Hero

Videos

Slideshows

Articles

Podcasts

Poll

practices psychiatry in Manhattan, New York. He continues to publish frequently on film, media, and popular culture. For many years, his cinema column appeared in Psychiatric Times. He has appeared frequently on national and international network and cable television programs including Good Morning America, Today, CBS Evening and Sunday News, PBS, CNN, Showtime, and BBC-TV. Please address communications to Dr. Greenberg at 

I’ve written about poker nearly as long as I’ve been playing it. I observed in these pages years ago that the game can be a great revealer of-but sometimes a great destroyer of-character, especially when one harbors the psycho-social and hereditary/genetic potential for compulsive gambling.

Gambling humor embraces the dark side. Poker argot is especially mordant. “Where’s Lennie?” asked one of my high-rolling patients about a legendary loser, absent from the tables for several months.

Came the laconic reply: “Lennie is in Poker Hospital…” meaning he was broke beyond redemption…possibly disappeared himself to elude loan shark thugs who would assuredly be playing castanets on his kneecaps with hammers if he didn’t pay up.

Molly Bloom, feisty heroine of the eponymous 

, wound up in poker hospital not from playing, but from running lavish underground poker games in LA and NY. Her “clients” were major Wall Street sharks, glitterati from the worlds of entertainment, sports, politics, and-to her final undoing-kingpins of the Russian mob.

No-Limit Texas Hold-em is the most popular form of poker today. You can easily google the rules, but it’s more enjoyable to learn them by watching 

(1998), the best poker picture ever lensed.

Each player-10 maximum-is dealt 2 down cards, which are then combined with a “window” of 5 common pasteboards. Betting proceeds before and after the window is flopped. The best 5-card hand wins.

The game looks disarmingly simple. In fact, it’s alarmingly complex. Any player can go “all in”-bet his or her entire stack-at any time during a round. The ability to bluff and suss out bluffing is crucial. Played for high stakes, the game requires extraordinary patience and battlefield courage. You strive to keep your head on straight during hours of boredom, punctuated by moments of sheer terror.

Fine players carefully bide their time until the right terrifying moment comes along. But Molly’s punters were action junkies, many pathological gamblers who were always all in, creating stratospheric pots. Molly was especially adept at winkling out “fish,” poor players with deep pockets, able to sustain formidable losses and come back week after week for more .

She took great pride running a legitimate game in a milieu prone to knavery. She paid her employees-dealers, servers, security-on the books, kept scrupulously to the letter of ambiguous gaming laws. She lived large, but only on big weekly tips.

Aaron Sorkin’s previous TV and theatrical work-eg, in 

-featured high octane plotting and rat-a-tat dialogue reminiscent of the screwball comedies and sizzling crime pictures of Hollywood’s studio era. 

 marks his debut as a film director; he also adapted the film from Bloom’s autobiography.

Sorkin’s skillset satisfyingly drives the picture until an unfortunate conclusion, of which more presently. (Molly is stunningly played by Jessica Chastain). In the scorching establishing sequence, Federal agents summarily yank Molly out of bed and into the slammer for illegal gambling. Her arrest came several years after she had closed her operations.

The feds actually cared little about Molly’s games. They jailed her with the goal of compelling her to rat out 30 badfellas under indictment who had played at her tables. But Molly refused to co-operate. She had substantial knowledge about her players’ private lives, and refused to break confidentiality so as not to shame them and their families. Their outside business wasn’t her business.

Sorkin adroitly interpolates Molly herself relating her picaresque, often harrowing backstory, and third person narration of her quest to escape incarceration. Her voiceover delivery is fast paced, ironic, curiously distanced-as if she’s describing someone else’s life in a galaxy far away. Staccato cutting accentuates Molly’s fragmentated modus vivendi-initially exciting, and terminally desolating.

Molly’s father (a one-note gruff Kevin Costner) is a charismatic psychology professor, who relentlessly helicoptered Molly and her 2 brothers to become academic and athletic super achievers.

We infer that the brothers accepted, indeed flourished, under their father’s iron tutelage. Molly brashly challenged and disrespected him at every step; yet identified with his Ayn Randish vision of a world in which the meek are crushed and the elite rewarded.

Molly rose to early prominence in breakneck downhill ski racing, until a freak accident demolished her career. She migrated to LA against her father’s wishes and without his support. She became the factotum of a repellant Hollywood wanabee mogul. She serviced, then stole his game; eventually moved to Manhattan, where she ran more games at higher stakes.

Her judgement eventually deteriorated under escalating self-generated stress. She became drug-addicted, brought key Russian mobsters and an FBI informant to her tables. After refusing to partner up with the Mafia, she was shockingly beaten, then recovered her senses; fled back to California, got herself straight, and lived under the radar until her arrest. Making bail reduced her to penury. The Feds had already confiscated her savings, and taxed them to boot.

Molly’s players were all men; and crooked timber to a man. Their crude narcissism could gag a goat. The majority constituted an omnium gatherum of gambling addicts-perennial chasers after Lady Luck-massive losers who offered every rationale in the sordid book for behavior ruinous to others as themselves. Her biggest winner, no addict, was an odious predator who delighted in demolishing his opponents’ self-esteem as much as savaging their bankroll. Molly’s prosecutors are portrayed as no less repugnant. Utterly devoid of pity, they’d happily let her rot in jail if she didn’t co-operate. (Intriguingly, her punters from the Russian mob left their vicious psychopathy outside Molly’s doorstep: in the film they come across as hapless, even likeable schlubs.)

Charlie Jaffey (the estimable Idris Elba), a prominent criminal lawyer, proves a shining exception to the prevailing male grottiness. Jaffey’s fee is high as his probity. He takes her case-probably pro bono-because he’s captivated by her sass, wit, and staunch, if naÃ¯ve to compromise her people. By her lights, what went on outside the game room-sports betting, prostitution-weren’t her concern. All that mattered was running a pleasurable, profitable man-cave.

