[Slide1]

PathologicalGamblingPathological Gambling and Alcohol Use Disorders

Timothy Fong MD
First-Year AMSP Scholar

December 2005

I. Introduction (This lecture is important for medicalstudentsmedical students because) [Slide 2]

A. LifetimeriskLifetime risk of pathological gambling (PG) is ~ 2%(1)

B. LifetimeriskLifetime risk of alcohol use disorders (AUD) is ~ 13% (2)

C. LessresearchLess research on PG vs. AUD

1. PubMed References: PG ~ 1,600, AUD ~ 55,000

2. MostphysiciansMost physicians know little about pathological gambling (3)

3. MedicalschoolMedical school curricula do not cover pathological gambling

D. Co-occurring PG and AUD are associated with worse outcomes (4)

1. TwiceasTwice as likely to dropout of treatment (5-7)

2. ↓quality of life

E. ThislectureThis lecture will cover: [Slide 3]

1. PathologicalgamblingPathological gambling (PG)

a. GamblinginGambling in the United States

b. DSM-IV criteria

c. Epidemiology

d. Consequences

e. Screening

f. RiskfactorsRisk factors

g. Treatment

2. Alcohol usedisordersuse disorders (AUD)

a. AlcoholuseAlcohol use in the United States

b. DSM-IVcriteriaIV criteria

c. Epidemiology

d. Consequences

e. Screening

f. RiskFactorsRisk Factors

g. Treatment

3. AUD and PG [Slide 4]

a. Outcomes

b. Epidemiology

c. Similarities

d. Differences

e. TreatmentconsiderationsTreatment considerations

II. Pathological gambling

A. GamblinginGambling in the United States (8) [Slide 5]

1. 85% of Americans have gambled over the last 12 months

2. 48 states in the United States have legalized gambling

3. $72billion/year net revenue; more than amusement parks, movies and sporting eventscombinedevents combined

4. IncreasedculturalIncreased cultural acceptance (9)

a. IncreasedpopularityIncreased popularity of televised gambling

b. SchoolandSchool and churches use gambling for fund-raising

c. 80% of parents aware and not opposed to children gambling (10)

B. DSM-IV Criteria (11, 12)

1. SocialgamblingSocial gambling(13) [Slide6]

a. SimilarmeaningSimilar meaning to “social drinking”

b. GamblingdoesGambling does not meaningfully impact life

c. ~85% of gamblers

2. ProblemgamblingProblem gambling (1) [Slide 7]

a. SimilartoSimilar to “substance abuse”

b. GamblingbehaviorsGambling behaviors: problematic and beginning to interfere

c. ~5-6% of the general US population

3. PathologicalgamblingPathological gambling: [Slides8 and 9]

a. DSM-IVcriteriaIV criteria (5/10 criteria over last 12 months)(14)

i. PreoccupationwithPreoccupation with gambling

ii. GambleswithGambles with increasing money to achieve desired excitement

iii. RepeatedunsuccessfulRepeated unsuccessful efforts to control, cut back, or stop gambling

iv. Restless/irritablewhenirritable when attempts cutting down or stopping

v. GamblestoGambles to escape problems or to relieve dysphoria

vi. ReturnstoReturns to get even ("chasing" one's losses)

vii. LiestoLies to conceal the extent of involvement

viii. IllegalactsIllegal acts (e.g. forgery, fraud, theft, or embezzlement) to) to finance gambling

ix. LostrelationshipLost relationship, job, education, or career because of gambling

x. OthersprovideOthers provide money for desperate financial situation

b. GamblingisGambling is not better accounted for by a manic episode

C. EpidemiologyofEpidemiology of PG (8, 15, 16) [Slide10]

1. LifetimeprevalenceLifetime prevalence

a. ~1%of general population (15, 17, 18)

b. Higher within 50 miles of a casino

2. VulnerablepopulationsVulnerable populations (19) [Slide11]

a. Adolescents(20)

i. HardertoHarder to recoup financial losses

ii. EarlyexposureEarly exposure to gambling increases risk

b. Co-occurringsubstanceoccurring substance use disorder; impairs judgment (21)

c. CasinoworkersCasino workers: high access (22)

d. CurrentlyincarceratedCurrently incarcerated (17)

i. HighfrequencyHigh frequency of gambling in prisons/jails

ii. BoredomandBoredom and lack of activities

D. ConsequencesofConsequences of PG (23, 24) [Slide12]

. 1. Financial

a. Debt: average is ~ $45,000 (25)

b. BankruptcyratesBankruptcy rates: 4 times higher, 20% (26)

c. EconomicburdenEconomic burden: $35 billion per year (27)

