Leigh Falls Holman, Ph.D., LPCS, RPTS, NCC, CSCAMHCA Diplomate & CMHS Substance Abuse & Co-

Occurring Disorders

Change diagnostic category from Substance-Related Disorders to Substance Use and Addictive Disorders

The addition of Addictive Disorders indicate acceptance of process or behavioral addictions as a concept by the APA workgroup that worked on this category.

Acknowledges behavioral processes can activate the reward system and produce behavioral symptoms similar to SUDS.

Includes Gambling Use Disorder as a diagnosis in Section II under the Substance-Related and Addictive Disorders category.

Includes Internet Gaming Disorder (p. 795) in Section III.

Other process addictions must be categorized under other diagnostic categories such as Feeding and Eating Disorders, Impulse Control Disorders, Obsessive Compulsive Disorders, and Sexual Disorders or Paraphilias.

Pre-occupation Tolerance Denial Progression Withdrawal

◦ Clinically significant impairment or distress◦ 4 or more criteria in 12 month period

More money to achieve desired excitement (tolerance) Restless or irritable when tries to cut down/stop (withdrawal) Can’t control behavior (compulsion) Preoccupied with gambling (obsession) Gambles when feeling distressed (emotion regulation) Lies to conceal extent of gambling Impaired functioning Relies on others to provide money to continue gambling◦ Not better explained by a manic episode

Episodic or Persistent Remission: ◦ Early: 3-12 months◦ Sustained:Over 1 year

Severity Level◦Mild: 4/5 Criteria (less in treatment)◦Moderate: 6/7 criteria◦ Severe: 8/9 criteria

Distorted Thinking:◦ Denial◦ Superstitions◦ Sense of power & control over the outcome of chance

events◦ Overconfidence

“Some are impulsive, competitive, energetic, restless, and easily bored” (p. 587).

“May be overly concerned with the approval of others and may be generous to the point of extravagance when winning.”

“Others may be depressed and lonely, and they gamble when feeling helpless, guilty, or depressed.”

About 50% in treatment have suicidal ideation & about 17% have attempted suicide.

Prevalence ◦ Last 12 months .2%-.3% of the general population

◦ Lifetime prevalence rate gender & ethnicityMales: .6%Females: .2%African Am .9%Whites .4%Hispanics .3%

◦ More common among young & mid-life

◦ Risk & Prognostic Factors: Temperament Genetic Course Modifiers

Earlier onset:More common with malesOften begin with family & friendsAssociated with impulsivity & substance abuseHS & college students who have the disorder may grow out of it Younger prefer sports betting

Older: Machine/bingo gambling more likely

Females: mid-late adult onset is typicalmore rapid development in femalesmore likely than males to have depression, bipolar, & anxiety

Low rate of treatment seeking in general <10%, but more older onset females present for treatment than other populations

Frequency gambling can be more associated with the type of gambling than the severity of gambling. (scratch ticket vs. casino)

Amount of money isn’t necessarily an indicator of a gambling problem.

Poor general health & utilize medical services at a high rates

◦ Tachycardia & angina more common in GD population even when other substance use disorders are controlled for.

Jeopardize or loss of important relationships

Repeated lying to cover up the extent of gambling

May request money used for gambling or to pay off gambling debts

Employment/educational activities may be adversely impacted◦ Absenteeism◦ Poor work/school performance

Differential Diagnosis:◦ Non-disordered gambling◦ Manic Episode◦ Personality Disorders◦ Other Medical Conditions (e.g. Parkinson’s meds)

Comorbidity◦ Substance use disorders◦ Depressive disorders◦ Anxiety disorders◦ Personality disorders

Genetics: research “suggests that the possession of the dopamine D2A1 allele receptor gene may result in deficits in the dopamine reward pathways” (Ashley & Boehlke, p. 56).

Trauma History: Kausch et al. found 64.4% Cognitive Distortions (next slide) Accessibility: Gerstein et al. double risk if within 50

miles of a casino - controversial Co-morbid SUDs, mood, ADHD Criminal behavior, Bankruptcy Suicidal Thinking