At the end, her case is unexpectedly thrown out by a benevolent judge. Her father also shows up with glib park bench psychoanalyzing, and a sappy declaration of love, dripping with crocodile tears. The reconciliation sequence strikes precisely the wrong bathetic note, in a solidly winning picture with a hollow Tinseltown heart. Watching it is akin to quaffing a good wine with a two-buck-chuck finish.

 has generally drawn excellent reviews. A few dissenters complained that Molly comes across as a stick figure, sans depth and complexity. Hollywood usually doesn’t “get” pathological gambling, glamorizing or demonizing it. Whatever his penchant for wearisome liberal pieties, Sorkin deserves credit for being spot on about the disorder’s psychopathology.

Pace the Goldwater ruling, the onscreen Molly Bloom’s shallowness isn’t due to vapid scripting, but the peculiar alexithymia native to the pathological gambler’s persona, which breeds massive unknowningness about inner life and motivations.

By this token, Molly is absolutely unable to register the dubious legality-and morality-of her games. Her insensate craving for “action” is another classic manifestation of the disorder: it precipitated the sinister slalom that ground down her ego strength and eroded her mortality (one notably sees this in end-stage gambling).

Molly also is fatally susceptible to the “gambler’s fallacy”-the unshakeable conviction that no matter how dire her straits, the odds will inevitably turn in her favor. Her gallows humor comprises yet another signature of the disorder.

I’ve elsewhere described pathological gambling as the dark underbelly of the American dream. It’s implied that by nurture or nurture, Molly has inherited her father’s cynical world view: if you’re not a stone-hearted winner, you’re a feckless loser.

Sorkin leaves Molly existentially unmoored, broke but not broken, already scanning the horizon to reinvent herself in some fashion. Given the dog-eat-dog tenor of the (Washington) times, her character pathology, ferocious intelligence, and ruthless ambition would seem to make going into politics a viable career option.

NB: For more information on pathological gambling, the reader is directed to Dr. Greenberg’s chapter on the subject in the latest edition of the Comprehensive Textbook of Psychiatry. His review of Rounders, which originally appeared in the now defunct Poker Pro magazine, can be found on the internationalpsychoanalysis.net website. 

This article was originally published on February 13, 2018 and has since been updated. 

The game looks disarmingly simple. In fact, it’s alarmingly complex.

Molly’s Game: Poker Hospital and Pathologic Gambling 

A patient is brought to the emergency department by her daughter for bizarre behavior and symptoms of mania after gambling  from the casino for 48 continuous hours. 

A Case of Gambling Disorder

If money is not the lure for problem gamblers, what is? 

Mini Quiz: Gambling Disorder

One of the many interesting shifts in DSM-5 was the reclassification of pathological gambling from the impulse control disorders category to substance addictions (“substance-related and addictive disorders”). The shift effectively recognized (the now re-labeled) “gambling disorder” as the first behavioral addiction. This is a fascinating construct in psychiatry. The other diagnoses in this category involve the compulsive administration of exogenous drugs. Much of our knowledge of addiction comes from studying the pharmacology of these drugs and their ability to “hijack” reward-oriented behavior in animal models.

[[{"type":"media","view_mode":"media_crop","fid":"40387","attributes":{"alt":"Â© katalinks/shutterstock.com, gambling","class":"media-image media-image-right","id":"media_crop_4132918533744","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"4131","media_crop_rotate":"0","media_crop_scale_h":"200","media_crop_scale_w":"130","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"float: right;","title":"Â© katalinks/shutterstock.com","typeof":"foaf:Image"}}]]In the case of gambling disorder, there is no exogenous substance; rather, there is excessive engagement in a behavior in which money is wagered on the uncertain prospect of a larger monetary prize. Even the role of money is unclear in this equation. While money is self-evidently a potent incentive, at a psychological level, it is a complex, learned reinforcer (as distinct from a natural reward, such as food or sex). For at least some gamblers, winning money appears to play a negligible role in maintaining their behavior.

So what is it about this behavior that enables gambling to yield a power that is comparable to drugs such as cocaine, heroin, and alcohol? And might other behaviors, such as video gaming, food addictions, shopping, and sex, be conceptualized as addictive behaviors in the future?

The DSM-5 diagnosis of gambling disorder uses a threshold of 4 of 9 symptoms. These symptoms have changed little from the original list in DSM-III, which was based on the diagnostic criteria for substance dependence. The symptoms include classic hallmarks of an addiction syndrome: preoccupation with gambling, gambling with larger amounts over time (akin to tolerance), and agitation when stopping gambling (akin to withdrawal).

The criteria also emphasize the negative consequences of gambling, such as occupational or interpersonal difficulties, borrowing money, and lying about gambling. Certainly, financial debt is ubiquitous in individuals with gambling disorder, and in the rare cases that do not involve significant debts, there is usually either some form of bailout from others or bankruptcy.

Gambling disorder is linked to high rates of criminal acts to support gambling, although clinicians should note that criminality was dropped as a specific criterion in DSM-5. Homelessness, physical health burden, and suicidal behavior are further corollaries that highlight the ultimately catastrophic downward spiral of gambling disorder.

Another feature that does not have an obvious counterpart in drug addiction is loss-chasing: continuing to play or returning to the venue at a later date in an effort to claw back recent debts. Loss-chasing is often regarded as a tipping point at which recreational gambling becomes problematic. In epidemiological datasets, loss-chasing is generally the most endorsed feature.

 These population studies also illustrate how the harms of gambling are continuously distributed: individuals who do not meet diagnostic criteria can nonetheless experience clear harm from gambling. The prevalence estimates for “at risk” gambling are in the range of 2% to 7%, with full DSM diagnosis in 0.5% to 1%.

One of the pivotal lines of evidence that shaped the DSM-5 reclassification was the neurobiological overlap between gambling disorder and the substance use disorders. From a neurocognitive perspective, elevated impulsivity is a reliable feature in patients with gambling disorder.

 This personality trait refers to the tendency for rapid responses and unplanned decisions. It can be measured with either questionnaires or behavioral tasks, and is conceptualized as arising from an imbalance between overactive subcortical reward systems and underactive prefrontal cortical control mechanisms.

 Similar cognitive markers are apparent in substance use disorders.

 Impulsivity tends to predate gambling disorder as well as other addictions, with predictive value from early childhood.