2. Relationships

a. DivorceratesDivorce rates 54% (28)

b. DomesticviolenceDomestic violence: 10x more likely (29)

c. ChildabuseChild abuse and neglect: case reports of abandonment in several states (30)

3. LossofLoss of time and productivity: ~ 25 hours spent per week (31)

4. Medical

a. IncreasedfrequencyIncreased frequency of stress-related illnesses like peptic ulcer, hypertension (28)

b. 25% attempt suicide (32)

5. Crime: 21% of PG commitPG commit non-violent, financial crimes (33)

6. SubstanceuseSubstance use disorders: 4x increased risk (34)

E. ScreeningtoolsScreening tools [Slide13]

1. SouthOaksSouth Oaks Gambling Screen (SOGS) (35, 36)

a. Self-reportquestionnairereport questionnaire re: gambling behaviors and consequences

b. ScoreofScore of ≥5 = probable PG

2. Lie/BetQuestionnaireBet Questionnaire (37, 38)

a. TwoquestionsTwo questions:

i. EverliedEver lied about your gambling?

ii. EverincreasedEver increased bet to get same sense ofactionof action?

b. Two “yes” responses = high= high sensitivity(sensitivity (.99), high, high specificity (.91) andhighand high positive predictive value (.92)

3. NoobjectiveNo objective tests

F. RiskfactorsRisk factors (19) [Slide14]

1. Biological(39-41)

a. FamilystudiesFamily studies: 2-3x increased risk in family members (42, 43)

b. TwinstudiesTwin studies: 60% genetic risk (44)

c. Neuroimaging: implicate same regions as substance use disorders (e.g. orbitofrontal cortexandcortex and reward systems (45)

d. AlterationsinAlterations in serotonin, dopamine and norepinephrine (41, 46)

2. Psychological [Slide 15]

a. PersonalitytraitsPersonality traits (47, 48)

i. ↑Impulsivity

ii. ↑Sensation-seeking

iii. ↑Risk-taking

b. ImpairedcopingImpaired coping strategies (49)

i. AvoidresponsibilitiesAvoid responsibilities

ii. ManageshameManage shame and emotional pain

iii. EscapestressEscape stress

c. CognitivedistortionsCognitive distortions about gambling (50-52)

i. FalseperceptionsFalse perceptions of ability to control gambling outcomes

ii. FalsebeliefsFalse beliefs that gambling will solve life problems

3. Social(53, 54) [Slide 16]

i. IncreasedaccessIncreased access to gambling

ii. LearningtoLearning to gamble at an earlier age (54)

G. TreatmentofTreatment of PG [Slide 17]

1. Pharmacotherapy: No FDA-approved meds;preliminarymeds; preliminary research evidence for: (55)

a. Naltrexone

i. Opiate antagonist used for alcoholandalcohol and opiate dependence

ii. Targets urges and cravings (56)

iii. Side effects: dysphoria, elevated LFTs, nausea, problems

controllingpaincontrolling pain

iv. Efficacy: 30% reduction inurgesin urges/craving to gamble (57)

b Selective serotonin reuptakeinhibitorsreuptake inhibitors (SSRI)

i. Antidepressants to target gamblingpreoccupationgambling preoccupation and obsessions (58, 59)

ii. Side effects: nausea, sexualdysfunctionsexual dysfunction, agitation

iii. Efficacy: Mixed results on gambling behaviors (59, 60)

c. Valproic Acid

i. Anticonvulsant used for bipolardisorderbipolar disorder

ii. Side effects: sedation, tremors,nauseatremors, nausea

iii. Efficacy: reduced gambling in non-bipolar disorder (61, 62)

d. Lithium

i. Natural salt used for bipolar disorder

ii. Side effects: tremor, sedation,nauseasedation, nausea, thyroid and kidney

impairments

iii. Efficacy: reduced gambling in non-bipolar and bipolar spectrumdisorderspectrum disorder PG (61, 63, 64)

2. Social assistanceSocial assistance[AB1] [Slide 18]

a. Self-exclusion programs

i. PGs sign up with casinos to barthemselvesbar themselves from entering

ii. Potential gateway into treatment (65)

b. FinancialcounselingFinancial counseling:

i. Debt relief/consolidation

ii. Bankruptcy

iii. Discharged casino debts

c. Gambler’s Anonymous [AB2] (66)

i. > 1500 chapters in U.S.

