Addressing Comorbidities* in the Treatment of Gambling Problems

Nady el-Guebaly, MDProfessor & Head, Division of Substance Abuse,

University of CalgaryMedical Director, Addictions Program, Calgary Health Region

* “Two or more concurrent, independent disorders in single individual interacting in the clinical picture”

Network PROGRAMCentre

ECA (2) NESARC (3) CCHS (4) N=36984 1 problem = 161 N=42898 Gamblers 14934; incl 29 PG DSM III PG .42; N=195 Problem = 1513

Comorbidities with (1): OR Lifetime OR ORSubstance Use Disorders: Alc 3.3 73% 6.0 2.9 Nicotine 2.1 60% 6.7 Illicit 1.3 38% 4.4Mood Disorders: 3.3 50% 4.4 1.8 (Mood & Anx)

Bipolar 3.4 --- 2.3 (5)Suicidality 1.6 ---

Anxiety Disorders, spec Phobias (not OCD) 2.3 41% 3.9Somatoform Disorders 3.0 ---Schizophrenia (severe & persistent MI) 3.5 --- Both 5.2ADHD? --- 20% trtAntisocial Personality (1ery & 2 ary) 6.1 61% PD 6.0

(obsC, par) >F

1. Crockford, el-Guebaly. Can Psych 1998;43:43-50.2. Cunningham-Williams, et al. Am J Public Health 1998;88:1093-1096; St. Louis DSM III DIS3. Petry et al. J Clin Psychiatry 2005; 66:564-573; Nat Epid S Alc & Related Conditions; DSM IV AUDADIS; lifetime4. el-Guebaly N et al J Gambling Stud 2006; 22: 275-287; CPGI, 12 m prev5. McIntyre et al. J Affective Dis 2007 [In Press]

Community Prevalence: Problem vs Non-Gambler OR

Correlation with Smoking & Alcohol –Can Community Health Survey (CCHS) 2003 – Stats Can

GAMBLING $

All sample

Frequency CIDI-

adult

Risk/adult G CPGI 9

Frequency Smoke 0-Daily Current

Pearson

N

.093***

1806

.157***

1372

.219***

1064

Frequency Alcohol 0-daily, last 12 m

Pearson

N

.090***

1353

.180***

1187

.064*

965

5 Drinks + 0 to > 1/wk

Pearson

N

.082**

1353

.083**

1187

.171***

965

Signif .000 = *** - Other drugs including marijuana NS

RISK OF GAMBLING CPGI 8-16

Thinking about the past 12 months (scale 1-4):

Have you bet more than you could really afford to lose?

Have you needed to gamble larger amounts to get same excitement?

Have you gone back another day to try & win back the money you lost?

Have you borrowed money or sold anything to get money to gamble?

Have you felt that you might have a problem with gambling?

Have people criticized your betting or told you that you had a problem?

Have you felt guilty about the way you gamble?

Has your gambling caused you any health problems (stress & anxiety)?

Has your gambling caused any financial problems?

Correlation with Personality Assessment Inventory (PAI) – Morey, 1991

GAMBLING (Pearson) $

N = 1370

Frequency CIDI N=1371

Risk CPGI 9 N=1063

Depression .065* .030 .265***

Mania .018 -.086** .176***

Suicidal Ideation .033 -.005 .236***

Anxiety .074** -.070* .238***

Anxiety related Dis

(OCD, Phobia)

.038 -.068* .227***

Aggression .059* .058* .136***

Somatic Complaints .064* .035 .219***

Schizophrenia .038 -.023 .244***

Paranoia .069* -.013 .231***

Antisocial Features .118*** .028 .231***

Signif .000 = *** - Composite Intern Diagn Interview (CICD-SF/DSM IV) = NS

Correlation for SF-8 Health Survey (Ware et al, 2001)

GAMBLING (Pearson) $ N=1370 Frequency CIDI N=1371

Risk CPGI 9 N=1063

General Health V poor- Excellent .082** .060* .174***

Physical Health .043 .097*** .128***

Impact of Physical Health in Daily Life .088** .072** .167***

Bodily Pain 0 – V severe

.026 .083** .095**

Vitality .089** .050* .182***

Physical/Emotional Problems limit social function

.113*** -.030 .227***

Presence of Emotional Problems .107*** -.052* .201***

Impact of Mental Health in Daily Life .093** -.070** .220***

Signif .000 = ***

Correlation with Childhood Trauma Questionnaire (CTQ) – Bernstein & Fink, 1998

GAMBLING (Pearson) $ N=1806

Frequency (CIDI)