Neuroimaging experiments have begun to characterize the underlying neural basis of gambling disorder. Functional MRI studies illustrate changes in brain reward circuitry, centered on the ventral striatum and medial prefrontal cortex.

 This system is robustly activated in healthy volunteers by winning money and during risky gambling decisions.

 While these areas are abnormally recruited in persons with gambling disorder (and also in drug addicts), the precise nature of this pathophysiology is proving elusive, with reports of hypoactivity and hyperactivity in equal measure.

Positron emission tomography studies may help untangle these complex findings, by identifying the neurochemical modulators within this circuitry, which may also guide medication development. In persons with substance use disorders, there is a reduction in dopamine D2 receptors in the striatum; problem gamblers show a similar effect, albeit only in those with higher levels of trait impulsivity.

 Persons who have gambling disorder also show heightened levels of dopamine release.

 This finding is consistent with a clinical observation that dopamine agonist treatments for Parkinson disease can sometimes induce excessive gambling and other risky reward behaviors.

DSM-5 changes to the addictions category “Internet gaming disorder” were also considered, but the scientific research behind this condition was insufficient. Ultimately, it was listed in section III of DSM-5 as a condition for further study. This has triggered a wave of research on the clinical, epidemiological, and neurobiological aspects of excessive video gaming. Prevalence rates are particularly alarming in youths: a US survey of 8- to 18-year-olds reported pathological video gaming in 8%.

 A recent study in 12,000 teenagers across 11 European countries found problematic Internet use in 4.4%.

We are now seeing progress in refining the clinical phenotype. It is recognized that the Internet is a route of access to a range of different activities (also including gambling and pornography). There is international consensus on 9 diagnostic criteria for Internet gaming disorder.

 The threshold of 5 of 9 symptoms is slightly higher than for gambling and substance addictions.

At a psychological level, video games have much in common with gambling (eg, their unpredictable schedules of reinforcement and their capacity to provide distraction from or a means of coping with life stresses). Although there is emerging neurobiological overlap with gambling disorder and substance use disorders, in terms of cue-induced cravings and impulsivity, challenges remain.

One concern is the gradual pathologization of everyday behaviors. The negative consequences of gambling disorder are irrefutable, primarily with respect to the debts arising from excessive gambling. For excessive gaming (and many other “soft” addictions), the negative consequences can be much harder to quantify and relate to time expenditure, a loss of productivity (eg, as a consequence of late nights), or failure to prioritize real-life responsibilities (eg, education, child care).

Obesity is a third area that has seen a recent emergence of credible research within a framework of behavioral addiction. Scientists recognize that obesity is a heterogeneous health problem with multiple determinants. A detailed understanding of the neuroscience of feeding behavior has laid the foundation for the concept of “food addiction” as a potentially useful description of at least a subtype of obese persons.

Persons with food addiction can potentially benefit from the translation of existing effective treatments for drug addiction, such as medications that target µ-opioid receptors.

 Food cues recruit the same neuroanatomical and neurochemical systems that are targeted in drug addiction. Exogenous stimulation of these neural hot spots can trigger excessive and binge-like eating beyond satiety.

 Indeed, binge eating disorder has emerged as the phenotype, with the greater clinical and neurobiological resemblance to an addiction profile. In one study, dopamine release to food cues was enhanced in binge eaters but not in non–binge eaters.

 This is comparable to the aforementioned effect in problem gamblers.

Preclinical models of sugar-bingeing rodents showed progres-sive behavioral signs of dependence as well as a range of neuroadaptive changes in the brain that were previously thought to be confined to drugs of abuse.

 Some of these effects were also seen in experimental models looking at binge-like administration of fatty foods.

As with electronic forms of gambling and video games, we must bear in mind that modern food stuffs are highly engineered products, and certain sugar-fat combinations can have powerfully rewarding properties. An ongoing dispute is whether this putative syndrome is best described in relation to the behavior (eating addiction) or a particular dietary substance (food addiction).

The DSM-5 reclassification has raised the profile of gambling disorder, which appears to be having a beneficial effect on treatment. Nevertheless, services that are available for disordered gambling, and their degree of integration with other mental health services, vary widely across jurisdictions. This is particularly pronounced in the US, given that state-specific gambling regulation entails state-specific treatment provision for those with problematic gambling.

In general, first-line treatment is cognitive-behavioral therapy (CBT), which aims to identify gambling triggers and provide alternative means of coping with those triggers. In addition, CBT seeks to identify and restructure any faulty cognitive distortions about gambling, such as the tendency to over-interpret winning or losing streaks in play or the significance of gambling near-misses.

The human brain is naturally limited in its grasp of randomness and chance and its ability to reason about low-likelihood events (such as lottery wins); these faulty cognitions are more evident in individuals with gambling disorder. A recent Cochrane review of psychological treatments for gambling disorder concluded that CBT has moderate efficacy

; it is also adaptable to group settings and Web-based modes of delivery.

As with other addictions, only a minority of affected individuals actively seek treatment for gambling disorder. Most jurisdictions offer additional forms of support that include telephone helplines and voluntary self-exclusion programs in which the gambler can request that gambling venues or Web sites refuse him or her future entry or credit.

CBT is also frequently augmented with financial counseling and family therapy. With few large-scale randomized controlled trials, there is no clear evidence for the effectiveness of pharmacological treatments for gambling disorder. There are promising signs of efficacy for opioid receptor antagonists, although the mechanism of action is unclear, and SSRIs and mood stabilizers may be beneficial in individuals with depressive or bipolar comorbidities.

Behavioral addictions are a nascent construct in psychiatry, and they have been ratified in principle by the inclusion of gambling disorder in the DSM-5 addictions category. Given the lack of accepted biomarkers for addictions, it remains to be seen which conditions will join gambling disorder.

From a clinical perspective, gambling disorder is a debilitating condition that is frequently comorbid with other mental health problems-including substance use, mood, and anxiety disorders. Gambling represents a potent means of regulating negative mood states (via distraction or the prospect of an exciting win), but one that confers the inevitability of long-term losses. As such, a diagnosis of gambling disorder is likely to exacerbate comorbid conditions and is highly relevant to their treatment. It is recommended that clinicians across all mental health services screen patients for gambling disorder.

