Shane W Kraus PhD Department of Psychology UNLV Regis College November 10 2021 Abstainer Range of Behaviors Health Promotion Harm Reduction intensive Treatment brief Range of Gambling Behavior ID: 1045436
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1. Gambling: Crossing the LineShane W Kraus, Ph.D. Department of Psychology, UNLVRegis College November 10, 2021
2. AbstainerRange of BehaviorsHealth PromotionHarm ReductionintensiveTreatmentbriefRange of Gambling BehaviorNoneMildModerateSevereRecreationalGamblingDisordered
3. 3Show Me the Money! Casino-type table gamesSlot machinesScratch ticketsCard gamesLotteriesDice gamesWagering Sports betting / E-sportsBingoRouletteGrowing Gambling Industry: Forecasts, Technologies, and Trends. According to The Business Research Company, the global gambling market is expected to reach a value of around $565.4 billion, growing at an annual rate of 5.9% through 2022
4. 4DSM-5 Gambling Disorder CriteriaPersistent and recurrent problematic gambling behavior leading to clinically significant impairment or distress as indicated by the individual exhibiting 4 (or more) of the following in a 12-month period:Increasing amounts of money to achieve desired excitementRestless/irritable when attempting to cut down or stopRepeated unsuccessful efforts to control, cut back, or stopPreoccupied with gambling Gambling when distressed Often returning another day to get even* Lying to conceal the extent of involvement with gamblingJeopardizing or losing relationship/job/educational opportunitiesBorrowing money
5. 5DSM-5 Gambling Disorder CriteriaSpecify if:Episodic: Meeting diagnostic criteria at more than one time point, with symptoms subsiding between periods of gambling disorder for at least several months.Persistent: Experiencing continuous symptoms, to meet diagnostic criteria for multiple years.Specify if:In early remission: After full criteria for gambling disorder were previously met, none of the criteriafor gambling disorder have been met for at least 3 months but for less than 12 months.In sustained remission: After full criteria for gambling disorder were previously met, none of thecriteria for gambling disorder have been met during a period of 12 months or longer.Specify current severity: Mild: 4–5 criteria met. Moderate: 6–7 criteria met. Severe: 8–9 criteria met.(APA, 2013)
6. Gambling Disorder Prevalence in U.S. AdultsUp to 90% of U.S. adults gamble in their lifetimeLifetime problem gambling:2-5% of U.S. adults 10% of U.S. veterans (see Etuk et al., 2020 for review)Lifetime gambling disorder:6% college students1-2% of U.S. adults3% of U.S. veteransAbout 1/3 of problem gamblers experience natural remission (Slutske et al., 2012).4.2% of US OEF/OIF/OND veterans exhibit at-risk/probable pathological gambling (Whiting et al., 2016)A US national survey of veterans found that 2.2% screened positive for at-risk/problem gambling (Stefanovics, Potenza, & Pietrzak, 2017)6
7. 7Gambling among Women (vs. Men)Prevalence:Problem Gambling: 0.7% women vs. 2.7% menAt-Risk Gambling: 5.6% women vs. 9.6% menDevelopment (telescoping for women):Start laterProgress fasterClinical Characteristics:Psychiatric & Substance UseSensation-seeking for men
8. Gambling Problems in US Military Veterans (Etuk et al., 2020) U.S. veterans have higher rates of gambling disorder compared with civilian populations (3 times higher than civilians). Gambling disorder often co-occurs with trauma-related conditions, substance use, and suicidality, which may complicate treatment outcomes.The lack of standardized screening for gambling problems among Veterans across U.S. federal agencies (e.g., Department of Defense, Department of Veterans Affairs) is concerning and remains a significant gap for ongoing prevention and treatment efforts.8
9. Psychiatric Co-Occurring DisordersIndividuals with gambling disorder have high rates of co-occurring disorders, including mood, personality, substance-use, and post-traumatic stress disorder (Kessler, Hwang, LaBrie et al., 2008; Petry, Stinson, & Grant, 2005). At-risk/problem gambling is associated with any personality disorders, particularly for cluster-B personality disorders (Ronzitti, Kraus, Hoff, Clerici, & Potenza, 2017).Veteran with problem gamblers seeking treatment report high rates of alcohol (77%), cocaine (43%), opioids (23%), and cannabis (16%) use disorders (Shirk, Kelly, Kraus et al., 2018)
10. Psychiatric Co-Occurring Disorders40% of US veteran gamblers seeking treatment reported a previous suicide attempt (Kausch, 2003). Problematic levels of gaming and gambling was modest, with only 10.5% of the 466 problem gamblers also being problem video gamers and 24.1% of the 203 problem video gamers also being problem gamblers (Sander & Williams, 2019).About one-in-five men seeking treatment for compulsive sexual behavior disorder reported a lifetime history with gambling disorder (Kraus et al., 2015).
