To do or not to do? The complexities of addiction, motivation, self-control, and impulsivity.
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Behavior, Addictive↗
Biomedical subjects
Marc N Potenza
Publications and source records attributed to Marc N Potenza.
Behavioral impulsivity predicts treatment outcome in a smoking cessation program for adolescent smokers.
OBJECTIVE: To examine the relationship between impulsivity and smoking cessation treatment response among adolescents. METHODS: Thirty adolescent smokers participated in a high school based smoking cessation program combining contingency management and cognitive behavioral therapy. Self-report (Barratt impulsiveness scale (BIS-II); Kirby delay discounting measure (DDM)) and behavioral (experiential discounting task (EDT); continuous performance task (CPT)) measures of impulsivity were assessed at treatment onset. RESULTS: Sixteen participants (53%) were abstinent from smoking at completion of the four-week study. Compared to abstinent adolescents, those not achieving abstinence discounted monetary rewards more on the EDT and committed more commission errors on the CPT. Group differences were not observed on the BIS-II or DDM. CONCLUSIONS: These preliminary results suggest that specific behavioral measures of impulsivity may be associated with the ability to initiate and/or maintain abstinence from smoking among adolescent smokers.
Adolescent↗
Characteristics of older adult problem gamblers calling a gambling helpline.
BACKGROUND: Few investigations have characterized groups of older adults with gambling problems, and published reports are currently limited by small samples of older adult problem gamblers. Gambling helplines represent a widespread mechanism for assisting problem gamblers to move into treatment settings. Given data from older adult problem gamblers in treatment, we hypothesized that older as compared with younger adult problem gamblers calling a gambling helpline would be less likely to report gambling-related problems. DESIGN AND METHODS: Logistic regression analyses were performed on data obtained from January 1, 2000 to December 31, 2001, inclusive, from callers with gambling problems (N = 1,084) contacting the Connecticut Council on Problem Gambling Helpline. RESULTS: Of the 1,018 phone calls used in the logistic regression analyses, 168 (16.5%) were from older adults and 850 (83.5%) from younger adults. Age-related differences were observed in demographic features, types and patterns of gambling reported as problematic, gambling-related problems and psychiatric symptoms, substance use problems, patterns of indebtedness, and family histories of addictive disorders. Older as compared with younger adult problem gamblers were more likely to report having lower incomes, longer durations of gambling, fewer types of problematic gambling, and problems with casino slot machine gambling and less likely to report gambling-related anxiety, family problems, illegal behaviors and arrests, drug problems, indebtedness to bookies or acquaintances, family histories of drug abuse, and problems with casino table gambling. CONCLUSIONS: Older as compared with younger adult problem gamblers calling a gambling helpline differ on many clinically relevant features. The findings suggest the need for improved and unique prevention and treatment strategies for older adults with gambling problems.
Adult↗
Characteristics of adolescent past-year gamblers and non-gamblers in relation to alcohol drinking.
A preliminary examination of mental health and gambling characteristics as a function of alcohol use in adolescents was conducted in a nationally representative sample of 16- and 17-year-olds using data from the 1998 Gambling Impact and Behavior Study. Adolescents were stratified by past-year alcohol use into abstainers/low-frequency (ALF) drinkers and moderate to high-frequency (MHF) drinkers as done previously [Desai, R. A., Maciejewski, P. K., Pantalon, M. V., & Potenza, M. N. (in press). Gender differences among recreational gamblers: Association with the frequency of alcohol use. Psychology of Addictive Behaviors]. A greater proportion of MHF drinkers reported past-year gambling than did ALF drinkers (66.1% vs. 38.2%). In the ALF drinking group but not the MHF one, past-year gambling was associated with dysphoria/depression (odds ratio for ALF: 1.94, odds ratio for MHF: 0.88) and drug use (odds ratio for ALF: 2.57, odds ratio for MHF: 0.49). A significant gambling-by-alcohol-use group interaction was observed for drug use (p<0.01). Among past-year gamblers, MHF drinkers were more likely than ALF ones to report frequent gambling. These results suggest a complex relationship between gambling alcohol use, drug use, and mental health in adolescents.