ii. Modeled after AA, providesfellowshipprovides fellowship and peer support

iii. 8% abstinence rate after 1 year ofparticipationof participation

3. PsychosocialtreatmentsPsychosocial treatments [Slide19]

a. CognitivebehavioralCognitive behavioral therapy (67, 68)

i. FocusesonFocuses on reworking cognitive distortions about gambling

ii. CanbeCan be manualized

iii. 40%reduction in gambling behavior after 12 sessions

iv. 50%treatment retention rate [AB3]

v. Long-term efficacy data needed, especially after therapy ends

b. HelplinesHelp lines

i. 24-hourtelephonehour telephone counseling

ii. TrainedgamblingTrained gambling counselor provides crisis intervention, education and referrals

iii. NodataNo data on effectiveness, yet widely used.

III. AlcoholUseAlcohol Use Disorders: The second diagnosis

A. Alcohol Use in the United States [Slide 20]

1. 63%percent drank over last 12 months

2. GrossrevenueGross revenue 2005: $6 billion

B. DSM-IVCriteriaIV Criteria (69) [Slide 21]

1. Abuse: significant impairment/distress in>1 over 12 months

a. FailuretoFailure to fulfill major obligations

b. PhysicallyhazardousPhysically hazardous (e.g. driving while intoxicated)

c. LegalproblemsLegal problems (e.g. disorderly conduct, DUIs)

d. Social/interpersonalproblemsinterpersonal problems (e.g. arguments, physical fights)

2. Dependence: >3 in a 12-month period [Slide 22]

a. Tolerance(Tolerance (e.g. increased amount needed for effect)

b. Withdrawal(Withdrawal (e.g. increased autonomic hyperactivity, tremor)

c. LargeramountsLarger amounts/longer period than intended

d. PersistentdesirePersistent desire/unsuccessful attempts to cut down

e. ExcessivetimeExcessive time spent with alcohol

f. ActivitiesgivenActivities given up due to alcohol

g. ContinueduseContinued use despite problems

C. Epidemiology [Slide23]

1. Abuse/Dependence(70, 71)

a. LifetimeprevalenceLifetime prevalence - abuse/dependence :dependence: 15-20%

b. 15 million individuals meeting criteria

2. EconomicburdenEconomic burden: $155 billion

D. Consequences [Slide24]

1 Medical

a. Cardiovascular:hypertensionCardiovascular: hypertension, cardiomyopathy, MI.

b. GastrointestinalsystemGastrointestinal :system: Mallory Weiss tear, gastric bleeding, fatty

liver, cirrhosis.

c. Neurological: Korsakoff’s and Wernicke’s syndrome (opthalmoplegia, ataxia, and encephalopathy), peripheralneuropathyperipheral neuropathy, cerebellar degeneration, cognitive deficits

2. Work: ↑unemployment; ↑lateness; ↑injury; ↓weeks of employment; and

↓ performance

3. Family

a. > 80% of cases of spouse-to- spouse violence

b. 25% of heavydrinkersheavy drinkers abuse children

E. Screening [Slide25]

1. AlcoholUseAlcohol Use Disorder Inventory Test (AUDIT) (72)

a. 10 items

b. Self-administeredoradministered or interview

c. 2 minutes to complete

d. IncludesquestionsIncludes questions on quantity/frequency and alcohol use problems

e. OriginallydevelopedOriginally developed as screening instrument for primary care setting  

2. Michigan Alcohol Screening Test (MAST) (73)

a. 25 items (also a 10 item version)

b. Self-administeredoradministered or interview

c. 10 minutes to complete

3. StatemarkersState markers: ↑GGT, ↑ MCV, ↑CDT

F. RiskFactorsRisk Factors [Slide26] 1. Gender (femalestendfemales tend to have less body water, more body fat)

2. Genetics (differential risk for level of intoxication,diseasesintoxication, diseases, alcohol dependence)

3. Body weight (smaller size achieves higher bloodlevelsblood levels)

4. Metabolism (less activity ofalcoholof alcohol dehydrogenase results in slower metabolism, higher levels and longerdurationlonger duration of sustained alcohol levels)

5. Medical illness (e.g. liverdiseaseliver disease, diabetes, hepatitis C, etc.)

6. Pregnancy (risk for fetalalcoholfetal alcohol syndrome, spontaneous abortion, low

birthbabybirth baby, developmental delays, etc)

G. TreatmentofTreatment of AUD (74) [Slide 27]

1. Pharmacotherapy

a. Disulfiram (75)

i. Inhibits aldehydedehydrogenase;

ii. Aversive effect if ETOH consumed; Disulfiram-Ethanol Reaction (flushing, nausea, tachycardia)

iii. Side effects: metallic taste, nausea, hepatitis, psychosis.

