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Alcohol and Gambling Addiction
C H A P T E R
54 Alcohol and Gambling Addiction Marko Martinac1, Dalibor Karlovi´c2 and Dragan Babi´c3 1
Center for Mental Health, Mostar, Bosnia and Herzegovina 2Department of Psychiatry, Catholic University of Croatia, University Hospital Centre Sestre Milosrdnice, Zagreb, Croatia 3Department of Psychiatry, University Hospital Mostar, Mostar, Bosnia and Herzegovina
LIST OF ABBREVIATIONS ADHD CBT DSM-IV-TR DSM-V GABA
attention-deficit/hyperactivity disorder cognitive behavior therapy diagnostic and statistical manual of mental disorders, fourth edition, text revision diagnostic and statistical manual of mental disorders, fifth edition gamma-aminobutyric acid
INTRODUCTION Alcohol abuse worsens gambling problems, entices risky behaviors in gamblers, and contributes to the development and maintenance of a gambling disorder (Stewart & Kushner, 2005). Gambling disorder is a behavioral addiction that overlaps with alcohol and drug addiction, such as losing control, tolerance, and abstinence (Goudriaan, Oosterlaan, de Beurs, & van den Brink, 2006; Lawrence, Luty, Bogdan, Sahakian, & Clark, 2009). The term pathologic gambling from DSM-IV-TR was renamed into gambling disorder in DSM-V and is situated in the section SubstanceRelated and Addictive Disorders (American Psychiatric Association, 2013). Often, a gambling disorder is in comorbidity with alcohol addiction, anxiety, and depressive disorders. Alcohol abuse, on many occasions, precedes gambling development; under the influence of alcohol, gamblers engage more in gambling and spend more money, and it is more probable they will develop a gambling disorder (Jauregui, Estevez, & Urbiola, 2016; Lyvers, Mathieson, & Edwards, 2015). Gamblers who play for larger stakes drink more alcohol than those who play for smaller stakes, which leads to greater alcohol abuse and the
Neuroscience of Alcohol. DOI: https://doi.org/10.1016/B978-0-12-813125-1.00054-4
risk of alcohol addiction (Harvanko, Schreiber, & Grant, 2013). In other words, alcohol addiction can predispose the development of a gambling disorder and vice versa (Messerlian, Gillespie, & Derevensky, 2007). It is likely that there are variables pathogenically related to both disorders, such as mutual genetic vulnerability, disturbed dopamine reward brain regulation, premorbid childhood disorder, prenatal alcohol exposure and mother’s alcohol abuse during later childhood, impulsiveness, and compulsive behavior patterns (Choi et al., 2014; Florez et al., 2016; Kully-Martens, Treit, Pei, & Rasmussen, 2013; Stewart & Kushner, 2005; Temcheff, Dery, St-Pierre, Laventure, & Lemelin, 2016; Tran, Clavarino, Williams, & Najman, 2016). Due to dysfunction of ventromedial prefrontal cortex there is an indication of disordered decision-making in gamblers and alcoholics (Goudriaan, Oosterlaan, de Beurs, & van den Brink, 2005). Behavioral and social consequences of alcohol abuse and gambling are very similar; comorbidity in gambling disorder and alcoholism is related to poor treatment response. (Jimenez-Murcia et al., 2016; Josephson, Carlbring, Forsberg, & Rosendahl, 2016; Messerlian et al., 2007; Toneatto, Brands, & Selby, 2009).
ALCOHOLISM AND GAMBLING COMORBIDITY, EPIDEMIOLOGICAL DATA A lifetime prevalence of gambling affects around 86% of adults, while the frequency of a gambling disorder is between 0.5% and 2% of the general population (Dabrowska, Moskalewicz, & Wieczorek, 2017;
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Harries, Redden, Leppink, Chamberlain, & Grant, 2017). Often, alcohol addiction is in comorbidity with a gambling disorder, where the comorbidity is more prevalent in men. Alcohol addiction rates in gamblers are around 73%, and alcoholics are 5 6 times at greater risk to developing a gambling disorder when compared to the general population (Jauregui et al., 2016; Skaal, Sinclair, Stein, & Myers, 2016; Tran et al., 2016). The severity of a gambling disorder is connected with the amount of alcohol consumed and the age when drinking began. Furthermore, the rate of alcoholism is more frequent in pathological gamblers (Florez et al., 2016; Jimenez-Murcia et al., 2016; Miguez Varela Mdel & Becona, 2015; Stewart & Kushner, 2005; Tran et al., 2016; Yip et al., 2013). Apart from alcohol addiction, even acute alcohol abuse increases odds for gambling, encourages persistence in gambling even while experiencing losses, prolongs gambling periods, and encourages gamblers to play for higher stakes (Barrett, Collins, & Stewart, 2015; Kyngdon & Dickerson, 1999). The theory which explains how alcohol incites gambling is called the model of divided attention, according to which alcohol decreases the ability to process available information and limits attention to the most challenging stimuli, or in other words, it leads to cognitive constriction which, in this case, is called alcohol myopia (Cronce & Corbin, 2010).