N= 1372

Risk CPGI 9

N=1064

Emotional Abuse .013 .043 .125***

Physical Abuse .038 .105*** .129***

Sexual Abuse .016 .044 .097**

Emotional Neglect .021 .098*** .124***

Physical Neglect .034 .096*** .155***

ALSO: Vietnam Vets Twins Registry – Health Related QOL: gambling, SUD & MH> Physical PG & Depression (Potenza et al): Overlap Genetics> Environment

Shared stress response, impulse control? µ alleles & naltrexone? Sig .000 = ***

Case “A” (1)

42 y/o, married female; postal clerk 8 y; 2 daughters: 20 y & 14 y “Job was stressful”; ending a 4 yr educational leave; Quite involved in her union PRESENTING COMPLAINT: GAMBLING (last 3 yrs):

- progressive increase in VLT use

- currently gambles ~ once/week, 8-10 hours/session, spending 3-600$ each time

- last month, stole husband’s bank card: worried!

- reported being given the “run-around” when seeking help & no follow-up

“A” (2)

SUBSTANCES

- age 18-24, 26 oz liquor every W/E, many blackouts;

currently drinking once/week, 4 drinks/sitting

- one joint of cannabis/day, “most difficult to give up”

- 1/2 pack cigs/day

- experimented with solvents, LSD & cocaine

- FH +ve: mother & 5 out of 7 siblings from 4 fathers have alcohol problems

“A” (3)

DEPRESSION/DYSTHYMIA

- emotional abuse from parents & siblings,

no sexual abuse

- episodes of depression throughout her life, particularly severe 1 yr ago

- occasional suicide ideation & one serious attempt

- Paroxetine 20 mgm/day

“A” (4)

CHRONIC PAIN- chronic cervical disc degeneration from “repetitive movement at work”

- history of TM Jaw pain & fainting spells for 6 years

- Medications: Tylenol #3, 3 times/day

Elavil, 150 mgm hs, for sleep & pain

Physical comorbidities? - Stress related disorders, - Medication side-effects- CHR 1000/3 hospital-wide consults: 12 Prob G, all MH- Survey of 51 New Zealand urban & rural practices (N=2536): no relation with

physical inactivity or weight concerns

“A” (5)

PERSONALITY

- 5 y ago, 6 m psychological FU for Union “bullying”

- Charge of mischievous conduct; running key down

co-workers’ cars with whom she had difficulty

- Postal service may release her; on probation for abusing educational leave. She plans legal action.

COURSE: motivated to seek help for GAMBLING!

- Residential program entered but on relapse wished to deal with “one addiction at a time”

- Repeated complaints up “the managerial chain” about “personality conflicts” with therapist!

The Role of Gambling?

PRESENTING COMPLAINT: GAMBLING (last 3 years) BUT Substances Depression/Dysthymia Chronic Pain Personality Treatment Course

WHERE TO START? Rules of engagement “common ground” Find out sources of strength & your true friends “co-therapists”: sig other;

daughters? Address the behaviors! No RCTs! the closest :

- Hollander et al ’02: lithium & bipolar spectrum gamblers - Grant & Potenza ’06: Escitalopram “open label” anxiety & gamblers (N=13 - 12 w)

(2) SUBSTANCE DEPENDENCE

1. Increasing amounts of money for excitement

2. Restless or irritable when cutting down/ stop

3. Unsuccessful efforts to control, stop…

4. Preoccupied with gambling

5. Escaping from problems or dysphoria

6. Lies to family members, therapist, or others

7. Illegal acts to finance gambling

8. Jeopardized or lost significant opportunities

9. “Chasing” one’s losses

10. Relies on others for money

Maladaptive pattern of substance use 3+ within 12 months:

Persistent & recurrent maladaptive gambling 5+ (if not mania)

(1) PATHOLOGICAL GAMBLING

1. Tolerance

2. Withdrawal

3. Unsuccessful efforts to cut/control

4. A great deal of time spent to obtain substance

5. Substance taken in larger amounts or over a longer period than intended

6. Important social, occupation or recreation given up or reduced

7. Use is continued despite physical or psychological problems

COMORBID IMPACT: - Rosenthal & Lesieur DSM “plot” addiction-impulsivity-compulsivity Loss of control? Is persistence of erroneous cognition = physiological craving?

