uo addictive behaviors: disordered gambling

Julie Hynes, Sr. Community Health AnalystLane County Public Health

SAPP 407 | University of Oregon | Feb. 2014

GAMBLING

OVERVIEW• History & trends  

• Defining the issue: problem gambling

• Gambling & the brain

• Addiction & mental health connections

• Addressing the issue

POTENTIAL

DEFINITION:

______ something of valuein the _________________

something of greater value.

hopes of obtainingRISKING

Source: American Psychiatric Association ‐ DSM‐5 (2013). 

Howquicklythings

are changing

Source: insidefacebook.com

Source: WSJ.com 2/11/14

GAMING & GAMBLING: PARALLELS

Stimulate dopamine

Play for similar reasons (escape, relax, stimulate, etc.)

Potential for addiction?

Anything can be a bet…

(especially

online!)

Sources: linemakers.sportingnews.com, bovada.lv

What are the 2 states that DON’T have

legalized gambling?

AVAILABILITY OF LEGAL GAMBLING IN U.S., 2014

Horsetrack

1931

Video poker began

1992

Nine tribal casinos opened

1994 - 2004

Lottery approved

1984

Image sources: Oregon Lottery, Hynes

Image sources: Oregon Lottery, Hynes

$7 out

of every

$10lottery dollars

ELECTRONIC GAMBLING:“Video Poker/Slots/Line Games”

Source: Oregon Health Authority (2012; ibid)

Photo source: Daniel Berman.

Photo:  Hynes

Photo:  Daniel Berman

1 in 1751 in 175,000

1 in 175 million1 in 175 billion

1 in 175 Million(174,233,510)

Odds of getting struck by lightning: 1 in 280,000

Let’s say there is 1 RED popcorn kernel in this bag of

10,000 pieces of popcorn

….you’d have a better chance of reaching in and grabbing the one red kernel of popcorn in this bag than you would of winning $100 on a powerball ticket

So…if your lucky numbers have “almost” come up in the

last 5 drawings, are your chances better, worse, or the

same?

Sports betsLottery ticketsVideo & onlineBingo & raffles

Video lottery  

& online gambling

Electronic Gambling

89% Cards6%

Other5%

Gambling Treatment ClientsGamblers' Preferences

0.1%11.2%

1.2%2.7%

Research shows about what percentage of Oregon adults have a gambling problem?

2.7% of Oregon adults

(1 in 37 people)

have a gambling problem.

Behind every story…

there’s a story…

PATHOLOGICAL:Persistent and recurrent maladaptive gambling behavior...results in the   LOSS OF CONTROL over     

gambling. (DSM‐IV)

Definitions

Newlanguage

GAMBLING

DOESN’T START BY BEING A

PROBLEM.

It’s a“Continuum”

No Gambling Experimentation

Recreational Problem Pathological

Sources: 1. Moore (2006). 2. Volberg, Hedberg, & Moore (2008). 3.  Shaffer & Hall (2001). 4. Northwest Survey & Data Services (2007). 5. Moore (2001). 

At-Risk“GAMBLING DISORDER”

5.6% college age (18‐24)

2½ % all adults (18+)

4% teens (13‐17)

This is the first generation of widely available electronic gambling. We really don’t know the effects yet.

The new DSM-5 (May 2013) definespathological gambling as a

“behavioral addiction,” the first of its kind.

SIMILAR BEHAVIORAL CONDITIONS, like internet and

Binge eating, aren’t yet in the category of

“behavioral addiction.”

(It is thought They might be soon.)

IS IT AN “ADDICTION”

1. Solidly established, problematic pattern of a pleasurable & reinforcing behavior

2. Physiological/psychological components of behavior pattern that create dependence

3. Interaction of these components in an individual which makes person resistant to change

Definition of addiction from Diclemente, 2003

IS SOMEONE YOU KNOW…

• Gambling to escape problems• "Chasing" losses with more gambling• Lying to family and others about the

extent of gambling• Committing crimes to finance gambling• Jeopardizing or losing relationships,

jobs, education because of gambling• Relying on others to bail him or her

out relieve a desperate financial situation caused by gambling

EXAMPLESREAL LIFE‐ in the news

http://www.oregonlive.com/portland/index.ssf/2013/06/former_postal_service_worker_s.html

Register‐Guard, 5/13/11

But really, the consequences are usually much more than crime and 

being in the news…

THE STORIES GO ON.