Dr Clark is Director of the Centre for Gambling Research at UBC in the department of psychology at the University of British Columbia in Vancouver. The Centre for Gambling Research at UBC is supported by funding from the Province of British Columbia and the British Columbia Lottery Corporation. He receives research funding in the UK from the Medical Research Council, and he is a paid consult to Cambridge Cognition Ltd on issues relating to neurocognitive assessment. Dr Clark has not received any direct or indirect payments from the gambling industry or any other groups substantially funded by gambling to conduct research or to speak at conferences or events.

Addiction by Design: Machine Gambling in Las Vegas

. Princeton, NJ: Princeton University Press; 2012.

 Toce-Gerstein M, Gerstein DR, Volberg RA. A hierarchy of gambling disorders in the community. 

 Kessler RC, Hwang I, LaBrie R, et al. DSM-IV pathological gambling in the National Comorbidity Survey Replication. 

 Verdejo-GarcÃ­a A, Lawrence AJ, Clark L. Impulsivity as a vulnerability marker for substance-use disorders: review of findings from high-risk research, problem gamblers and genetic association studies. 

 Munakata Y, Herd SA, Chatham CH, et al. A unified framework for inhibitory control. 

 Slutske WS, Moffitt TE, Poulton R, Caspi A. Undercontrolled temperament at age 3 predicts disordered gambling at age 32: a longitudinal study of a complete birth cohort. 

 Limbrick-Oldfield EH, van Holst RJ, Clark L. Fronto-striatal dysregulation in drug addiction and pathological gambling: consistent inconsistencies? 

 Studer B, Apergis-Schoute AM, Robbins TW, Clark L. What are the odds? The neural correlates of active choice during gambling. 

 Clark L, Stokes PR, Wu K, et al. Striatal dopamine D2/D3 receptor binding in pathological gambling is correlated with mood-related impulsivity. 

 Boileau I, Payer D, Chugani B, et al. In vivo evidence for greater amphetamine-induced dopamine release in pathological gambling: a positron emission tomography study with [(11)C]-(+)-PHNO. 

 Weintraub D, Koester J, Potenza MN, et al. Impulse control disorders in Parkinson disease: a cross-sectional study of 3090 patients. 

 Gentile D. Pathological video-game use among youth ages 8 to 18: a national study [published correction appears in Psychol Sci. 2009;20:785]. 

 Durkee T, Kaess M, Carli V, et al. Prevalence of pathological internet use among adolescents in Europe: demographic and social factors. 

 Petry NM, Rehbein F, Gentile DA, et al. An international consensus for assessing internet gaming disorder using the new DSM-5 approach. 

 Meng Y, Deng W, Wang H, et al. The prefrontal dysfunction in individuals with Internet gaming disorder: a meta-analysis of functional magnetic resonance imaging studies. 

 Cambridge VC, Ziauddeen H, Nathan PJ, et al. Neural and behavioral effects of a novel mu opioid receptor antagonist in binge-eating obese people. 

 Kenny PJ. Common cellular and molecular mechanisms in obesity and drug addiction. 

 Wang GJ, Geliebter A, Volkow ND, et al. Enhanced striatal dopamine release during food stimulation in binge eating disorder. 

 Avena NM, Bocarsly ME, Hoebel BG. Animal models of sugar and fat bingeing: relationship to food addiction and increased body weight. 

 Hebebrand J, Albayrak Ã, Adan R, et al. “Eating addiction,” rather than “food addiction,” better captures addictive-like eating behavior. 

 Cowlishaw S, Merkouris S, Dowling N, et al. Psychological therapies for pathological and problem gambling. 

 Hodgins DC, Stea JN, Grant JE. Gambling disorders. 

Now placed “substance-related and addictive disorders” in DSM-5, gambling disorder has similiarities to other behavioral addictions, such as “food addiction” and “Internet gaming disorder.” 

From Impulsivity to Addiction: Gambling Disorder and Beyond

[[{"type":"media","view_mode":"media_crop","fid":"34279","attributes":{"alt":"The State of Addiction Psychiatry","class":"media-image media-image-right","id":"media_crop_6629934968287","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"3645","media_crop_rotate":"0","media_crop_scale_h":"125","media_crop_scale_w":"150","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"float: right;","title":" ","typeof":"foaf:Image"}}]]Over the past 50 years, the addiction field has exploded, thanks to a convergence of neurobiological research, psychopharmacological advances, and an exponentially growing evidence base. Nevertheless, despite a deep-rooted foundation, addiction psychiatry faces an ongoing struggle to achieve acceptance among physicians-from general practitioners to primary care psychiatrists. All too often, true neuro-pathologies such as alcoholism and injection drug use are marginalized, ignored, and sidelined for comorbid medical-or psychiatric-diagnoses.

In 1952, DSM-I formally recognized addiction as a subset of “sociopathic personality disorder” (alongside dyssocial reaction and unspecified sexual deviation). Almost 3 decades later, DSM-III dedicated an entire chapter to substance use disorders, providing separate abuse and dependence criteria for alcohol, barbiturates and sedative/hypnotics, opioids, amphetamines and sympathomimetics, phencyclidine (PCP)/arylcyclohexylamines, hallucinogens, cannabis, and tobacco. DSM-IV famously incorporated polysubstance dependence, which was redacted in DSM-5 to allow better conceptualization of individualized patient care.

In addition to removing polysubstance use, DSM-5 features several salient changes in its approach to patients struggling with addiction. First, addictive disorders no longer exist as “abuse” or “dependence”; both criteria sets have been combined into “use disorders.” This change promotes diagnostic reliability, validity, and clarity while it proposes a unidimensional spectrum of severity informed by both abuse and dependence.

Next, “craving” now serves as a symptom of substance use disorders. This addition reflects recent strong correlations of subjective craving data and functional neuroimaging. Conversely, legal consequences are no longer included as a criterion for substance use disorders; compared with other diagnostic criteria, their diagnostic yield was negligible because of their relatively low prevalence and accuracy.

Several nonsubstance addictive behaviors have been reclassified. 

 now falls under addictive disorders (previously it was an impulse-control disorder), and addiction to online 

 is considered a “condition for further study.” Both shifts echo an increasing prevalence and expanding evidence base.