- See-Saw association - Anti-craving meds: Naltr/Nalmefine- Range of Support: OP residential; Twelve Steps

(3) MOOD DISORDERS

Sadness MAJOR DEPRESSIVE EPISODE > 2 wksA. Depressed Mood +B. 4 for either: - change in weight, sleep …

- feelings of worthlessness or guilt, - difficulty thinking or concentrating - recurrent thoughts of death/suicide + plan

DYSTHYMIC DISORDER > 2 yrsMore days than not, chronic, less severe depressive symptoms

COMORBID IMPACT: Role of SSRI’s; ineffectual with substance CBT – gambling + depression?

Suicide assessment

MANIC/BIPOLAR EPISODES

Mood Stabilizers: Lithium; Anticonvulsants

Group Support, ie, Integrated Group Therapy (Weiss)

Interpers & Social Rhythm Therapy (Frank)?

ANXIETY DISORDERS Fear & Tension reduction “lost in machine”

Bi-directional and complex, i.e., social phobia preceding & GAD following alcohol!

SCHIZOPHRENIA Withdrawal AISH & Internet

Lower “cumulative” threshold of care!

Concurrent approach

Review diagnoses after behavior ends!

(4) CHRONIC PAIN & DISABILITY

TREATMENT PHASES

Assessment

Education & CBT group – 10 wkly Sessions

Claresholm Residential Program for Taper & Rehab 3 – 24 wks

Follow-up support groups

(5) AXIS II - PERSONALITY DISORDER

CLUSTERS A. Paranoid* B.ANTISOCIAL: impulsivity + disregard rights C. Avoidant

Schizoid Borderline: impulsivity + affect instability DependentSchizotypa Histrionic Obsessive-Compulsive*

Narcissistic* (N Petry P109) > 33% NOS

COMORBID IMPACT:Idiopathic or Symptomatic?Continuum with Normalcy StigmaTherapy subject to: Crisis/Consequences

Introspection potential

ADDICTION CENTRE ADULT OUTPATIENT SEQUENTIAL/CONCURRENT FLEXIBILITY = RETENTION!

Level I (Pre-Contemplation) < 6 individual

Level II (Pre-Contemplation)Group (2/wk for 3 wks)

Level III (Contemplation) (3 days/wk)

Level IV (Action & Maintenance) (5 days/wk)

SPECIFIC OBJECTIVES

Build motivation for change

Engagement & assessment;Assess group treatment suitability

Move patient into action ( Level IV) Reduce psychiatric/Add symptomsEngage supports (e.g., AA).

Prevent relapse Confidence; Psychiatric/SA symptoms

Speciality groups

Inpt for Crisis stabilization only

Case management

+

Open: harm reduction & supportCouple: prevent relapse, communication Chr pain: reduce med reliance, non-drug coping GAMBLING: CBT & PREVENT RELAPSE (8 sessions)

What about Mrs. “A”?

July Assessment; Family? enabling or detached

Sept-Oct Second residential programDuring childhood was the family social workerH sold marihuana; she gambled his money!Strengths: a leader in groups; attended GA; spiritual life

Oct-Dec On discharge: no shows, no GA; using alcohol & marihuana Anxious about return to work; enquired about ADHD?Requested sole focus on “gambling” which was refusedAngry phone call to managers in Nov about “personality conflict” & need to switch therapist

Dec Discharge back to GP with information – latter acknowledged PD

PROGNOSIS “It’s a long life!” – she is a bright, resourceful ladyLoss of job/income may be the crisis requiredCouple therapy? Or separation? Anger managementCrisis management until meaningful involvement

PG: TYPOLOGY OF BEHAVIORAL DRIVERS?

A. GENO-PHENOTYPES? Serotonin – impulse control Endorphin – urges, cravings Dopamine – reward, re-enforcement Norepinephrine – arousal, excitement

B. SEVERITY LEVELSSocial Abuse & Dependence LI, LII, L III Non-problem Problem Pathological

C. ONSET (Early Late), Childhood stability & Psychopathology Blaszczynski’s Pathways

D. CORMORBIDITIES % rangeSUD incl nicotine 20 – 70Mood 30 – 75Anx/PTSD 20 – 40Impulse control 20(sex, spending)Antisocial 20-40

COMPULSIVE Body dysmorphia Anorexia

Tourette

Path Gambling Sexual

compulsions Impulsive PD

IMPULSIVE

“Repetitive behavior with inhibition defect, ADDICTION: Behavior with tolerance, withdrawal i.e., from hyper-vigilance & rituals to risk seeking & loss of control causing harm “cravers”