DEVELOPMENT FACTORS RELATED TO COMORBIDITY BETWEEN ALCOHOLISM AND GAMBLING Alcohol damages brain development in many ways. It interferes with neural proliferation, decreases myelination, and provokes cell death. The consequences of prenatal alcohol exposure are learning and memory disabilities, lower IQ, language disabilities, poor academic performance, disturbed visual-spatial abilities, motor function disturbances, and poor adaptive behavior, attention, and executive functioning. Damage in the frontal cortex and basal ganglia caused by alcohol has a negative effect on the decision-making process, executive function, and learning-experience ability which contributes to impulsive behavior, such as gambling or alcohol abuse (Kully-Martens et al., 2013). Apart from prenatal alcohol exposure, the mother’s drinking patterns have an independent effect on the risk of gambling and alcohol abuse in their children, where male children are more sensitive than females. The mother’s alcohol abuse during their children’s early childhood is related to the risk of gambling and alcoholism when their male children are adults (Tran et al., 2016). Childhood behavior disorders are a very significant, nonspecific, risk factor and are significantly connected
to an increased risk for regular alcohol consumption in early adolescence. A number of symptoms of behavior disorders are related to greater risk of developing heavy alcoholism, earlier start of drinking, and frequent drinking. Apart from alcohol abuse, behavior disorders are closely connected to gambling in adolescents and young adults. (Temcheff et al., 2016).
BIOLOGICAL FACTORS RELATED TO ALCOHOLISM AND GAMBLING COMORBIDITY Alcohol effect is primarily anxiolytic via GABA receptors inhibition in amygdala. Besides, alcohol, on one hand, by affecting the dopamine reward system, strengthens the feeling of reward in the prefrontal cortex while, on the other hand, it inhibits the activity of the prefrontal cortex more than other brain regions. In other words, alcohol has an impact on the increased reward reactivity and on the decreased punishment reactivity (Lyvers et al., 2015). In healthy people, the mesolimbic reward system is activated by standard positive reinforcement. Ventral striatum is activated in reward anticipation and during the reward itself, while the medial prefrontal cortex is only activated during the reward. Unlike healthy people who have mesolimbic reward system active in situations when they win money, in gamblers, the activity in the ventral striatum and ventromedial prefrontal cortex is decreased, which indicates diminished reward sensitivity. In addition, there are indications of functional changes in the area of the mesolimbic reward system, particularly in the ventral striatum, in alcohol addicts where alcohol, instead of positive reinforcing, plays the role of an activator in the ventral striatum area (Lyvers et al., 2015; Romanczuk-Seiferth, Koehler, Dreesen, Wustenberg, & Heinz, 2015). In alcoholic gamblers there is reduced activity in the ventral striatum in the period of reward anticipation and increased activity, or without change, after receiving a reward (Romanczuk-Seiferth et al., 2015). The average amount of invested money during gambling is negatively related to the activation of the striatum in the period while anticipating huge rewards, which can indicate weaker activation in the reward system in those who play with bigger stakes. Heavy drinking in these gamblers serves the purpose to strengthen activation of the reward system (Harvanko et al., 2013). A few theories exist which could explain changes in the limbic reward system and the way these changes contribute to individuals developing addictive behavior. One of the theories puts the process of long-term synaptic potentiation in a central position, which represents experience-related strengthening of synaptic
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BIOLOGICAL FACTORS RELATED TO ALCOHOLISM AND GAMBLING COMORBIDITY
transmission and is considered crucial for learning and memory. This is inevitable in the processes of synaptic plasticity, which is the basis for neural adjustment in the development of tolerance and addiction. It is believed that the mechanism occurs in the dopamine mesolimbic reward system through which alcohol and gambling have gratifying effects on the potentiation of an addiction development (Slutske, Ellingson, Richmond-Rakerd, Zhu, & Martin, 2013). The second theory is concerns sensitization, according to which repeated alcohol abuse or gambling leads to long-term and progressive changes in the brain reward system, acting in a way that alcohol- or gambling-connected stimuli become very attractive and more capable to control emotions than conventional rewards (Romanczuk-Seiferth et al., 2015). The third possibility is that repeated action of facing