Adolescent↗
Sexual orientation of men with pathological gambling: prevalence and psychiatric comorbidity in a treatment-seeking sample.
Although gay men represent a high-risk group for psychiatric illness and impairment, they are largely an understudied population. The purpose of the present study was to examine the sexual orientation and clinical correlates of men with pathological gambling (PG). Sexual orientation was assessed in 105 men presenting with PG. Gay and bisexual men with PG were compared with heterosexual men in terms of gambling symptoms, impairment, and co-occurring psychiatric disorders. Of 22 men (21.0%) with PG, 15 were gay (14.3%) and 7 were bisexual (6.7%). Gay and bisexual men vs heterosexual men were more likely to be single (81.8% vs 21.7%; chi(2)(2) = 28.2; P < .001), have a lifetime (81.8% vs 44.6%; chi(2)(1) = 9.7; P = .002) or current (68.2% vs 34.9%; chi(2)(1) = 7.9; P = .005) impulse control disorder, and have a lifetime substance use disorder (59.1% vs 31.3%; chi(2)(1) = 5.7; P < .05). Gay and bisexual men with PG also showed a trend toward greater impairment (P = .04). Psychiatric comorbidity and impairment are high in gay and bisexual men with PG. Research is needed to optimize patient care for gay and bisexual men with PG.
Adult↗
Association of dopamine agonist use with impulse control disorders in Parkinson disease.
OBJECTIVE: To determine the frequency and correlates of impulse control disorders (ICDs) in Parkinson disease (PD). DESIGN: An unstructured screening interview for ICDs (compulsive gambling, buying, and sexual behavior) followed by a telephone-administered structured interview for screen-positive patients. SETTING: Two university-affiliated movement disorders centers. PARTICIPANTS: A convenience sample of 272 patients with idiopathic PD who were screened for psychiatric complications. MAIN OUTCOME MEASURES: Presence of compulsive gambling, buying, or sexual behavior as assessed by the Minnesota Impulsive Disorders Interview. RESULTS: Eighteen patients (6.6%) with PD met criteria for an ICD at some point during the course of PD, including 11 (4.0%) with an active ICD. Compulsive gambling and compulsive sexual behavior were equally common. In a multivariate model, treatment with a dopamine agonist (P = .01) and a history of ICD symptoms prior to PD onset (P = .02) predicted current ICD. There were no differences between the dopamine agonists in their association with ICDs (P = .21), and daily doses of dopamine agonists were higher in patients with an ICD than in dopamine agonist-treated patients without an ICD (P < .001). CONCLUSIONS: Patients with PD treated with a dopamine agonist should be made aware of the risk of developing an ICD and monitored clinically. Because dopamine agonists are increasingly being used for other indications, future research should assess the dopamine agonist-associated risk for ICDs in other populations.
Adult↗
A gender-based examination of past-year recreational gamblers.
BACKGROUND: Most adults gamble recreationally yet few studies have systematically investigated for gender-related differences in recreational gamblers. METHODS: Logistic regression analyses were performed on data from a nationally representative sample of respondents from the 1998 Gambling Impact and Behavior Study. RESULTS: Female gamblers versus non-gamblers were more likely to report use of alcohol and drugs. Male gamblers versus non-gamblers were more likely to report alcohol use and abuse/dependence, any substance abuse/dependence, and lifetime incarceration. An analysis of gambling by gender group interaction effects did not identify significant differences in health-related measures. Male as compared with female gamblers reported beginning gambling earlier, experiencing higher past-year maximal losses and wins, and finding favorite and engaging in different types of gambling. CONCLUSIONS: Despite heavier gambling in male as compared with female recreational gamblers, similar mental health functioning was observed in female and male past-year recreational gamblers. Types of gambling problematic for men and women are reflected in the gambling preferences of recreational gamblers.
Adult↗
Impulse control disorders in Parkinson's disease.