The articles in this Special Report provide a broad, cross-cutting perspective on the current state of addiction psychiatry, insofar as it may pertain to your own clinical practice. We hope you enjoy this addiction “smorgasbord” featuring cannabis use disorder, psychosocial addictions, pathological gambling, opioid use disorder, 

Introduction: The State of Addiction Psychiatry

An Update on Street and Club Drugs: What Clinicians Need to Know

Opioid Use Disorder: Update on Diagnosis and Treatment

Marijuana and Madness: Clinical Implications of Increased Availability and Potency

A Brief Review of Gambling Disorder and Five Related Case Vignettes

The Therapeutic Alliance and Psychosocial Interventions for Successful Treatment of Addiction

Mr Mals is a fourth-year University of New Mexico medical student, currently awaiting Match results for general psychiatry. Dr Foster is Assistant Professor of Addiction Psychiatry at the University of New Mexico and Medical Director of the Services for Teen Addiction in Recovery in Albuquerque. They report no conflicts of interest concerning the subject matter of this Special Report.

The articles in this Special Report provide a broad, cross-cutting perspective on the current state of addiction psychiatry, insofar as it may pertain to your own clinical practice. 

Nearly 4% of the population has gambling-related problems, and 6% will experience harm from gambling during their lifetime-including financial, legal, relational, and health problems.

 In addition, individuals with gambling problems have exponentially higher rates of suicide attempts and completions. One study found that 81% of pathological gamblers in treatment showed some suicidal ideation, and 30% reported one or more suicide attempts in the preceding 12 months.

DSM-5 criteria for gambling disorder represent the most common symptoms experienced by those with gambling problems. These symptoms characterize 3 heterogeneous dimensions related to gambling disorder: damage or disruption, loss of control, and dependence. The loss of control over urges and behaviors may be the central component of gambling disorders, and the inability to control gambling may be a component of a progressively worsening process in the life span of some gamblers.

Individuals who encounter gambling-related problems but who do not reach the diagnostic threshold (subthreshold gambling disorder meets only 1 to 3 criteria) are referred to as problem gamblers. For the most part, those with subthreshold gambling disorder continue to experience social, psychological, and health repercussions but to a lesser degree. They are also at increased risk for progression to gambling disorder compared with non-gamblers.

Gambling disorder is referred to as a hidden addiction because of the minimal signs and symptoms associated with this condition.

 The level of severity can also be concealed and involve multiple components. For example, a gambler who “hits rock bottom” (or one who has lost everything, including financial assets and social relationships) may have stopped gambling because of the lack of finances, but he or she may be severely depressed and suicidal because of the ongoing repercussion. Other components of severity include gambling behavior (frequency, duration, amount gambled), extent of gambling desires (cravings, urges), repercussions (eg, employment, legal, relationships), level of control, and comorbid symptoms (eg, suicidality, impulsivity, depression). These factors help predict treatment outcome and determine the appropriate treatment (ie, brief intervention, intensive outpatient, hospitalization). In research, severity is usually assessed using the total number of criteria endorsed, which can also be a quick and straightforward method in the clinical setting.

Gambling disorders are strongly associated with comorbid psychopathology. A meta-analysis of 11 population surveys found high mean prevalence for nicotine dependence (60.1%), a substance use disorder (57.5%), mood disorders (37.9%), and anxiety disorders (37.4%).

 A longitudinal 3-year study also found that any mood, anxiety, or substance use–related disorder was more likely to develop in individuals with either subthreshold gambling disorder or gambling disorder than in those who did not gamble.

Clinically, it may be helpful to assess sleep. Those with gambling problems have an increased risk of difficulty in initiating sleep, maintaining sleep, and more and early awakenings.

 Sleep disturbances can impair self-control and decision making, increase impulsivity, degrade cognition in executive functioning tasks, attenuate responses to losses, and increase expectations of gains that can affect gambling behavior.

There are no FDA-approved pharmacological treatments for gambling disorder, but several studies have evaluated the effects of medications on gambling behavior and comorbid symptoms. Grant and colleagues

 reviewed 18 double-blind placebo-controlled studies that included antidepressants, antipsychotics, mood stabilizers, glutamatergic agents, and opioid antagonists. Although the results were mixed and conclusions were limited because of the small sample sizes, opioid antagonists and glutamatergic agents (

-acetylcysteine) seemed to have the most promising results, especially for those with intense gambling urges.

A number of psychosocial strategies have shown promise in controlling aberrant gambling behavior, including self-help manuals, brief one-session interventions (motivational therapy), psychodynamic therapy, cognitive-behavioral therapy (CBT), and referrals to 12-step support groups.

 Research findings indicate that the treatment for gambling disorder not only reduces gambling behavior but can also help reduce comorbid psychiatric symptoms, such as anxiety and depression; improve quality of life; decrease psychological stress; and decrease the likelihood of comorbid psychopathology.

Jack, a 16-year-old 10th grader, is brought by his mother for evaluation of his “excessive online gaming.” Jack’s mother is concerned that her son plays casino-based “freemium” games 5 hours every day. (Freemium games are free to download but require tokens that are purchased with real money and gambled among players.) He buys approximately $30 worth of tokens every day and has spent more than $5000 on tokens in the past 6 months. He constantly argues with his parents regarding his playing time, his school work has deteriorated, and he no longer has any social interactions.

Jack admits that he lies to his parents about the extent of his playing-he sometimes plays more than 10 hours a day. He has a hard time stopping and usually plays until he loses all his tokens. He uses his mother’s credit card to buy tokens without permission. He is proud of his online accomplishments and enjoys the winning and competition with real adults. Although he now has no desire to interact with peers outside of school, he had enjoyed participating in a recreational sports league in the past.

Jack does not appear to suffer from any other disorder. He has never had problems with alcohol or drugs, and he has never seen a mental health professional or received psychotropics. His childhood and development have been without incident. Last year, his mother returned to work and Jack started taking care of his 7-year-old sister after school (during which he games the most).