the loss and avoiding it could result in adjustments in the brain reward system in a way that avoiding money loss becomes dominant in gamblers in relation to natural reward situations (Romanczuk-Seiferth et al., 2015). To sum up, alcohol abuse and gambling can lead to progressive and long-term changes in the dopamine brain reward system and it is possible that these changes in the mesolimbic system represent a biological basis for the development of addiction-related substances as well as substance-free addictions. Structural and functional disorders of the prefrontal cortex and executive function disorders were found in alcoholics and persons with a gambling disorder. Executive functions incorporate the prefrontal cortex’s regular functioning with the accompanying neural circuits in subcortical structures. Executive functions which originate in these brain structures are attention, estimating time, working memory, flexible thinking, planning, using strategies, and inhibition. In alcoholics and gamblers, executive function disorders are manifested through the disorder of objective-oriented behavior, planning, and inhibition. An executive function disorder, on the one hand, can be a direct consequence of alcohol abuse, although, on the other hand, it can be a risk factor for the development of alcohol and gambling addiction (Goudriaan et al., 2006; KullyMartens et al., 2013). Neuroimaging studies show that executive functioning activates different areas within the prefrontal cortex along with areas related to the prefrontal cortex, such as in the nc caudatus, putamen, thalamus, cingulum, and parietal cortex. In gamblers, abnormalities in the ventromedial prefrontal cortex with accompanying neural projections from the thalamus and basal ganglia were found. In alcoholics, disorders and microstructural abnormalities in frontostriatal circuits and the anterior corpus callosum were found (Goudriaan et al., 2006; Yip et al., 2013). Different imaging studies show that structural and functional
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damage in the lateral prefrontal cortex in alcoholics, along with detected acute alcohol effects on executive functions, related to this region (Lawrence et al., 2009). Further damage was noticed in the dorsolateral prefrontal function, presumably caused by structural damage from alcohol intake (Yip et al., 2013). Studies additionally indicate a connection between white matter integrity and impulsiveness. Damage seen in myelination between frontal areas in gamblers were more prevalent in the presence of comorbidity with alcoholism. On the other hand, a correlation was noticed between damaged white matter and alcoholism in alcoholics which also indicates a high prevalence of gambling disorder (Yip et al., 2013). Taking all these observations into account, it is justifiable to assume that damage in the ventral prefrontal cortex with accompanying neural circuits represents a common pathophysiologic basis for the development of alcohol addiction and gambling disorder. Decision-making ability, which is an executive function, is distorted in alcoholics. Decision-making can be divided into decisions based on ambiguity and risk. In ambiguous conditions the decision must be made among different options without explicitly knowing the possible results and the possibility for reward and punishment. In risky situations, decisions are made between options which are consequently rewarded or punished. The dorsal striatum and posterior parietal cortex play a role in the assessment of possible risky outcomes, while the amygdala, striatum, and orbitofrontal cortex are involved in the coding of insecurity levels. Alcohol addiction has harmful effects on executive functions by disturbing activities in frontal regions, such as the dorsolateral prefrontal cortex and frontal cingulate cortex. Alcoholics who develop early alcohol addiction show abnormal tendency for an immediate reward in situations of decision-making (Kim, Sohn, & Jeong, 2011). In this way, alcohol influences decision-making in risky situations and significantly increases the tendency toward risky behavior in the gambling environment. A similar tendency toward taking risks is found in people with damage in the prefrontal cortex regions, and similar deficit is seen in normal persons under the influence of alcohol. According to these findings, alcohol consumption leads to acute dysfunction of the ventromedial prefrontal cortex. Consequently, many casinos serve free drinks during gambling (Lyvers et al., 2015; Slutske et al., 2013). Some research found a genetic relation between gambling disorder and alcohol addiction. The concordance ratio was between 50% and 75%. Results from these studies indicate that gambling and alcoholism have a common genetic background equally present in both males and females (Slutske et al., 2013).