There is an increasing awareness that impulse control disorders (ICDs), including pathologic gambling and compulsive sexual behavior, can occur as a complication of Parkinson's disease (PD). Anecdotal experience and case reporting have suggested an association between ICDs in PD and the use of dopamine agonists. Lacking established treatments for ICDs in PD, clinical management should initially consist of modifications to or discontinuation of dopamine replacement therapy, particularly dopamine agonists. It is important that PD patients be aware that dopamine agonist use may lead to the development of an ICD, and that clinicians monitor patients as part of routine clinical care. As empirically validated treatments for ICDs are emerging, it will be important to examine their efficacy and tolerability in individuals with co-occurring PD and ICDs.
Disruptive, Impulse Control, and Conduct Disorders↗
Compulsive aspects of impulse-control disorders.
Impulsivity and compulsivity have been considered opposite poles of a continuous spectrum, but their relationship seems to be more complex. Disorders characterized by impulsivity often have features of compulsivity and vice-versa. Impulse-control disorders (ICDs) are characterized by repetitive behaviors and impaired inhibition of these behaviors, suggesting a similarity to the frequently excessive, unnecessary, and unwanted rituals of obsessive-compulsive disorder (OCD). There are, however, important differences be-tween ICDs and OCD. The construct of compulsivity as related to ICDs and OCD warrants additional investigation to identify the similarities and differences and to examine the implications for prevention and treatment strategies.
Compulsive Behavior↗
The neurobiology of substance and behavioral addictions.
Behavioral addictions, such as pathological gambling, kleptomania, pyromania, compulsive buying, and compulsive sexual behavior, represent significant public health concerns and are associated with high rates of psychiatric comorbidity and mortality. Although research into the biology of these behaviors is still in the early stages, recent advances in the understanding of motivation, reward, and addiction have provided insight into the possible pathophysiology of these disorders. Biochemical, functional neuroimaging, genetic studies, and treatment research have suggested a strong neurobiological link between behavioral addictions and substance use disorders. Given the substantial co-occurrence of these groups of disorders, improved understanding of their relationship has important implications not only for further understanding the neurobiology of both categories of disorders but also for improving prevention and treatment strategies.
Arousal↗
Gender differences among recreational gamblers: association with the frequency of alcohol use.
This study examines the interactive effects of alcohol use and gender on health and gambling attitudes and behaviors in recreational gamblers. The Gambling Impact and Behavior Study (D. Gerstein et al., 1999) surveyed by telephone 2,417 adults targeted to be representative of the U.S. adult population. The authors compared male and female recreational gamblers (n = 1,471) who were stratified by frequency of alcohol use on measures of health and gambling. Significant Gender x Alcohol Use group interactions were observed such that moderate-to-high frequency alcohol consumption correlated with heavier gambling in men than in women, whereas such an association did not exist among abstinent or low frequency drinkers. There were few gender differences in the correlations between alcohol consumption and health. Future research should consider gender-related influences when examining alcohol use and gambling behaviors.
Adolescent↗
Cue-induced brain activity changes and relapse in cocaine-dependent patients.
This study used functional magnetic resonance imaging (fMRI) to examine the association between brain activation during exposure to cocaine-related cues and relapse to drug use in cocaine-dependent (CD) patients. We imaged 17 CD subjects during a 2-week in-patient stay. The subjects then entered a 10-week outpatient placebo-controlled, double-blind randomized clinical trial where urine toxicologies were assessed three times weekly to calculate the treatment effectiveness score (TES). Worse TES correlated with BOLD activation in the left precentral, superior temporal, and posterior cingulate cortices (PCC), and right middle temporal and lingual cortices (R>0.65; P<0.005). The left PCC activation also distinguished eight nonrelapsers (TES above mean and completed treatment) from nine relapsers. Cocaine-free urines were significantly greater in the nonrelapsers (92%) than in the relapsers (66%), who also remained in treatment for an average of only 3.2 weeks. Self-reports of craving during fMRI did not differ between nonrelapsers and relapsers and did not correlate with TES. Relapse to cocaine abuse was associated with increased activation in the sensory association cortex, the motor cortex, and PCC while viewing images of cocaine-related cues. These results suggest that relapse to cocaine abuse is associated with increased brain activation to cocaine cues in sensory, motor, and cognitive-emotional processing areas. This physiological activation was a better predictor of relapse than subjective reports of craving, and may be a useful target for treatment development.