neuropathy

iv. Efficacy: equivocal forabstinentfor abstinent rates, best for highly motivated, directly observed patients

b. Naltrexone(76)

i. Opiate antagonist to blockurgesblock urges/cravings

ii. Side effects: nausea, dysphoria, increased LFTs

iii. Efficacy: reduces number ofdrinksof drinks and number of drinking days

c. Acamprosate (77)

i. Taurine derivative, restores NMDA receptor tone in the glutamate system, also impacts GABA neurotransmission.

ii. Side effects: diarrhea, rash

iii. Efficacy: greater treatmentcompletiontreatment completion, increased time to first drink

2. SocialassistanceSocial assistance for AUD (73, 78)[AB4] [Slide28]

a. 12-Step,AlcoholicsStep, Alcoholics Anonymous

i. PeersupportPeer support and fellowship

ii. 75,000 groups in the United States

iii. DifficulttoDifficult to study empirically

b. SMART Recovery (Self-Management and Recovery Training)

i. Self-reliance

ii. Discussion groups

iii. No sponsors

iv. Essentially no empirical data

3. PsychosocialTreatmentsPsychosocial Treatments

a. CognitivebehavioralCognitive behavioral therapy (79, 80)[AB5]

i. IncreasemotivationIncrease motivation for abstinence

ii. IdentifymotivationsIdentify motivations for drinking and develop alternatives

iii. SimilartechniquesSimilar techniques used for PG

iv. Efficacy:longerEfficacy: longer in treatment, better the outcome

b. Relapse Prevention Therapy

i. Identify high-risk situations

ii. Develop new coping behaviors

iii. Effective in reducing frequency of relapse

IV. AlcoholuseAlcohol use disorders and pathological gambling (81, 82) [Slide29]

A. A. Co-occurringPGoccurring PG and AUD associated with worse treatment outcomes (83-85)

1. MoredifficultMore difficult for treatment engagement and retention

2. LowercomplianceLower compliance rates with treatment recommendations

3. MorelikelyMore likely to have other co-occurring disorders such asdepressionas depression, anxiety disorders or antisocial personality disorder

4. MorelikelyMore likely to relapse as compared to persons with only PG or AUD

B. Epidemiology (84, 86, 87) [Slide30]

1. PG have higher rates of AUD (88)

a. AUD in PG: 40%

b. IncreasedseverityIncreased severity of PG = increased risk for AUD

2. AUD have higher rates of PG (4, 89)

a. PG in AUD: ~10%

b. Most AUD providers do not screen for PG

3. Neither PG or AUD more likely to emerge first (90)

C. SimilaritiesbetweenSimilarities between PG and AUD (4) [Slide31]

1. Preoccupation:intensePreoccupation: intense urges and cravings

2. Tolerance;gamblingTolerance; gambling more to achieve desired affect

3. Lying:coverLying: cover-up debt and extent of involvement

4. OngoinggamblingOngoing gambling despite negative consequences

D. DifferencesbetweenDifferences between PG and AUD (91) [Slide 32]

1. NoobjectiveNo objective tests

a. Nointoxicated states

b. NophysicalNo physical signs and symptoms

2. FinancialimpactFinancial impact

a. PG may lose large amounts at one time

b. PGmayPG may win large amounts of money at one time

E. TreatmentconsiderationsTreatment considerations for co-occurring PG and AUD (87, 92)

[Slide 33]

1. MuchmoreMuch more data needed; use “common-sense practices”

2. For co-occurring AUD + PG, use similar treatments as for AUD or PG, alone.

3. IftreatIf treat only one disorder, the other disorder will persist (84)

4. GetcollateralGet collateral information from relatives and friends

5. PeriodicurinePeriodic urine drug toxicology testing, breathalyzers, LFTs

6. NoobjectiveNo objective test available to monitor gambling behavior

7. InsurancedoesInsurance does not cover PG treatment

III. Conclusions [Slide 34]

A. PG is a psychiatric disorder with serious negative consequences

B. PG and AUD commonly co-occur

C. PhysiciansmustPhysicians must screen for PG and AUD in order to intervene early

D. TreatmentsandTreatments and interventions are available for both disorders

References

1. ShafferHJ, Hall MN, Vander Bilt J: Estimating the prevalence of disordered gamblingbehavior in the United States and Canada: a research synthesis. Am J PublicHealth 1999; 89:1369-76