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PERSONALITY TRAITS AND COMORBIDITY OF ALCOHOLISM AND GAMBLING DISORDER Impulsive and Compulsive Behavior Impulsiveness is characterized by a tendency to sudden and unplanned behavior regardless of the possible negative effects. It is believed to be a consequence of the inhibitory control damage which is a basic component of executive function. Inhibitory control is a function of neural circuits in the cortical and subcortical structures, in which the lateral prefrontal cortex is an important part (Choi et al., 2014; Lawrence et al., 2009; Spoelder et al., 2015). Impulsiveness is an important factor in the development and durability of different addiction types, and the relation between impulse control and gambling has been shown in many studies (Barnes, Welte, Hoffman, & Dintcheff, 2002; Florez et al., 2016). Impulsiveness is a strong personality trait in gamblers, (Yip et al., 2013) and a crucial risk factor for developing gambling addiction and severe gambling problems are connected to stronger impulsiveness (Harries et al., 2017). In gamblers, impulsiveness is correlated to cognitive disorders, and impulsive decision-making can increase the possibility for accepting wrong beliefs (Florez et al., 2016). Gamblers with earlier onset of gambling disorder are more impulsive and usually suffer from severe disorder types (Harvanko et al., 2013). In addition, impulsiveness is a risk factor for developing alcohol addiction, prolonging alcoholism, and causing relapse. Alcoholics display reduced impulse control and distorted decisionmaking skills. In other words, impulsive behavior accompanied with distorted decision-making can present a vulnerability factor for alcoholism; it usually precedes alcoholism, although it can be caused by longterm alcoholism (Lawrence et al., 2009; Spoelder et al., 2015) due to the fact that regular alcohol consumption diminishes the individual’s experience-based learning ability (Spoelder et al., 2015). Alcoholics with earlier onset in alcoholism are more impulsive, manifest a greater desire for sensations, show aggressive behavior, and seek immediate rewards (Harvanko et al., 2013). However, alcohol abuse is a risk factor, regardless of impulsiveness, for the progression of a gambling disorder and the tendency towards serious gambling types in men, while alcohol abuse in females is a risk factor for progression of gambling disorder only in the case of an equally present high impulsiveness rate (Barnes et al., 2002; Messerlian et al., 2007). Impulsiveness is a significant risk factor for developing a gambling disorder in both sexes, regardless of alcohol intake, as well as being a risk factor for developing alcoholism. Higher impulsiveness rates are evident in gamblers addicted to alcohol
and also in gamblers with comorbidity alcoholism than in persons who are either alcoholics or gamblers, which corroborates with impulsiveness being a mutual risk factor for developing a gambling disorder and alcohol addiction (Barnes et al., 2002; Florez et al., 2016; Stewart & Kushner, 2005). In alcoholics and gamblers, impulsiveness is at the root of the tendency toward short-term rewards. If regular alcohol use or gambling reoccur during a longer time period, learning mechanisms based on rewards develop into compulsive behavior (Choi et al., 2014), and it is possible that addictive pathology includes progression from impulsiveness to obsessive compulsiveness (Choi et al., 2014). In gamblers with very high impulsiveness rate, alcohol fosters riskier gambling, influences the amount of average stakes, and leads to quicker money loss (Cronce & Corbin, 2010).
Emotion Regulation Apart from impulsiveness, emotion regulation can also be one of the factors which contributes to the development of alcohol addiction and a gambling disorder (Jauregui et al., 2016). Executive function can be divided into cognitive and affective component. The cognitive aspect of executive function is dominant in situations which demand abstract information manipulation and, consequently, carries no reward or punishment. Affective executive function is prevalent in situations which demand the regulation of emotions and motivations, and actions are based on reward and punishment. Daily decision-making involves cognitive aspects, such as impulse control and flexible and responsive responses to cognitive strategies. Nevertheless, in rare occasions, decisions are made without affective or motivational influence, which can interfere with the implementation of the cognitive aspects. (Kully-Martens et al., 2013). Gamblers have difficulties with emotion regulation, and emotion regulation is in direct relation to alcohol abuse. Gambling is connected to the expectation of a positive effect or with diminishing a negative effect, while drinking alcohol soothes negative emotions, reduces stress, increases positive impact, and diminishes desire. Negative emotional states along with bad self-control can lead to impulsive behavior, such as gambling and drinking alcohol, which helps negative emotion regulation (Jauregui et al., 2016).