Adult↗
Escitalopram treatment of pathological gambling with co-occurring anxiety: an open-label pilot study with double-blind discontinuation.
Although co-occurring disorders are common in pathological gambling (PG), investigations of the response to pharmacotherapy in individuals with PG and co-occurring psychiatric symptomatology are limited. Thirteen subjects with DSM-IV PG and co-occurring anxiety were treated in a 12-week open-label trial of escitalopram. Subjects were assessed with the Yale-Brown Obsessive Compulsive Scale Modified for Pathological Gambling (PG-YBOCS; primary outcome measure), the Hamilton Anxiety Rating Scale (HAM-A), the Clinical Global Impressions scale (CGI), and measures of psychosocial functioning and quality of life. Those subjects who 'responded' (defined as a 30% or greater reduction in PG-YBOCS total score at endpoint) were offered inclusion in an 8-week double-blind discontinuation phase. PG-YBOCS scores decreased from a mean of 22.2+/-4.5 at baseline to 11.9+/-10.7 at endpoint (P=0.002) and 61.5% were responders. Scores on the HAM-A decreased by 82.8% over the 12-week period (mean of 15.9+/-3.2 at baseline to a mean of 2.8+/-3.6 at endpoint) (P<0.001). On the CGI, 38.5% of subjects (n=5) were 'very much improved' and 23.1% (n=3) were 'much improved' by study endpoint. The Sheehan Disability Scale, Perceive Stress Scale and Quality of Life Inventory all showed improvement (P< or = 0.001, P=0.002 and P=0.029, respectively). The mean end-of-study dose of escitalopram was 25.4+/-6.6 mg/day. Of three subjects assigned to escitalopram during the discontinuation phase, none reported statistically significant worsening of gambling symptoms. However, one subject assigned to placebo reported that gambling symptoms returned within 4 weeks. Open-label escitalopram treatment was associated with improvements in gambling and anxiety symptoms and measures of psychosocial functioning and quality of life. Larger, longer, placebo-controlled, double-blind studies are needed to evaluate further the safety and tolerability of escitalopram in the treatment of PG and co-occurring anxiety.
Adult↗
A framework for reporting outcomes in problem gambling treatment research: the Banff, Alberta Consensus.
OBJECTIVE: The objective is provide a framework concerning the minimum features of reporting efficacy of treatment in the problem gambling field. Research to date has not used uniform outcome measures and it is, therefore, difficult to compare the relative efficacy of various approaches. Some studies emphasize self-reported behavioural measures such as frequency and intensity of gambling whereas others emphasise change with respect to the criteria used to diagnose problem gambling or use composite measures of symptom severity in multiple domains involving gambling-related thoughts, urges, and behaviours. METHODS: An expert panel consensus. RESULTS: The proposed minimum features of reporting the efficacy of treatment outcome studies are: measures of gambling behaviour - the net expenditure each month, the frequency (in days per month) with which gambling takes place, and the time spent thinking about or engaged in the pursuit of gambling each month; measures of the problems caused by gambling - especially problems in the areas of personal health, relationships, financial, and legal; these measures can be complemented by additional measures of quality of life. measures of the processes of change - whatever mechanisms of change are assumed to occur. CONCLUSIONS: We believe that these guidelines are broad enough to allow clinical research conducted from diverse perspectives to allow valid cross study evaluations of intervention studies. Such conditions will facilitate the development of empirically validated best practice guidelines for use by clinicians in the management of problem gambling.
Behavior, Addictive↗
Should addictive disorders include non-substance-related conditions?
