. (2005) compared the brain activity of participants before and after the wins and losses.
• The controls showed a strong response from the the striatum and prefrontal cortex (re: dopamine).
• This is reduced in gamblers – the level of blunting is also related to how severe their gambling problem is.

Near-Miss Outcomes

• The lecturer and his colleagues (Clark et al., 2009) wanted to design a more sophisticated version of the Reuter et al. (2005) study, particularly looking at near-miss outcomes.
• Gamblers reported finding near-misses aversive, and yet, a few seconds later, reported a higher level of motivation to continue gambling.
• They then used neuroimaging and found that areas of the brain that respond to actual wins also respond to near-miss outcomes, even when no actual reinforcement has been delivered.

Cognitive Approach to Gambling

• A gambler plays to excess because of distortions in his or her decision-making that creates a heightened expectancy of winning.
• These distortions exist in everyone (Re: Daniel Kahnema’s ‘Thinking, Fast and Slow‘)
• Problem gamblers, however, tend to be more susceptible to these cognitive disorders than the general population.
• There are two main kinds of distortions that apply to gambling: (1) Illusion of Control (e.g., confusion of skill and chance) and (2) Gambler’s Fallacy (e.g., how we think about repeated but random events).

Effects of Near-Misses & The Gambler’s Fallacy

• Clark et al. (2014) followed up on their previous study with near-misses by focusing on the insula region, testing neurological patients with acquired brain injury.
• Most participants reported increased motivation to play after near-miss outcomes compared to full-misses, but this effect did not exist in participants who had damage to the insula – they do not show a motivational response to the near-miss outcomes.
• Referring to the Gambler’s Fallacy, most participants were less likely to choose RED after a run of consecutive REDs, but this effect, again, did not exist for those with insula damage.

The Role of the Insula: Interoception

• Clark et al. (2014) brought focus upon the insula as a core component in the brain system in relation to gambling.
• The insula has a key role in what is called ‘interoception‘ – detecting and perceiving what is going on in your body (e.g., visceral sensation, excitement).
• Gambling is associated with increased physiological arousal (e.g., as people gamble, there is an increase in heart rate, cortisol, and so on).
• It’s possible that patients with insula damage may be less able to detect these signals that are coming from the body, and if this is true, it generates an important clinical prediction.
• If damage to the insula wipes out these distortions, which are increased in people with problem gambling, we could target treatment towards this (e.g., mindfulness, biofeedback).

The Multi-Line Game

• The prior research is simulated and very basic compared to real casino games, which have multiple lines and reels where you could win on several different line combinations.
• Research by Dixon & Harrigan et al. (2013) show, however, that by betting on multiple lines simultaneously, the player can ‘win’ on one line, but this does not cover the full bet. If you completely lose on these games, the machine is silent, but for one of these lines coming up, you get all the bells and whistles of a win, and thus the excitement.
• This effect is called ‘the loss disguised as a win‘ – it’s a loss but it triggers the sensory impact, the sounds, and the sights of a winner.

Losses Disguised as Wins

• Generate physiological arousal similar to wins (Dixon et al., 2010).
• Distort players’ memory for the number of ‘true wins’ in the session (Jensen et al., 2013).
• Dramatically reduce the length of ‘losing streaks’ without winning feedback
• Problem gamblers report finding multi-line games more ‘immersive’ and more skilful than equivalent single-line games (Dixon et al., 2014).

Gambling Disorder

• DSM-5 Diagnosis for Gambling Disorder [PDF]
• Gamblers Anonymous
• Gambling Addiction & the Brain
• Gambling Disorder
• How Anticipation Primes the Brain for Problem Gambling
• How Gambling Affects the Brain & Who is Most Vulnerable to Addiction
• My Gambling Addiction Ruined My Life
• The Psychology of Gambling
• The Psychology of Gambling
• The Rise & Fall of a Gambling Addict
• The Science Behind Gambling
• The Secret World of Female Gamblers
• The Silent Addiction
• Treatment Recommendations for Gambling Disorder
• Women’s Gambling Behaviour

The Science Behind Addiction

• 2-Minute Neuroscience: The Reward System
• Addiction and Brain Reward and Anti-Reward Pathways
• Addiction Explained, Rises & Falls in Dopamine
• Addiction Neuroscience 101
• Dopamine and Addiction: Separating Myths and Facts
• Dopamine System, Craving & Pursuit Explained
• Drugs, Brains, and Behavior
• How an Addicted Brain Works
• Introduction to the Reward Pathway
• Reward Circuitry in Addiction
• Serotonin vs. Dopamine – 7 Key Differences Between Pleasure and Happiness
• The Neurobiology of Drug Addiction (NIDA, 2007) [PDF]
• The Neuroscience of Drug Reward and Addiction