…each problem gambler affects anaverage of 6‐12 others.

>70%are current 

tobacco users

32%have current 

alcohol problems

10%actually attempt 

suicide

Source: Oregon Health Authority, 2012

48%experience 

suicidal ideation

Have current drug problems

Hey man we r here @ starbucks on 13th c u soon

…

It’s been 2 more hrs.  U coming or what?

running late sorry

on my way

Never mind. We finished the project. AGAIN. Sorry but the group is done w/your excuses.

Jordan SAPP10:49PM

5:11PM

PROCESS of

ADDICTION.

Typical Phases of

Problem Gambling

Source: Custer, R. & Rosenthal, M.

WINNING

LOSING

DESPERATION

HOPELESSNESS

Winning PHASE

Losing PHASEI’ll get my

money back in no time.

My big win is just around the

corner!

Desperation PHASE

Hopelessness PHASE

Source: http://www.oregon.gov/oha/amh/gambling/gear‐workbook.pdf

THOUGHTS, FEELINGS, ANTICIPATION,

FANTASY(Gambler’s Mind, “Gambling Time/

Gambling Money”)

PLANNING(Removing obstacles

to gambling)

GAMBLING(“Winning & Losing”)

Serotonin AdrenalineDopamine

CRASHGuilt, Shame, Anger, Denial, Justification, Restless, Irritable, Depression, Panic or Numb, Suicidal Thoughts Dopamine

REALITY(Self with Others)“Real Time, Real Money”

WHAT CAN TRIGGER ACTION?Lots of things, but these are some key triggers. People at risk should especially avoid gambling when:

H

A

L

T

ungry

ngry

onely

ired

These comparisons are of course generalizations and do not by any means reflect all male and female gamblers.

Comparison by Start gambling at older age than men

Get addicted faster

Games of choice: video slots

More likely to be “escape” gamblers

Start gambling younger

Tend to like games of strategy & “action” (poker, sports bets)

Less likely to seek help

$32k

85%

90%

24%

$27k$!

IS THE AVERAGE HOUSEHOLD INCOME. Range is from $0 to over $1million/year.

ARE WHITE.  4.4% Hispanic/Latino., 3.4% Asian.  People of color are under‐represented in treatment.

prefer ELECTRONIC GAMBLING. Video (slots/poker/line games). Cards 4.1%; scratch‐its 1.3%; sports 0.9%;

HAVE COMMITTED CRIMES TO FINANCE THEIR GAMBLING. Most crimes are “white collar” (forgery, check fraud, embezzlement.)

IS THE AVERAGE INDIVIDUAL GAMBLING DEBT.

Oregonians in gambling treatment, 2012:

Comparison of “Action” and “Escape” Pathological

Gamblers

Excitement, competition

Early onset of gambling

Relief, escape from stress

Later onset of gambling

“Skilled” forms of gambling (sports/poker, etc)

More likely to present narcissistic or antisocial traits

“Luck” forms of gambling (lottery, slots, bingo)

More likely to presentdepressive/dysthymic traits

Action Escape

Source: Center for Substance Abuse Treatment, 2005. 

CAUSES? (RISK FACTORS)

• Trauma --stemming from abuse or neglect

• Mental health issues

• Substance use• Parental

attitudes & behavior

• Competitive family

• Community norms/laws

• Early initiation

• Friends favorable toward gambling

18

25

21

16

At what age is the

brain considered

fully developed?

The PREFRONTAL CORTEX is the LAST PART to develop.

The brain is still

developinguntil

Depression/mood disorders 

Narcissistic personality disorderPTSD  

ImpulsivityADHD Substance abuse Alcohol abuse 

Sources  Ledgerwood & Petry (2006). Kausch et al. (2006). Biddle et al. (2005). Oregon Health Authority (2010). The WAGER (2002, February 12);  Specker, et al., (1995); Kim & Grant (2001)

For more info: see article “The Almost Winning Addiction” in the readings.

It’s really about the action, not the money!

“ALMOST WINNING” causes dopamine to be activated the same as ACTUALLY winning.

Problem gamblers are more likely to see their near misses as “NEAR WINS”

People play LONGER when machines give them NEAR MISSES.