AIMS: In anticipation of the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V), to consider whether addictive disorders should include non-substance use disorders. METHODS: The author reviewed data and provided perspective to explore whether disorders such as pathological gambling (PG) should be grouped together with substance dependence, given that they share many features. RESULTS: PG and substance dependence currently reside in the DSM, fourth edition, text revision (DSM-IV-TR) within separate categories, with PG classified as an impulse control disorder (ICD) and substance dependence as a substance use disorder (SUD). Arguments can be forwarded to support each categorization, as well as to justify their inclusion together as addictions. CONCLUSIONS: The current state of knowledge suggests that there exist substantial similarities between PG and SUDs. Further research is indicated prior to categorizing PG and other ICDs together with SUDs.
Brain↗
Multicenter investigation of the opioid antagonist nalmefene in the treatment of pathological gambling.
OBJECTIVE: Pathological gambling is a disabling disorder experienced by approximately 1%-2% of adults and for which there are few empirically validated treatments. The authors examined the efficacy and tolerability of the opioid antagonist nalmefene in the treatment of adults with pathological gambling. METHOD: A 16-week, randomized, dose-ranging, double-blind, placebo-controlled trial was conducted at 15 outpatient treatment centers across the United States between March 2002 and April 2003. Two hundred seven persons with DSM-IV pathological gambling were randomly assigned to receive nalmefene (25 mg/day, 50 mg/day, or 100 mg/day) or placebo. Scores on the primary outcome measure (Yale-Brown Obsessive Compulsive Scale Modified for Pathological Gambling) were analyzed by using a linear mixed-effects model. RESULTS: Estimated regression coefficients showed that the 25 mg/day and 50 mg/day nalmefene groups had significantly different scores on the Yale-Brown Obsessive Compulsive Scale Modified for Pathological Gambling, compared to the placebo group. A total of 59.2% of the subjects who received 25 mg/day of nalmefene were rated as "much improved" or "very much improved" at the last evaluation, compared to 34.0% of those who received placebo. Adverse experiences included nausea, dizziness, and insomnia. CONCLUSIONS: Subjects who received nalmefene had a statistically significant reduction in severity of pathological gambling. Low-dose nalmefene (25 mg/day) appeared efficacious and was associated with few adverse events. Higher doses (50 mg/day and 100 mg/day) resulted in intolerable side effects.
Adult↗
Shared genetic contributions to pathological gambling and major depression in men.
CONTEXT: Although pathological gambling (PG) and major depression (MD) frequently co-occur, little is known regarding the relative contributions of environmental and genetic factors to the codevelopment of the disorders. OBJECTIVES: To estimate environmental and genetic contributions to PG and MD as defined in DSM-III-R and the lifetime co-occurrence of PG and MD. DESIGN: Survey data from the Vietnam Era Twin Registry were examined in biometric models. SETTING: Telephone interview. PARTICIPANTS: Of 10, 253 eligible participants, 7869 were successfully interviewed. MAIN OUTCOME MEASURES: Estimated genetic, shared environmental, and unique environmental contributions to PG and MD and their lifetime co-occurrence in bivariate models. RESULTS: Elevated odds ratios for MD were associated with those of PG (4.06; 95% confidence interval, 2.68-6.13), and the association remained significant following adjustment for sociodemographic and other psychiatric variables (odds ratio = 1.98; 95% confidence interval, 1.14-3.45). The best-fitting bivariate model indicated that 66% of the variance in PG and 41% of the variance in MD were owing to genetic factors, and 34% of the variance in PG and 59% of the variance in MD were owing to unique environmental factors. There was a substantial correlation between the genetic components of PG and MD (r(A) = 0.58), with 34% of the genetic variance for each disorder also contributing to that of the other. The best-fitting model estimated that 100% of the total overlap between PG and MD was genetic. CONCLUSIONS: The correlation between PG and MD in middle-aged men appears to be largely influenced by overlapping genetic factors. Future research is needed to determine the extent to which these findings extend to other groups (eg, women), identify specific genes, and generate improved prevention and treatment strategies.
Adult↗
Advancing treatment strategies for pathological gambling.
Experiences from treatment trials are described. The use of structured instruments for subject characterization and symptom change assessment is discussed and the challenges of treating specific groups (e.g., those with co-occurring alcohol use disorders) explored. Treatment for pathological gambling might be advanced most rapidly through collaborative multi-center efforts.
Behavior Therapy↗