TREATMENT PROBLEMS In the treatment of patients who are alcoholics with a gambling disorder comorbidity, the complexity of the psychopathology—which is manifested in multiple psychiatric disorders, which besides alcohol addiction
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KEY FACTS
and gambling disorders, are personality disorders, depressive, and anxiety disorders—needs to be taken into consideration (Cowlishaw & Hakes, 2015). Previous experience shows that a small number of patients are being treated and that around 75% have never asked for treatment. The biggest obstacles when entering treatment are the belief that they can resolve their problems on their own, experiencing shame, fear of stigmatization, poor adaptation to program rules, lack of social support, low personal motivation, poor insight into the severity of problem, and a negative opinion of the treatment efficacy. Stigma and shame are barriers which are usually identified in alcoholics and gamblers (Dabrowska et al., 2017). In gamblers there is a negative relation between alcohol abuse and treatment response (Jimenez-Murcia et al., 2016). The treatment of these patients which has proven to be effective includes integrated strategies for resolving gambling problems in comorbidity with alcohol, accompanied with intensive psychotherapy. A therapeutic approach aimed at gambling issues mostly includes modified treatment modalities which are already being used in alcohol addiction such as motivational interviewing, CBT, and relapse prevention. Patients with a gambling disorder in comorbidity with alcoholism will greatly benefit from motivational interviewing (Josephson et al., 2016). Brief interventions aimed at reducing gambling can also be helpful (Jimenez-Murcia et al., 2016). Using a pharmacological approach, there have been attempts of introducing naltrexone in the treatment of comorbidity of alcohol addiction and gambling disorder. However, treatment with naltrexone has not proven to be more efficient than a placebo in reducing drinking alcohol or with a reduction of gambling in alcoholics with a gambling disorder (Toneatto et al., 2009). It has been noted that methylphenidate in patients with ADHD improves decision-making processes and decreases the tendency towards risky behavior, and, given its beneficial effect on the executive function disorders in ADHD patients, it would be justified to consider this kind of treatment for gambling and alcohol addicts (DeVito et al., 2008; Goudriaan et al., 2006). An additional problem is comorbidity with other psychiatric disorders, such as personality, depressive, and anxiety disorders. In such cases, pharmacological treatment of comorbidity states according to existing guidelines for the treatment of psychiatric disorders is used (Babi´c, 2016).
CONCLUSION Alcohol drinking and gambling are mutually connected activities and the comorbidity of alcoholism
and a gambling disorder is more of a rule than an exception. Apart from the fact that one disorder can precede the other, and vice versa, alcoholism and gambling disorders share mutual genetic vulnerability, they are influenced by similar neurodevelopmental factors and personality traits, and entail similar brain changes. Comorbidity of alcoholism and a gambling disorder is by far a more serious clinical and social problem than the individual disorders. Comorbidity is stigmatized, and often is concomitant with a lack in treatment cooperation with resulting unsatisfactory outcomes in many cases. It is indicative to perform further research for the purpose of finding appropriate treatments for these patients.
MINI-DICTIONARY OF TERMS Behavioral addiction Addiction to a behavior like gambling rather than to a drug. Comorbidity The simultaneous presence of two chronic conditions in a patient. Reward system The reward system is a group of neural structures responsible for positive emotions. Impulsiveness Tendency to act without consideration of consequences. Compulsive behaviors Actions that people feel driven to do that they cannot resist or control. Cognitive behavior therapy This psychotherapy method combines the techniques of cognitive psychotherapy and behavior therapy. Relapse Recurrence of alcohol abuse in an individual who has previously achieved and maintained abstinence for a significant period of time beyond withdrawal. Lifetime prevalence The proportion of individuals in a population that at some point in their lives have experienced a disease or a negative/destructive behavior. Positive reinforcement The presentation of a stimulus that increases the future likelihood that a behavior will occur.
KEY FACTS Alcohol and Gambling Disorder • The comorbidity of alcoholism and gambling disorder is more a rule than an exception. • One disorder can precede the other, and vice versa. • Alcoholism and gambling disorders share mutual, genetic vulnerability. • The mesolimbic reward system is deficient in both disorders. • Structural and functional disorders of the prefrontal cortex and deficient executive functioning are found in both disorders. • Impulsivity is a significant personality trait in both disorders.
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SUMMARY POINTS • Alcohol abuse usually precedes the development of a gambling disorder. • Comorbidity of alcohol addiction with a gambling disorder is more prevalent in men. • The severity of a gambling disorder is related to the amount of alcohol consumed and the age when the drinking began. • Possible variables which may contribute to pathogenesis of these disorders are: • genetic vulnerability • prenatal alcohol exposure • mother’s alcohol abuse during childhood • conduct problems in childhood • impulsive and compulsive behaviors • deficit emotion regulation • dysregulation of the dopamine reward system • defects in the prefrontal cortex • deficient executive functioning • Comorbidity between gambling disorder and alcoholism is related to poor response to treatment.