Neurotransmitter

Serotonin

Norepinephrine

Opioids

Dopamine

Role in Relation to

Gambling

Behavior Initiation/Cessation

Arousal, Excitement

Pleasure, Urges

Reward, Reinforcement

Dopamine: most studied neurotransmitter in problem gambling

Serotonin -- risk taking

Gambling - β-endorphin

PGs - NE levels

PGs - dopamine response

Neurotransmitter “PGs” = problem gamblers | Neurotransmitters are brain chemicals that transmit nerve impulses. Dopamine is known as the brain’s “reward system.”

Source: Brain Briefings (2007, October), Society for Neuroscience, Washington, DC

Gambling & Dopamine

Dopamine not released when expecting a loss.Flooded with dopamine when expecting a win!

It’s not about the money – it’s about the action of the game and the hope of winning.  

Sources: Tonneato, T. (1999). Cognitive psychopathology of problem gambling. Subst Use Misuse. Sep;34(11):1Anecdotal reports from problem gamblers in treatment and recovery.

Image source: Anheuser‐Busch

COGNITIVE Distortions

Lucky #’sFavorite shirt“My” machine

Superstition

Rituals/habits that are believed

to affect the outcome.

COGNITIVE Distortions

Example (win): “Yeah buddy! I was just waiting on my card. I know this game inside and out.”Example (loss): “I would’ve won if that idiot didn’t get lucky and draw an ace.”

Biased EvaluationAttributing wins to one’s special skill or luck, while losses are blamed on external circumstances.

Image source: Anheuser‐Busch

COGNITIVE Distortions

Forgetting about losses, only remembering wins.

Selective Memory

COGNITIVE Distortions

Failure to see each event as independent. Examples:• Trying to see patterns in coin flips.• “This slot machine is DUE to hit!”

Gambler’s Fallacy

THIS

…those are other ways our

minds trick us. We are wired to

see patterns in things.

Reflect: cognitive distortion

Have you ever experienced a

cognitive distortion? What was the

experience like?

VULNERABLE POPULATIONS

• Older adults• College students• Ethnic minorities• Incarcerated 

persons• Military & veterans• Women

• Substance abuse history

• Mental health history

• Youth

The “Addiction” Connection

Differences?Similarities?

The “Addiction” Connection

• Loss of control• Denial• Depression/mood swings• Progressive• Tolerance• Use as an escape• Preoccupation• Similar “highs”• Self‐help groups• Family involvement• Use of rituals

Differences?Similarities? Defining “use” (gambling) Behavior not attributable to chemical ingestion

No biological test More intense sense of shame and guilt (anecdotal)

Unpredictable outcome Fantasies of success /quitting is giving up hope

Easier to hide

Effects of Problem Gambling on Children

• Prone to abuse and/or neglect• Child endangerment may increase• Higher levels of tobacco, alcohol, drug use, and overeating than peers

• Higher risk of pathological gambling • Suffer effects from lack of financial stability

“The earlier people begin gambling, the more likely

they are to experience problems from gambling.”

- National Academy of Sciences

Not Your Uncle’s Gambling

Youth gambling still under-studied & under the radar

Research on:

•Amygdala active  •Fight or flight,

emotion•Decision-making

altered•More vulnerable to risk‐

taking & impulsive behaviors

Source: Ramoski, S., Nystrom, R. (2007). 

“The adolescent brain is especially sensitive to the

effects of dopamine.

• Single‐parent household• Gambling on 

cards/sports• Being male, older teen• Lower household 

income• Competitive• Having lost more than 

$50 in a single month

• Started gambling before 8th grade (early initiation)

• Parents who gamble‐‐youth twice as likely to be at‐risk gamblers & four times as likely to be problem gamblers

Source: Volberg, et al (2008; bid).

RISK FACTORS FOR YOUTH

Gambling & Oregon Teens

Six in 10 Oregon (63 percent) have gambled46 percent gambled in the past year3 percent gamble weekly or more 

Six percent problem gamblers or at riskPreferred games in order:

Free Internet gambling-type gamesCards (poker)Sports bets

Games of personal skill

Source: Volberg, et al (2008; bid).