11. 11Risk Factors for Gambling DisorderHistory of an early big win (leading to false expectation of future wins)Cognitive distortions about the odds of winning (i.e., luck)Recent loss or change (e.g., divorce, job loss, retirement, bereavement)Self-esteem is tied to gambling wins or lossesHistory of risk taking or impulsivityHistory of financial problemsDepression Trauma history (Post traumatic stress disorder) Family history of gamblingSubstance use
12. Barriers to Help Seeking for Gambling DisorderPublic funding for substance abuse treatment is 281 times greater than for problem gambling services ($17 billion vs. $60.6 million) (Marotta, 2013).~ 11% of U.S. adults with gambling disorder seek professional help in their lifetime (Lister et al., 2015). A study of veterans with gambling disorder found that less than 5% had previously sought treatment (Shirk et al., 2018). High levels of stigma and shame among helping seeking clients12
13. Representativeness: An event is judged likely to be drawn from a particular class, to the extent it resembles a typical member of that class.Gambler’s Fallacy: When events generated by a random process have deviated from the population average in a short run (e.g., when a roulette ball has fallen on a red slot four consecutive times), individuals may erroneously believe that the opposite deviation (e.g., a black winner) becomes more likelyOverconfidence: Phenomenon wherein individuals express a degree of confidence in their knowledge or abilityTrends in Number Picking: Lottery players commonly try to apply long-run random patterns to short strings in their picksCognitive Distortions (Fortune & Goodie, 2012)
14. Cognitive Distortions (Fortune & Goodie, 2012)Availability: An event is deemed more likely to occur if it is easier to recall from memory, or in other words is more available in memory.Illusory Correlations: Individuals believe that events they expect to be correlated, due to previous experiences. Availability of Others’ Wins: When reinforces the belief that they will win if they continue to play. individuals see and hear fellow gamblers winningInherent Memory Bias: Individuals’ memory is biased to recollect wins with greater ease than losses. This interpretive bias allows gamblers to reframe their memories regarding gambling experiences in a way that focuses on positive experiences (wins) and disregards negative experiences (losses).
15. Assessed for gambling disorder among Veterans seeking mental health services in Primary Care Behavioral Health at the Bedford VAMC, Bedford, MA (funded by the Massachusetts Gaming Commission; Kraus, Potenza, et al., 2020).Used the Brief Biosocial Gambling Screen (Gebauer, LaBrie & Shaffer, 2010) to assess for problem gambling and used the DSM-5 criteria for diagnosing gambling disorder.Gambling behaviors were assessed during a routine, one-hour intake appointment for all new Veteran patients seeking mental health services in primary care. 260 Veterans were screened for gambling disorder between Nov 1, 2017, and Sept 15, 2018. 5% of patients reported at-risk/problem gambling. 15Screening for Gambling Disorder in Primary Care
16. Brief Biosocial Gambling Screen (BBGS)16Have you gambled in the past 12 months? No/ Yes*During the past 12 months, have you become restless irritable or anxious when trying to stop/cut down on gambling?No / YesDuring the past 12 months, have you tried to keep your family or friends from knowing how much you gambled? No / YesDuring the past 12 months, did you have such financial trouble as a result of your gambling that you had to get help with living expenses from family, friends or welfare?Any “yes” responses, suggestive of possible problem gambling. No / Yes (Gebauer et al., 2010)
17. Other Problem Gambling Screening Instruments National Opinion Research Center DSM-IV Screen (Gerstein et al., 1999)Massachusetts Gambling Screen (Shaffer et al., 1994)Problem Gambling Severity Index (PGSI) (Ferris & Wynne, 2001) – Score higher than 8, indicative of problem gamblingNo risk, low-risk (1-2), moderate risk (3-7), and high-risk (8 or higher) 17
18. Treatments for Gambling DisorderGambling disorder responds to similar treatments as substance use disorders.Recovery support services–peer support & 12-step program (Gamblers Anonymous)Brief advice-giving/psychoeducationCognitive behavioral therapies (Petry, Rash, & Alessi, 2016)Oral naltrexone (opioid antagonist) has shown efficacy in controlled trials (Bartely & Bloch, 2013). Veterans with gambling problems and alcohol use disorder had worst outcomes on medication (disulfiram or naltrexone) compared to Veterans with only alcohol use disorder (Grant, Potenza, Kraus & Petrakis, 2017) in terms of mental health functioning.Mindfulness based relapse prevention shown to be helpful for US veterans with co-morbid gambling and substances use or mental health challenges (Shirk et al., 2021). 18
19. Few randomized controlled trials have studied pharmacotherapies for gambling disorder. Opioid antagonists like naltrexone showed promise in the pharmacological treatment of gambling disorder. Pharmacotherapy combined with psychotherapy treatments for gambling disorder may provide better rates of patient retention in comparison to pharmacology-only treatments, though further research is needed in this area. Future studies should address gaps relating to considerations of racial, ethnic, gender and other individual differences in clinical studies (Kraus, Etuk, & Potenza, 2020).Medications for Gambling Disorder19
20. Gambling ResourcesVeteran patients: VA Southern Nevada Healthcare System, Las Vegas, NVLas Vegas VA Residential Recovery and Renewal Center (LVR3)All patients: The National Problem Gambling Helpline, 1-800-522-4700, is available 24/7 and is 100% confidential. Massachusetts Problem Gambling Hotline: https://gamblinghelplinema.org/ Nevada resource locator: https://www.nevadacouncil.org/get-help-now/resource-locator/Las Vegas: Robert Hunter Problem Gambling Treatment Center: https://gamblingproblems.org/20
21. Questions? 21Shane W. Kraus, Ph.D. Assistant ProfessorDirector, UNLV Behavioral Addictions LabDepartment of Psychology, University of Nevada, Las VegasAdjunct Assistant Professor of PsychiatryUNLV School of Medicineshane.kraus@unlv.edu Lab: http://ba.sites.unlv.edu/ Office: 702-895-0214