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54 Alcohol and Gambling Addiction Marko Martinac1, Dalibor Karlovi´c2 and Dragan Babi´c3 1
Center for Mental Health, Mostar, Bosnia and Herzegovina 2Department of Psychiatry, Catholic University of Croatia, University Hospital Centre Sestre Milosrdnice, Zagreb, Croatia 3Department of Psychiatry, University Hospital Mostar, Mostar, Bosnia and Herzegovina
LIST OF ABBREVIATIONS ADHD CBT DSM-IV-TR DSM-V GABA
attention-deficit/hyperactivity disorder cognitive behavior therapy diagnostic and statistical manual of mental disorders, fourth edition, text revision diagnostic and statistical manual of mental disorders, fifth edition gamma-aminobutyric acid
INTRODUCTION Alcohol abuse worsens gambling problems, entices risky behaviors in gamblers, and contributes to the development and maintenance of a gambling disorder (Stewart & Kushner, 2005). Gambling disorder is a behavioral addiction that overlaps with alcohol and drug addiction, such as losing control, tolerance, and abstinence (Goudriaan, Oosterlaan, de Beurs, & van den Brink, 2006; Lawrence, Luty, Bogdan, Sahakian, & Clark, 2009). The term pathologic gambling from DSM-IV-TR was renamed into gambling disorder in DSM-V and is situated in the section SubstanceRelated and Addictive Disorders (American Psychiatric Association, 2013). Often, a gambling disorder is in comorbidity with alcohol addiction, anxiety, and depressive disorders. Alcohol abuse, on many occasions, precedes gambling development; under the influence of alcohol, gamblers engage more in gambling and spend more money, and it is more probable they will develop a gambling disorder (Jauregui, Estevez, & Urbiola, 2016; Lyvers, Mathieson, & Edwards, 2015). Gamblers who play for larger stakes drink more alcohol than those who play for smaller stakes, which leads to greater alcohol abuse and the
Neuroscience of Alcohol. DOI: https://doi.org/10.1016/B978-0-12-813125-1.00054-4
risk of alcohol addiction (Harvanko, Schreiber, & Grant, 2013). In other words, alcohol addiction can predispose the development of a gambling disorder and vice versa (Messerlian, Gillespie, & Derevensky, 2007). It is likely that there are variables pathogenically related to both disorders, such as mutual genetic vulnerability, disturbed dopamine reward brain regulation, premorbid childhood disorder, prenatal alcohol exposure and mother’s alcohol abuse during later childhood, impulsiveness, and compulsive behavior patterns (Choi et al., 2014; Florez et al., 2016; Kully-Martens, Treit, Pei, & Rasmussen, 2013; Stewart & Kushner, 2005; Temcheff, Dery, St-Pierre, Laventure, & Lemelin, 2016; Tran, Clavarino, Williams, & Najman, 2016). Due to dysfunction of ventromedial prefrontal cortex there is an indication of disordered decision-making in gamblers and alcoholics (Goudriaan, Oosterlaan, de Beurs, & van den Brink, 2005). Behavioral and social consequences of alcohol abuse and gambling are very similar; comorbidity in gambling disorder and alcoholism is related to poor treatment response. (Jimenez-Murcia et al., 2016; Josephson, Carlbring, Forsberg, & Rosendahl, 2016; Messerlian et al., 2007; Toneatto, Brands, & Selby, 2009).
ALCOHOLISM AND GAMBLING COMORBIDITY, EPIDEMIOLOGICAL DATA A lifetime prevalence of gambling affects around 86% of adults, while the frequency of a gambling disorder is between 0.5% and 2% of the general population (Dabrowska, Moskalewicz, & Wieczorek, 2017;
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Harries, Redden, Leppink, Chamberlain, & Grant, 2017). Often, alcohol addiction is in comorbidity with a gambling disorder, where the comorbidity is more prevalent in men. Alcohol addiction rates in gamblers are around 73%, and alcoholics are 5 6 times at greater risk to developing a gambling disorder when compared to the general population (Jauregui et al., 2016; Skaal, Sinclair, Stein, & Myers, 2016; Tran et al., 2016). The severity of a gambling disorder is connected with the amount of alcohol consumed and the age when drinking began. Furthermore, the rate of alcoholism is more frequent in pathological gamblers (Florez et al., 2016; Jimenez-Murcia et al., 2016; Miguez Varela Mdel & Becona, 2015; Stewart & Kushner, 2005; Tran et al., 2016; Yip et al., 2013). Apart from alcohol addiction, even acute alcohol abuse increases odds for gambling, encourages persistence in gambling even while experiencing losses, prolongs gambling periods, and encourages gamblers to play for higher stakes (Barrett, Collins, & Stewart, 2015; Kyngdon & Dickerson, 1999). The theory which explains how alcohol incites gambling is called the model of divided attention, according to which alcohol decreases the ability to process available information and limits attention to the most challenging stimuli, or in other words, it leads to cognitive constriction which, in this case, is called alcohol myopia (Cronce & Corbin, 2010).