During the initial session, gaming patterns and repercussions are discussed (financial, educational, and developmental). Recommendations are made that include changing passwords to the app store and limiting Internet access to supervised sessions, and Jack’s access to his mother’s credit card is cut off. After-school activities for both children are also highly encouraged, possibly restarting recreational sports competitions for Jack. Potential positive reinforcement methods for complying with clean Internet play are also discussed. The family is referred to a family therapist to continue working on family dynamics.

A 19-year-old college sophomore is referred by student health for evaluation of his gambling problems. Michael’s gambling has become pathological in the past year: he either bets on sports online or spends about 6 hours at a local casino daily. Although he does not work, he lost $50,000 in the past year, using money from his sports scholarship and financial aid. His mother has bailed him out multiple times by paying his credit card bills. He still has a credit card debt and owes money to his friends, which totals $25,000. He usually chases his losses, has strong cravings to gamble during the day, and experiences anxiety trying to find money to use for gambling. The time he spends on academics and team practices has become significantly reduced.

His primary care physician (PCP) prescribed stimulants after a diagnosis of ADHD in middle school, which Michael took until 12th grade. He has never seen a mental health professional or taken any psychotropic medication. He started binge drinking at college parties (probably twice a month, enough to black out); in addition, he smokes one blunt of marijuana every week.

Michael started gambling recreationally with friends in middle school, but he acknowledges that his problem controlling gambling started last year. Although he is disheartened by his gambling problem (and its repercussions), he is not depressed, still enjoys hobbies (which he indicates is gambling), and has fun with his girlfriend. He seems intelli-gent and brags about knowing the poker odds. He is seeking treatment because he wants to control his gambling (make only smart bets or play the good hands). His biggest problem is “losing a few bets in a row and going on tilt!”

During the first session, gambling patterns and repercussions are discussed, which he had initially minimized (ie, the possibility of losing his scholarship and being kicked off the team). He agrees to restart treatment with a stimulant, to include his mother in the next session via phone, and to go to Gamblers Anonymous. He agrees to continue CBT at the student health center to work on his aberrant alcohol use.

During the second session (3 weeks later), he reports that he has restarted the stimulant, which helps his impulsivity and studying habits. He has completed 8 sessions of CBT at the student center. He went to a Gamblers Anonymous meeting but did not agree with their tenet for abstinence. His mother agrees to stop bailing him out, control his credit cards and scholarship checks, and provide a limited allowance.

For the next few months, his gambling decreases (both in duration and frequency), but he places larger bets and loses more. Since his mother stopped bailing him out, he borrows money from a loan shark. He is kicked off the team and his scholarship is terminated. He decides to contact a state-funded mental health professional for more regular therapy sessions. He also agrees to ask the loan shark for a repayment plan.

By the fifth session (4 months after his initial presentation), he has stopped gambling and has a part-time job. He is making regular payments to his loan shark, studying more, drinking less alcohol, and playing more sports recreationally. He still enjoys gambling but now is aware of the repercussions. He is more focused on raising his grade point average and returning to the sports team.

James, a depressed 40-year-old poker player, is referred by his wife. He was laid off from work 8 months earlier. Since then he plays poker for 8 hours a day at a nearby casino. He gambles “out of boredom” and enjoys the social atmosphere. Although he is well-off financially, he has lost more than $200,000 in the past year. He now plays at higher-limit tables and chases his bets. He lies to his wife regarding his gambling and is on the brink of getting a divorce. He started playing poker as a teenager and had weekly poker games with his colleagues at work.

He lacks motivation, has stopped taking care of himself, and has gained 30 pounds in the past year. He has a hard time falling asleep and at times is restless in the mornings. James has had 3 episodes of depression in the past; he has been taking aripiprazole, citalopram, and bupropion (prescribed by his PCP) for the past 6 months. There is no his-tory suggestive of mania, hypomania, suicidality, or aberrant substance use.

During the first session with James and his wife, his recent gambling winnings/losses are reviewed, including bank statements that his wife brings in. He is surprised at the total amount of losses. He loves poker, but he does not want a divorce. He agrees to give all his bank cards to his wife, ban himself from local casinos, and work on saving his marriage. The couple are given a self-help workbook and listings for Gamblers Anonymous and Gam-Anon, and proper sleep hygiene is emphasized. The couple are also referred to the state-funded gambling provider network to receive therapy to work on their relationship.

Mirtazapine is started to help with depression, and aripiprazole is tapered. (Case report findings suggest a potential correlation between aripiprazole and excessive gambling, which is similar to the association between dopamine replacement therapy for Parkinson disease and gambling.9)

By the next session, James has stopped gambling because he no longer has easy access to money. He has also started attending Gamblers Anonymous several times a week and enjoys their camaraderie. He appreciates how attending Gamblers Anonymous has helped diminish his strong urges to play poker.

By the fourth session (third month), he has completed his rÃ©sumÃ© and started exercising again. His sleep is improved, he regularly attends meetings of Gamblers Anonymous, and he has a sponsor in addition to making a commitment to the group. He is also in the process of completing 12 sessions with the marriage and family therapist. He misses playing poker, but realizes how abstaining has improved his relation-ship with his wife.

Jackie, a 34-year-old nurse, is referred by her coworker for gambling at work. Compelled by her colleague, Jackie came to the addiction clinic to receive help for her uncontrollable need to gamble at work. She plays online slots on her phone for about 6 hours during her night shifts; after work, she usually tries to win back her losses at the local casino. Although she has lost $50,000 in the past 6 months, with an annual salary of $150,000, she does not have any financial difficulties and is still well regarded at work.

Six months earlier, Jackie called off her wedding after discovering her fiancÃ©’s infidelity. Since that time, gambling has been a great escape for her, specifically helping with ruminations. She is sad, has almost daily crying spells, lacks motivation to care for herself, has problems falling asleep and sustaining sleep, and has some thoughts that she may be better off dead. She is also irritable, easily snapping at colleagues and difficult patients at work. She drinks several glasses of wine every day to “help her nerves.”