2. RobinsLN, Price RK: Adult disorders predicted by childhood conduct problems: resultsfrom the NIMH Epidemiologic Catchment Area project. Psychiatry 1991; 54:116-32

3. DaghestaniAN: Why should physicians recognize compulsive gambling? Postgrad Med 1987;82:253-6, 259, 262-3

4. WelteJ, Barnes G, Wieczorek W, Tidwell MC, Parker J: Alcohol and gambling pathologyamong U.S. adults: prevalence, demographic patterns and comorbidity. J StudAlcohol 2001; 62:706-12

5. GrantJE, Kim SW, Kuskowski M: Retrospective review of treatment retention inpathological gambling. Compr Psychiatry 2004; 45:83-7

6. ShafferHJ, Labrie RA, Laplante DA, Kidman RC, Donato AN: The Iowa Gambling TreatmentProgram: Treatment Outcomes for a Follow-up Sample. J Gambl Stud 2005; 21:59-71

7. LedgerwoodDM, Downey KK: Relationship between problem gambling and substance use in amethadone maintenance population. Addict Behav 2002; 27:483-91

8. Cunningham-WilliamsRM, Cottler LB: The epidemiology of pathological gambling. Semin ClinNeuropsychiatry 2001; 6:155-66

9. RayluN, Oei TP: Role of culture in gambling and problem gambling. Clin Psychol Rev2004; 23:1087-114

10. GuptaR, Derevensky JL: Adolescents with gambling problems: from research totreatment. J Gambl Stud 2000; 16:315-42

11. ShafferHJ, Korn DA: Gambling and related mental disorders: a public health analysis.Annu Rev Public Health 2002; 23:171-212

12. PotenzaMN, Kosten TR, Rounsaville BJ: Pathological gambling. Jama 2001; 286:141-4

13. DesaiRA, Maciejewski PK, Dausey DJ, Caldarone BJ, Potenza MN: Health correlates ofrecreational gambling in older adults. Am J Psychiatry 2004; 161:1672-9

14. StinchfieldR, Govoni R, Frisch GR: DSM-IV diagnostic criteria for pathological gambling:reliability, validity, and classification accuracy. Am J Addict 2005; 14:73-82

15. GersteinDR, Volberg RA, Harwood H, Christensen MH: Gambling Impact and Behavior Study:Report to the National Gambling Impact Study Commission. Chicago, NationalOpinion Research Centre at the University of Chicago, 1999

16. VolbergRA, Steadman HJ: Refining prevalence estimates of pathological gambling. Am JPsychiatry 1988; 145:502-5

17. ShafferHJ, Hall MN: Updating and refining prevalence estimates of disordered gamblingbehaviour in the United States and Canada. Can J Public Health 2001; 92:168-72

18. VolbergRA: The prevalence and demographics of pathological gamblers: implications forpublic health. Am J Public Health 1994; 84:237-41

19. WelteJW, Barnes GM, Wieczorek WF, Tidwell MC, Parker JC: Risk factors forpathological gambling. Addict Behav 2004; 29:323-35

20. KaminerV, Petry NM: Gambling behavior in youths: why we should be concerned. PsychiatrServ 1999; 50:167-8

21. PetryNM, Stinson FS, Grant BF: Comorbidity of DSM-IV pathological gambling and otherpsychiatric disorders: results from the National Epidemiologic Survey onAlcohol and Related Conditions. J Clin Psychiatry 2005; 66:564-74

22. ShafferHJ, Vander Bilt J, Hall MN: Gambling, drinking, smoking and other health riskactivities among casino employees. Am J Ind Med 1999; 36:365-78

23. SlutskeWS, Jackson KM, Sher KJ: The natural history of problem gambling from age 18 to29. J Abnorm Psychol 2003; 112:263-74

24. KaminerY: Gambling use disorders--a public health problem. Conn Med 2000; 64:663-8

25. CrispBR, Thomas SA, Jackson AC, Smith S, Borrell J, Ho WY, Holt TA, Thomason N: Notthe same: a comparison of female and male clients seeking treatment fromproblem gambling counselling services. J Gambl Stud 2004; 20:283-99

26. PetryNM: A comparison of treatment-seeking pathological gamblers based on preferredgambling activity. Addiction 2003; 98:645-55

27. SingleE: Estimating the costs of substance abuse: implications to the estimation ofthe costs and benefits of gambling. J Gambl Stud 2003; 19:215-33

28. PotenzaMN, Fiellin DA, Heninger GR, Rounsaville BJ, Mazure CM: Gambling: an addictivebehavior with health and primary care implications. J Gen Intern Med 2002;17:721-32