DEVELOPMENT FACTORS RELATED TO COMORBIDITY BETWEEN ALCOHOLISM AND GAMBLING Alcohol damages brain development in many ways. It interferes with neural proliferation, decreases myelination, and provokes cell death. The consequences of prenatal alcohol exposure are learning and memory disabilities, lower IQ, language disabilities, poor academic performance, disturbed visual-spatial abilities, motor function disturbances, and poor adaptive behavior, attention, and executive functioning. Damage in the frontal cortex and basal ganglia caused by alcohol has a negative effect on the decision-making process, executive function, and learning-experience ability which contributes to impulsive behavior, such as gambling or alcohol abuse (Kully-Martens et al., 2013). Apart from prenatal alcohol exposure, the mother’s drinking patterns have an independent effect on the risk of gambling and alcohol abuse in their children, where male children are more sensitive than females. The mother’s alcohol abuse during their children’s early childhood is related to the risk of gambling and alcoholism when their male children are adults (Tran et al., 2016). Childhood behavior disorders are a very significant, nonspecific, risk factor and are significantly connected
to an increased risk for regular alcohol consumption in early adolescence. A number of symptoms of behavior disorders are related to greater risk of developing heavy alcoholism, earlier start of drinking, and frequent drinking. Apart from alcohol abuse, behavior disorders are closely connected to gambling in adolescents and young adults. (Temcheff et al., 2016).
BIOLOGICAL FACTORS RELATED TO ALCOHOLISM AND GAMBLING COMORBIDITY Alcohol effect is primarily anxiolytic via GABA receptors inhibition in amygdala. Besides, alcohol, on one hand, by affecting the dopamine reward system, strengthens the feeling of reward in the prefrontal cortex while, on the other hand, it inhibits the activity of the prefrontal cortex more than other brain regions. In other words, alcohol has an impact on the increased reward reactivity and on the decreased punishment reactivity (Lyvers et al., 2015). In healthy people, the mesolimbic reward system is activated by standard positive reinforcement. Ventral striatum is activated in reward anticipation and during the reward itself, while the medial prefrontal cortex is only activated during the reward. Unlike healthy people who have mesolimbic reward system active in situations when they win money, in gamblers, the activity in the ventral striatum and ventromedial prefrontal cortex is decreased, which indicates diminished reward sensitivity. In addition, there are indications of functional changes in the area of the mesolimbic reward system, particularly in the ventral striatum, in alcohol addicts where alcohol, instead of positive reinforcing, plays the role of an activator in the ventral striatum area (Lyvers et al., 2015; Romanczuk-Seiferth, Koehler, Dreesen, Wustenberg, & Heinz, 2015). In alcoholic gamblers there is reduced activity in the ventral striatum in the period of reward anticipation and increased activity, or without change, after receiving a reward (Romanczuk-Seiferth et al., 2015). The average amount of invested money during gambling is negatively related to the activation of the striatum in the period while anticipating huge rewards, which can indicate weaker activation in the reward system in those who play with bigger stakes. Heavy drinking in these gamblers serves the purpose to strengthen activation of the reward system (Harvanko et al., 2013). A few theories exist which could explain changes in the limbic reward system and the way these changes contribute to individuals developing addictive behavior. One of the theories puts the process of long-term synaptic potentiation in a central position, which represents experience-related strengthening of synaptic
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BIOLOGICAL FACTORS RELATED TO ALCOHOLISM AND GAMBLING COMORBIDITY
transmission and is considered crucial for learning and memory. This is inevitable in the processes of synaptic plasticity, which is the basis for neural adjustment in the development of tolerance and addiction. It is believed that the mechanism occurs in the dopamine mesolimbic reward system through which alcohol and gambling have gratifying effects on the potentiation of an addiction development (Slutske, Ellingson, Richmond-Rakerd, Zhu, & Martin, 2013). The second theory is concerns sensitization, according to which repeated alcohol abuse or gambling leads to long-term and progressive changes in the brain reward system, acting in a way that alcohol- or gambling-connected stimuli become very attractive and more capable to control emotions than conventional rewards (Romanczuk-Seiferth et al., 2015). The third possibility is that repeated action of facing the loss and avoiding it could result in adjustments in the brain reward system in a way that avoiding money loss becomes dominant in gamblers in relation to natural reward situations (Romanczuk-Seiferth et al., 2015). To sum up, alcohol abuse and gambling can lead to progressive and long-term changes in the dopamine brain reward system and it is possible that these changes in the mesolimbic system represent a biological basis for the development of addiction-related substances as well as substance-free addictions. Structural and functional disorders of the prefrontal cortex and executive function disorders were found in alcoholics and persons with a