Jackie describes some history suggestive of hypomania (not sleeping for a few days, very energetic, happy, impulsively shopping, gambling, and having sex). She carries diagnoses of bipolar disorder, depression, borderline personality disorder, and ADHD. When she was 17, she had a psychiatric hospitalization after breaking up with her boyfriend; she had suicidal ideations and self-injurious behavior (cutting). Jackie saw a therapist for 3 years, went to an accelerated nursing school, and currently works full-time at the hospital. She sees a psychiatrist (about twice a year), who prescribes quetiapine extended-release. Her PCP also prescribes trazodone, fluoxetine, methylphenidate (twice daily), clonazepam (3 times daily), and zolpidem.

During the first session, Jackie is ambivalent about treatment for her gambling, but she does want help for her insomnia, irritability, and anxiety. She agrees to consolidate her prescriptions to one prescriber to optimize medications. She receives psychoeducation regarding the importance of sleep hygiene, especially the effects of smoking, alcohol, stimulants, and shift work. The repercussions of her gambling are also discussed, and she is given a self-help workbook with listings for Gamblers Anonymous meetings. She agrees to taper off most of her medications and to start lamotrigine.

During the second session (10 days later), she reports that her gambling at work has decreased significantly because she was being monitored by her colleagues, but her gambling outside of work has increased. She also started melatonin and diphenhydramine on her own to help with insomnia. Her passive suicidal ideations are stronger, because she thinks that she is not doing anything productive with her life. She does not have a specific plan to hurt herself; she believes that suicide is immoral; and she does not want to voluntarily admit herself to an intensive outpatient program, a residential treatment program, or an inpatient unit.

Jackie continues to be irritable and to have poor self-care and low self-esteem. She enjoys talking during the session and wants to come more often. She has not been to any Gamblers Anonymous meetings because she does not believe that she has a gambling problem. Medications continue to be optimized, and the benefits of sleep hygiene are reinforced. She is also referred to a state-funded therapist to help with her gambling problems.

During her third and fourth sessions (weekly), she reports that the new medication regimen is finally working and she feels less irritable. She has not gambled at work during the past week and feels good, and she has started working more shifts (about 90 hours per week). Consequently, she is usually exhausted af-ter work and does not have the energy to go gambling.

At the seventh session (about 10 weeks after intake), Jackie reports that her work shifts have become more irregular. She works subsequent day and night shifts, and then has a few days off. During her most recent off days, she accepted an invitation for free accommodations and a spa package at a casino/hotel. In those 3 days, she lost $30,000 and gambled for 40 hours. She maxed out her credit cards and emptied her savings account. She finally agrees that she has a gambling problem. She plans to remove herself from the casino’s mailing list, ban herself from the local casinos, close her online casino gambling accounts, schedule an appointment with the state-funded therapist, and ask her brother to start controlling her finances.

During the next 6 months (about 15 sessions), she stops gambling. She completes 10 sessions of gambling treatment with the state therapist and decides to continue the therapy out-of-pocket. Her sleep has improved, and her irritability and anxiety have decreased. Jackie also has started working only regular day shifts and has started exercising and socializing with old friends.

Mrs Kim, a 60-year-old manic gambler, is brought to the emergency department by her daughter for bizarre behavior. For the past month, Mrs Kim has been gambling more than usual and today she returned from the casino after gambling for 48 continuous hours. She had maxed out her credit cards and emptied her savings account. A family friend saw her at the casino acting provocatively toward random strangers. Apparently, she has not slept for the past 3 days. Her family has never seen her act this way.

Mrs Kim has no psychiatric history other than complaining of boredom and lack of motivation to her PCP last month, who prescribed an antidepressant.

Gambling has been a significant part of her life for years; she has been going to the local casino at least once a week for the past 16 years and playing for 5 to 8 hours each time. Before this past incident, she has never gambled more money than she could afford or chased her bets. She has also never experienced gambling-related repercussions.

On evaluation, Mrs Kim is restless but alert and oriented. She is talkative with rapid speech. She reports that she feels “amazing”; her affect is labile-she cries when discussing her deceased husband and then suddenly starts making jokes. She is fixated on leaving the hospital and returning to Thailand to see her deceased mother (whom she believes is still alive).

She is admitted to the inpatient unit after a negative medical workup. Medication-induced bipolar and related disorder are suspected. Her antidepressant is discontinued and a low-dose antipsychotic is started. Fourteen days later, she is discharged: her delusions and manic symptoms have resolved, including her urges to gamble uncontrollably.

These fictional case vignettes represent samples of individuals with gambling problems that any practicing psychiatrist may encounter. Although each patient suffered gambling-related problems, treatments were unique and personalized. It is also not uncommon to include significant others to help control finances, professionals (eg, accountants, lawyers), and health care workers (eg, counselors, therapists) in treatment plans. Specifically, free resources are available and can be used as part of the treatment plan, including self-help manuals and referrals to state-funded provider treatments and 12-step support groups (

Dr Parhami, is a PGY 3 Psychiatry Resident at the Delaware Psychiatry Residency Program, New Castle. He has completed a postdoctoral research fellowship at UCLA and will start a Child and Adolescent Psychiatry Fellowship at Johns Hopkins, Baltimore, in July. Dr Fong is Associate Psychiatry Professor, Co-Director of the UCLA Gambling Studies Program, Director of the UCLA Addiction Medicine Clinic, and Program Director for the UCLA Addiction Psychiatry Fellowship. Dr Parhami reports no conflicts of interest concerning the subject matter of this article; Dr Fong has received funding from the California Office of Problem Gambling.

 Lorains FK, Cowlishaw S, Thomas SA. Prevalence of comorbid disorders in problem and pathological gambling: systematic review and meta-analysis of population surveys. 

 Battersby M, Tolchard B, Scurrah M, Thomas L. Suicide ideation and behaviour in people with pathological gambling attending a treatment service. 

 Ladouceur R. Gambling: the hidden addiction. 

 Parhami I, Mojtabai R, Rosenthal RJ, et al. Gambling and the onset of comorbid mental disorders: a longitudinal study evaluating severity and specific symptoms. 

 Parhami I, Siani A, Rosenthal RJ, Fong TW. Pathological gambling, problem gambling and sleep complaints: an analysis of the National Comorbidity Survey: Replication (NCS-R). 