29. MuellemanRL, DenOtter T, Wadman MC, Tran TP, Anderson J: Problem gambling in the partnerof the emergency department patient as a risk factor for intimate partnerviolence. J Emerg Med 2002; 23:307-12

30. JamesK: National Gambling Impact Study Commission: Final Report. Washington, DC:,Government Printing Office.

Available at http://govinfo.library.unt.edu/ngisc/index.html., 1999

31. BreenRB, Zimmerman M: Rapid onset of pathological gambling in machine gamblers. JGambl Stud 2002; 18:31-43

32. KauschO: Suicide attempts among veterans seeking treatment for pathological gambling.J Clin Psychiatry 2003; 64:1031-8

33. PotenzaMN, Steinberg MA, McLaughlin SD, Rounsaville BJ, O'Malley SS: Illegal behaviorsin problem gambling: analysis of data from a gambling helpline. J Am AcadPsychiatry Law 2000; 28:389-403

34. ToneattoT, Brennan J: Pathological gambling in treatment-seeking substance abusers.Addict Behav 2002; 27:465-9

35. LesieurHR, Blume SB: The South Oaks Gambling Screen (SOGS): a new instrument for theidentification of pathological gamblers. Am J Psychiatry 1987; 144:1184-8

36. LadouceurR, Bouchard C, Rheaume N, Jacques C, Ferland F, Leblond J, Walker M: Is theSOGS an accurate measure of pathological gambling among children, adolescentsand adults? J Gambl Stud 2000; 16:1-24

37. GotestamKG, Johansson A, Wenzel HG, Simonsen IE: Validation of the lie/bet screen forpathological gambling on two normal population data sets. Psychol Rep 2004;95:1009-13

38. JohnsonEE, Hamer RM, Nora RM: The Lie/Bet Questionnaire for screening pathologicalgamblers: a follow-up study. Psychol Rep 1998; 83:1219-24

39. BlumK, Braverman ER, Holder JM, Lubar JF, Monastra VJ, Miller D, Lubar JO, Chen TJ,Comings DE: Reward deficiency syndrome: a biogenetic model for the diagnosisand treatment of impulsive, addictive, and compulsive behaviors. J PsychoactiveDrugs 2000; 32 Suppl:i-iv, 1-112

40. ComingsDE, Rosenthal RJ, Lesieur HR, Rugle LJ, Muhleman D, Chiu C, Dietz G, Gade R: Astudy of the dopamine D2 receptor gene in pathological gambling.Pharmacogenetics 1996; 6:223-34

41. GoudriaanAE, Oosterlaan J, de Beurs E, Van den Brink W: Pathological gambling: acomprehensive review of biobehavioral findings. Neurosci Biobehav Rev 2004;28:123-41

42. EisenSA, Slutske WS, Lyons MJ, Lassman J, Xian H, Toomey R, Chantarujikapong S,Tsuang MT: The genetics of pathological gambling. Semin Clin Neuropsychiatry2001; 6:195-204

43. SlutskeWS, Eisen S, True WR, Lyons MJ, Goldberg J, Tsuang M: Common geneticvulnerability for pathological gambling and alcohol dependence in men. Arch GenPsychiatry 2000; 57:666-73

44. ShahKR, Eisen SA, Xian H, Potenza MN: Genetic studies of pathological gambling: areview of methodology and analyses of data from the Vietnam era twin registry.J Gambl Stud 2005; 21:179-203

45. PotenzaMN, Steinberg MA, Skudlarski P, Fulbright RK, Lacadie CM, Wilber MK,Rounsaville BJ, Gore JC, Wexler BE: Gambling urges in pathological gambling: afunctional magnetic resonance imaging study. Arch Gen Psychiatry 2003;60:828-36

46. PotenzaMN, Winters KC: The neurobiology of pathological gambling: translating researchfindings into clinical advances. J Gambl Stud 2003; 19:7-10

47. MartinsSS, Tavares H, da Silva Lobo DS, Galetti AM, Gentil V: Pathological gambling,gender, and risk-taking behaviors. Addict Behav 2004; 29:1231-5

48. PetryNM, Casarella T: Excessive discounting of delayed rewards in substance abuserswith gambling problems. Drug Alcohol Depend 1999; 56:25-32

49. RosenthalRJ: The pathological gambler's system for self-deception. Journal of GamblingBehavior 1986:108-120

50. JoukhadorJ, Blaszczynski A, Maccallum F: Superstitious beliefs in gambling among problemand non-problem gamblers: preliminary data. J Gambl Stud 2004; 20:171-80