Lane County 2012 Student Wellness Survey (SWS)

2012 Gambling, Substance Use and Mental Health among Oregon Youth

0%

10%

20%

30%

40%

50%

Gambling Alcohol BingeAlcohol

Marijuana CigarettesDepression Psychdistress

Percen

tage

6th 8th

11th

Source: http://oregon.pridesurveys.com/esds.php?year=2011n=55,611 students (18,885 6th grade; 21,368 8th grade; 15,358 11th grade) 

Used alcohol in the past month

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Grade 6 Grade 8 Grade 11

Percen

tage

Did not gamble

Gambled

Available at: www.preventionlane.org/sws.htm

Binge drank in the last 30 days

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

50%

Grade 6 Grade 8 Grade 11

Percen

tage

Did not gambleGambled

Available at: www.preventionlane.org/sws.htm

Smoked cigarettes in the past month

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

50%

Grade 6 Grade 8 Grade 11

Percen

tage

Did not gambleGambled

Available at: www.preventionlane.org/sws.htm

Used marijuana in the past month

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

50%

Grade 6 Grade 8 Grade 11

Percen

tage

Did not gambleGambled

Available at: www.preventionlane.org/sws.htm

Skipped school one or more days in the past month

0%5%

10%15%20%25%30%35%40%45%50%

Grade 6 Grade 8 Grade 11

Percen

tage

Did not gamble

Gambled

Available at: www.preventionlane.org/sws.htm

Percent of youth who attempted suicide in the

past year

7.2%5.0%

11.3%9.0%

0%

5%

10%

15%

20%

25%

30%

Grade 8 Grade 11

Percen

tage

Did not gamble

Gambled

Available at: www.preventionlane.org/sws.htm

Percent of youth that attempted suicide in the past year

10.1%8.0%

21.0%18.6%

0%

5%

10%

15%

20%

25%

30%

Grade 8 Grade 11

Percen

tage Did not

bet/gamble morethan wanted to

Bet/gambledmore thanwanted to

Conclusion?

Teens who gamble are smoked up, toked up, drunk emo delinquents.

Conclusion?

Teens who gamble are smoked up, toked up, drunk emo delinquents.

delinquency

sexualbehavior

depression

substanceuse

gambling

ProblemBehaviors

Conclusion: Problem Gamblingis

ONE COMPONENT of Problem Behaviors

Identification & Treatment

Online: click here

Source: Written by Robert L. Custer, M.D; retrieved from Council on Compulsive Gambling of New Jersey, Inc..

Intervention

Helpline 541.741.7107: emergence Or 24/7: 1.877.MY.LIMIT

Referred to provider for assessment

Family members come in; later bring gambler in

A Simple Screen: Lie-Bet Tool(Johnson et al., 1988)

1.Have you ever felt the need to betmore and more money?

2.Have you ever had to lie to people important to you about how much you gambled?

Valid and reliable for ruling out pathological gambling behaviorResponse to ONE or both indicates referral for longer assessmentuseful in screening to determine whether a longer tool (e.g., SOGS, DSM‐IV) 

should be used in diagnostics

Assessment Tools

SOGSDSM

DSM Criteria Revisited1. Preoccupation

with gambling2. Increases amount

of money gambled3. Unsuccessfully

tries to quit4. Restless or

irritable when trying to cut down/stop

5. Gambles as an escape

6. “Chases” losses7. Lies to others to

conceal gambling8. Has jeopardized

relationships9. Relies on others

to bail him/her out

Gambling Disorder =

Four or more of above, AND: The gambling behavior is not better accounted for by a Manic Episode.

Treatment is Free.

24 hrs: 1877‐my‐limitOnline: 1877mylimit.org

Minimal intervention: GEAR (Gambling Education and Reduction)Outpatient treatment (44)Crisis respite (2)Residential treatment (1)

TREATMENT OPTIONS IN OREGON

EMERGENCE GAMBLING TREATMENT PROGRAM

Treatment free for gamblers and loved ones275 problem gamblers and family members treated last yearGender-specific

Multimodal treatment Individual sessions - Family therapyGroup sessions - Recreational counselingDidactic lectures - Audiovisual educ.