 Grant JE, Odlaug BL, Schreiber LR. Pharmacological treatments in pathological gambling. 

 Fink A, Parhami I, Rosenthal RJ, et al. How transparent is behavioral intervention research on pathological gambling and other gambling-related disorders? A systematic literature review. 

 Gaboriau L, Victorri-Vigneau C, GÃ©rardin M, et al. Aripiprazole: a new risk factor for pathological gambling? A report of 8 case reports. 

 National Center for Responsible Gaming. Brief Biosocial Gambling Screen. 

http://www.ncrg.org/resources/brief-biosocial-gambling-screen.

http://www.gamblersanonymous.org/ga/locations

 California Department of Public Health. Freedom From Problem Gambling. 

http://problemgambling.securespsites.com/ccpgwebsite/help-available/publications.aspx

The loss of control over urges and behaviors may be the central component of gambling disorders, but there is so much more to consider. Individuals with these problems have exponentially higher rates of suicide attempts and completions. 

Many people like to spend at least part of their free time playing video games; however, for some, what starts as innocent recreation becomes an addiction. Friends, family, work, school, and even personal hygiene are neglected because nearly every spare moment is spent playing a game. Video games are becoming increasingly complex, detailed, and compelling to a growing international audience of players. With sophisticated graphics, characters, and strategic challenges, it is not surprising that some teens and adults would rather play the latest video game than spend time with friends, engage in sports, or even watch television. In extreme cases, addicted gamers may become violent, threatening those who try to control how much they play or who try to stop them. In one tragic story, a 14-year-old boy stabbed his 77-year-old great-grandmother to death after she took away his video game.

Of course, not all gamers are addicts; many limit their video game playing to a few hours per week, successfully balancing school and/or work activities, friends, and family obligations. For others, gaming becomes an uncontrollable compulsion. Studies estimate that 10% to 15% of gamers exhibit signs that meet the World Health Organization criteria for addiction.

 and other compulsive behaviors, some gamers play compulsively, to the exclusion of other interests; their persistent and recurrent online gaming activity results in clinically significant deleterious effects. These gamers may endanger their academic or job functioning because of the amount of time they spend playing. They experience symptoms of withdrawal when pulled away from gaming.

The Internet is now an integral, even inescapable part of many people’s daily lives; they turn to it to send messages, read news, conduct business, and much more. However, scientific reports on the topic have recently begun to focus on preoccupation with certain aspects of the Internet, particularly online games.

Studies suggest that when individuals are engrossed in Internet games, certain pathways in the brain are triggered in the same direct, intense way that the brain of a drug addict is affected by a particular substance.

 Gaming prompts a response predominantly in the prefrontal cortex that influences feelings of pleasure and reward. Subsequent reinforcement of these pathways ultimately mimics “true” neurobiological addiction, and the result, in the extreme, is manifested as addictive behavior.

[[{"type":"media","view_mode":"media_crop","fid":"34307","attributes":{"alt":"Video Games: Recreation or Addiction?","class":"media-image media-image-right","id":"media_crop_6514097552211","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"3653","media_crop_rotate":"0","media_crop_scale_h":"200","media_crop_scale_w":"138","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"float: right;","title":"Â© stokkete/shutterstock.com","typeof":"foaf:Image"}}]]Persons of all ages, but especially teens and preteens, face very real, sometimes severe consequences associated with compulsive use of video games. Although it is not officially recognized as a diagnosable disorder by the American Psychiatric Association (APA), Internet gaming disorder (IGD) was included in Section III of DSM-5 as a “Condition for Further Study.” By listing IGD in DSM-5, the APA hopes to encourage research to determine whether the condition should be added as a disorder. At this time, the criteria for this condition are limited to Internet gaming and do not include general use of the Internet, online gambling, or social media. The criteria include persistent and consistent use of the Internet to engage in games, often with other players, leading to clinically significant impairment or distress.

As with any addiction, video game addiction is a multifaceted issue. Video games are designed to be addictive-not in the clinical sense of the word, but game designers are motivated to make their games more interesting so that users increase the amount of time they spend playing. Consequently, games are devised to be just difficult enough to be truly challenging while allowing small accomplishments that compel players to keep playing. In that respect, the design of video games is similar to the design of gambling casinos that allow players to have small wins that keep them playing.

. Often “hooks” are built into video games, with the intent of making them addictive. Showing a high score is one of the most easily recognizable hooks, because players try to beat their own or someone else’s high score. In online role-playing games, players try to “level up” to achieve higher status, power, and recognition, creating emotional attachment to their game characters.

. The social aspect is a primary factor in many game addictions. Frequently players are lonely and may never have felt as if they were part of a social group. Players can get a sense of belong-ing from the game, which may provide the only “friends” with whom they interact. When players rely on these new online personas, the distinction between what is real and what is a fantasy role-play game can become blurred. The more the gamer has emotionally invested in his or her character, the more likely that he or she will identify with that character.

Pseudosocial relationships drive modern gaming: game play begets alliances. Most online games include the option of “chats,” allowing players to interact with one another in the guise of the characters they represent. Patients with preexisting anxiety or developmental disorders (eg, social anxiety/phobia, acute stress disorder) are particularly vulnerable to the allure of this virtual escape.

. Addicted gamers may suffer from cognitive distortions that keep them compulsively engaged in the game. They may feel tense, lonely, restless, or depressed, but in an online game, the player is a great warrior who feels confident, well-liked, and proud. A person with low self-esteem who perceives himself as undesirable can use online gaming as a way to boost self-esteem.

Many people like to spend at least part of their free time playing video games. However, for some, what starts as innocent recreation becomes an addiction and, at times, tragedy ensues.

Gambling

Molly’s Game: Poker Hospital and Pathologic Gambling

A Case of Gambling Disorder

Mini Quiz: Gambling Disorder

From Impulsivity to Addiction: Gambling Disorder and Beyond

Introduction: The State of Addiction Psychiatry

A Brief Review of Gambling Disorder and Five Related Case Vignettes

Video Games: Recreation or Addiction?

Tipsheet: Pathological Gambling

Impulse Control Disorders: Clinical Characteristics and Pharmacological Management

The Psychiatrist and the Slot Machine