51. DelfabbroP: The stubborn logic of regular gamblers: obstacles and dilemmas in cognitivegambling research. J Gambl Stud 2004; 20:1-21

52. CorlessT, Dickerson M: Gamblers' self-perceptions of the determinants of impairedcontrol. Br J Addict 1989; 84:1527-37

53. OrfordJ: Low income and vulnerability for gambling problems. Addiction 2004; 99:1356

54. HardoonKK, Gupta R, Derevensky JL: Psychosocial variables associated with adolescentgambling. Psychol Addict Behav 2004; 18:170-9

55. HollanderE, Sood E, Pallanti S, Baldini-Rossi N, Baker B: Pharmacological treatments ofpathological gambling. J Gambl Stud 2005; 21:99-108

56. crockfordDN, el-Guebaly N: Naltrexone in the treatment of pathological gambling andalcohol dependence. Canadian Journal of Psychiatry 1998; 43

57. KimSW, Grant JE, Adson DE, Shin YC: Double-blind naltrexone and placebo comparisonstudy in the treatment of pathological gambling. Biol Psychiatry 2001;49:914-21

58. HollanderE, DeCaria CM, Finkell JN, Begaz T, Wong CM, Cartwright C: A randomizeddouble-blind fluvoxamine/placebo crossover trial in pathologic gambling. BiolPsychiatry 2000; 47:813-7

59. ZimmermanM, Breen RB, Posternak MA: An open-label study of citalopram in the treatmentof pathological gambling. J Clin Psychiatry 2002; 63:44-8

60. GrantJE, Kim SW, Potenza MN, Blanco C, Ibanez A, Stevens L, Hektner JM, Zaninelli R:Paroxetine treatment of pathological gambling: a multi-centre randomizedcontrolled trial. Int Clin Psychopharmacol 2003; 18:243-9

61. HollanderE, Pallanti S, Allen A, Sood E, Baldini Rossi N: Does sustained-release lithiumreduce impulsive gambling and affective instability versus placebo inpathological gamblers with bipolar spectrum disorders? Am J Psychiatry 2005;162:137-45

62. PallantiS, Quercioli L, Sood E, Hollander E: Lithium and valproate treatment ofpathological gambling: a randomized single-blind study. J Clin Psychiatry 2002;63:559-64

63. MoskowitzJA: Lithium and lady luck; use of lithium carbonate in compulsive gambling. N YState J Med 1980; 80:785-8

64. PallantiS, Quercioli L, Sood E, Hollander E: Lithium and valproate treatment ofpathological gambling: A randomized single-blind study. Journal of ClinicalPsychiatry 2002; 63:559-564

65. NapolitanoF: The self-exclusion program: legal and clinical considerations. J Gambl Stud2003; 19:303-15

66. PetryNM: Gamblers anonymous and cognitive-behavioral therapies for pathologicalgamblers. J Gambl Stud 2005; 21:27-33

67. LadouceurR, Sylvain C, Boutin C, Lachance S, Doucet C, Leblond J, Jacques C: Cognitivetreatment of pathological gambling. J Nerv Ment Dis 2001; 189:774-80

68. LadouceurR, Sylvain C, Letarte H, Giroux I, Jacques C: Cognitive treatment ofpathological gamblers. Behav Res Ther 1998; 36:1111-9

69. AmericanPsychiatric Association., American Psychiatric Association. Task Force onDSM-IV.: Diagnostic and statistical manual of mental disorders : DSM-IV.Washington, DC, American Psychiatric Association, 1994

70. KesslerRC, Crum RM, Warner LA, Nelson CB, Schulenberg J, Anthony JC: Lifetimeco-occurence of DSM-III alcohol abuse and dependence with other psychiatricdisorders in the National Comorbidity Survey. Arch Gen Psychiatry 1997;54:313-321

71. SubstanceAbuse and Mental Health Services Administration: Results from the 2003 NationalSurvey on Drug Use and Health: National Findings. Rockville M, SAMHSA: Officeof Applied Studies, 2004:

72. ReinertDF, Allen JP: The Alcohol Use Disorders Identification Test (AUDIT): a reviewof recent research. Alcohol Clin Exp Res 2002; 26:272-9

73. Ross HE, Gavin DR, Skinner HA: Diagnostic validityof the MAST and the alcohol dependence scale in the assessment of DSM-IIIalcohol disorders. J Stud Alcohol 1990; 51:506-13