Suggest to explore 12‐step program

• Only about 2% of Oregonians who need treatment enroll 

• Those enrolling who lived within a 50 mile radius of a casino were significantly more likely to report casino as their primary venue 

• 30% enter treatment through the statewide helpline

Source: http://www.oregon.gov/oha/amh/gambling/gear‐workbook.pdf

THOUGHTS, FEELINGS, ANTICIPATION,

FANTASY(Gambler’s Mind, “Gambling Time/

Gambling Money”)

PLANNING(Removing obstacles

to gambling)

GAMBLING(“Winning & Losing”)

Serotonin AdrenalineDopamine

CRASHGuilt, Shame, Anger, Denial, Justification, Restless, Irritable, Depression, Panic or Numb, Suicidal Thoughts Dopamine

REALITY(Self with Others)“Real Time, Real Money”

DISRUPTING THE ACTION CYCLE

• Barriers to Money• Treatment• Support Systems• Accountability• H.A.L.T. (hungry, angry, lonely, tired)

Slide credit: Janese Olalde, MEd, CGAC, CADC

FAMILY TREATMENT ISSUES

• Allow venting of rage and betrayal• Education of compulsive gambling as an illness• Family Groups• Renew sense of hope• Empowerment• Seek support – treatment • GAM‐ANON• DON’T KEEP SECRETS!

Slide credit: Janese Olalde, MEd, CGAC, CADC

Family Financial Issues

• Create own avenue to financial stability (employment or other)

• Protect financial assets• Close joint accounts• Use automatic/electronic deposits for gambler’s income

• NO BAILOUTS! 

Slide credit: Janese Olalde, MEd, CGAC, CADC

Couple Issues in Therapy

Sequencing with individual work  Assess possibility of domestic violence Impact on partner and children  Role of money in the relationship  Deal with hurt, anger, mistrust Dealing with “unfolding truths”

Slide credit: Janese Olalde, MEd, CGAC, CADC

Promotion & Prevention

Creating conditions in families, schools, and communities that

promote the wellbeing of people

Emotional and behavioral health

Physical health

Awareness & communication of the problem is relatively low.

2012 Oregon Student Wellness Survey, Lane County (“Esd”) and Oregon; available at http://oregon.pridesurveys.com/esds.php?year=2011

Targeting Parental Attitudes

Oregon parent/youth focus groups revealed:

• All parents in the groups said their kids didn’t gamble

• All kids in the groups said they did gamble• Neither sees gambling as risky

Targeting Parental Attitudes

Most parents believe:• Youth gambling is harmless • Youth who gamble are unlikely to have problems in school

• Youth gambling is not associated with alcohol or drug use

…and those beliefs are part of the problem

Crashed cars“Scared straight”

Boot campOne‐time activities

Our efforts in Oregon have

a focus on: • Public awareness• Policy• Support for in‐school prevention curriculum

• Parent education

Problem Gambling Advisory Committee

• Meets monthly• Works on policy & awareness issues

• Comprised of professionals & community members

Various Methods

ON THE RIGHT PATH

KEY CHALLENGES IN THE FIELD

• Youthful subject• Perception of harmlessness

• Stigma/shame• Industry

IS IT “SOCIAL” OR PROBLEM GAMBLING?

Social GamblerOccasional

Sticks w/ limits

Hopes to win, expects to lose

Can take it or leave it

Problem GamblerFrequent, preoccupied

Plays w/needed $, borrows

Hopes & expects to WIN

Primary source of “fun”

10 TIPS FOR RESPONSIBLE GAMBLING

1. Gamble only if it's fun.2. Think of the money you lose as the cost of 

entertainment.3. Set a dollar limit and stick to it.4. Set a time limit and stick to it.5. Accept losing as part of the game.

10 TIPS FOR RESPONSIBLE GAMBLING

6. Don't borrow money to gamble.7. Don't let gambling interfere with family, friends, 

or work.8. Don't gamble to win back losses.9. Don't use gambling as a way to cope with 

emotional or physical pain.10. Know the warning signs of problem gambling.

SUMMARIZING THIS CONTENT

• We defined gambling & problem gambling• We looked at trends• We looked at connections with other issues• We saw the effects on the brain• We looked at how to address problem gambling

•

Under $100$100‐$1,000

$1,000-$2,500More than $2,500

Problem gambling treatment is ‘free’ in Oregon for gamblers AND loved ones.

The average problem gambler in Oregon

gambling treatment owes

$4,000 in gambling-related debts.

The average problem gambler in Oregon gambling treatment owes 

$30,000 in 

gambling‐related debts.

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