74. MarianiJJ, Levin FR: Pharmacotherapy for alcohol-related disorders: what cliniciansshould know. Harv Rev Psychiatry 2004; 12:351-66

75. HughesJC, Cook CC: The efficacy of disulfiram: a review of outcome studies. Addiction1997; 92:381-95

76. Modesto-LoweV, Van Kirk J: Clinical uses of naltrexone: a review of the evidence. Exp ClinPsychopharmacol 2002; 10:213-27

77. BoothbyLA, Doering PL: Acamprosate for the treatment of alcohol dependence. Clin Ther2005; 27:695-714

78. HeatherN: Waiting for a match: the future of psychosocial treatment for alcoholproblems. Addiction 1996; 91:469-72

79. LongabaughR, Donovan DM, Karno MP, McCrady BS, Morgenstern J, Tonigan JS: Activeingredients: how and why evidence-based alcohol behavioral treatmentinterventions work. Alcohol Clin Exp Res 2005; 29:235-47

80. FeeneyGF, Connor JP, Young RM, Tucker J, McPherson A: Alcohol dependence: the impactof cognitive behaviour therapy with or without naltrexone on subjective healthstatus. Aust N Z J Psychiatry 2004; 38:842-8

81. NathanPE: The role of natural recovery in alcoholism and pathological gambling. JGambl Stud 2003; 19:279-86

82. OrfordJ, Morison V, Somers M: Drinking and gambling: a comparison with implicationsfor theories of addiction. Drug Alcohol Rev 1996; 15:47-56

83. MaccallumF, Blaszczynski A: Pathological gambling and comorbid substance use. Aust N Z JPsychiatry 2002; 36:411-5

84. StewartSH, Kushner MG: Recent research on the comorbidity of alcoholism andpathological gambling. Alcohol Clin Exp Res 2003; 27:285-91

85. PietrzakRH, Petry NM: Antisocial personality disorder is associated with increasedseverity of gambling, medical, drug and psychiatric problems amongtreatment-seeking pathological gamblers. Addiction 2005; 100:1183-93

86. BarnesGM, Welte JW, Hoffman JH, Dintcheff BA: Shared predictors of youthful gambling,substance use, and delinquency. Psychol Addict Behav 2005; 19:165-74

87. GrantJ, Kushner M, Kim S: Pathological gambling and alcohol use disorder. AlcoholResearch and Health 2002; 26:143-150

88. LesieurHR, Blume SB: Evaluation of patients treated for pathological gambling in acombined alcohol, substance abuse and pathological gambling treatment unitusing the Addiction Severity Index. Br J Addict 1991; 86:1017-28

89. LaddGT, Petry NM: A comparison of pathological gamblers with and without substanceabuse treatment histories. Exp Clin Psychopharmacol 2003; 11:202-9

90. Cunningham-WilliamsRM, Cottler LB, Compton WM, Spitznagel EL, Ben-Abdallah A: Problem gambling andcomorbid psychiatric and substance use disorders among drug users recruitedfrom drug treatment and community settings. J Gambl Stud 2000; 16:347-76

91. LangenbucherJ, Bavly L, Labouvie E, Sanjuan PM, Martin CS: Clinical features ofpathological gambling in an addictions treatment cohort. Psychol Addict Behav2001; 15:77-9

92. Oakley-BrowneMA, Adams P, Mobberley PM: Interventions for pathological gambling. CochraneDatabase Syst Rev 2000:CD001521

---

[AB1]Tim, are these really“treatments”? Treatment usually refers to a clinical interaction that isfacilitated by a clinical professional. Maybe better to call them “socialprograms for PG” or “social assistance for PG”

[AB2]Tim, 12 step programs are nottreatment. (12step facilitation is.) Treatment occurs when a trainedprofessional provides it. I would consider this a “social program” or“assistance” and put it in that section. Then, you can do the same for AUD(i.e., have a section entitled “social programs/assistance”.

[AB3]Tim, this reference is a casereport. I would say this is pretty preliminary evidence. It’s not just thatlong term data are needed—it’s that more methodologically rigorousstudies need to be done before you can say this is efficacious. It’s fine tohave prelim evidence if that’s the state of the literature. It’s just that it’simportant to let the audience know this.

[AB4]Tim, see my AA comments abovere AA and treatment.

[AB5]If you want to have a separatesection of psychosoc treatments for EtOH, you’ll need to have >1 treatment(i.e., CBT). Feel free to use the summaries and references in my chapter tomention other tx’s –like relapse prevention therapy or 12 stepfacilitation, for example.