gambling disorder. Executive functions incorporate the prefrontal cortex’s regular functioning with the accompanying neural circuits in subcortical structures. Executive functions which originate in these brain structures are attention, estimating time, working memory, flexible thinking, planning, using strategies, and inhibition. In alcoholics and gamblers, executive function disorders are manifested through the disorder of objective-oriented behavior, planning, and inhibition. An executive function disorder, on the one hand, can be a direct consequence of alcohol abuse, although, on the other hand, it can be a risk factor for the development of alcohol and gambling addiction (Goudriaan et al., 2006; KullyMartens et al., 2013). Neuroimaging studies show that executive functioning activates different areas within the prefrontal cortex along with areas related to the prefrontal cortex, such as in the nc caudatus, putamen, thalamus, cingulum, and parietal cortex. In gamblers, abnormalities in the ventromedial prefrontal cortex with accompanying neural projections from the thalamus and basal ganglia were found. In alcoholics, disorders and microstructural abnormalities in frontostriatal circuits and the anterior corpus callosum were found (Goudriaan et al., 2006; Yip et al., 2013). Different imaging studies show that structural and functional
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damage in the lateral prefrontal cortex in alcoholics, along with detected acute alcohol effects on executive functions, related to this region (Lawrence et al., 2009). Further damage was noticed in the dorsolateral prefrontal function, presumably caused by structural damage from alcohol intake (Yip et al., 2013). Studies additionally indicate a connection between white matter integrity and impulsiveness. Damage seen in myelination between frontal areas in gamblers were more prevalent in the presence of comorbidity with alcoholism. On the other hand, a correlation was noticed between damaged white matter and alcoholism in alcoholics which also indicates a high prevalence of gambling disorder (Yip et al., 2013). Taking all these observations into account, it is justifiable to assume that damage in the ventral prefrontal cortex with accompanying neural circuits represents a common pathophysiologic basis for the development of alcohol addiction and gambling disorder. Decision-making ability, which is an executive function, is distorted in alcoholics. Decision-making can be divided into decisions based on ambiguity and risk. In ambiguous conditions the decision must be made among different options without explicitly knowing the possible results and the possibility for reward and punishment. In risky situations, decisions are made between options which are consequently rewarded or punished. The dorsal striatum and posterior parietal cortex play a role in the assessment of possible risky outcomes, while the amygdala, striatum, and orbitofrontal cortex are involved in the coding of insecurity levels. Alcohol addiction has harmful effects on executive functions by disturbing activities in frontal regions, such as the dorsolateral prefrontal cortex and frontal cingulate cortex. Alcoholics who develop early alcohol addiction show abnormal tendency for an immediate reward in situations of decision-making (Kim, Sohn, & Jeong, 2011). In this way, alcohol influences decision-making in risky situations and significantly increases the tendency toward risky behavior in the gambling environment. A similar tendency toward taking risks is found in people with damage in the prefrontal cortex regions, and similar deficit is seen in normal persons under the influence of alcohol. According to these findings, alcohol consumption leads to acute dysfunction of the ventromedial prefrontal cortex. Consequently, many casinos serve free drinks during gambling (Lyvers et al., 2015; Slutske et al., 2013). Some research found a genetic relation between gambling disorder and alcohol addiction. The concordance ratio was between 50% and 75%. Results from these studies indicate that gambling and alcoholism have a common genetic background equally present in both males and females (Slutske et al., 2013).
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PERSONALITY TRAITS AND COMORBIDITY OF ALCOHOLISM AND GAMBLING DISORDER Impulsive and Compulsive Behavior Impulsiveness is characterized by a tendency to sudden and unplanned behavior regardless of the possible negative effects. It is believed to be a consequence of the inhibitory control damage which is a basic component of executive function. Inhibitory control is a function of neural circuits in the cortical and subcortical structures, in which the lateral prefrontal cortex is an important part (Choi et al., 2014; Lawrence et al., 2009; Spoelder et al., 2015). Impulsiveness is an important factor in the development and durability of different addiction types, and the relation between impulse control and gambling has been shown in many studies (Barnes, Welte, Hoffman, & Dintcheff, 2002; Florez et al., 2016). Impulsiveness is a strong personality trait in gamblers, (Yip et al., 2013) and a crucial risk factor for developing gambling addiction and severe gambling problems are connected to stronger impulsiveness (Harries et al., 2017). In gamblers, impulsiveness is correlated to cognitive disorders, and impulsive decision-making can increase the possibility for accepting wrong beliefs (Florez et al., 2016). Gamblers with earlier onset of gambling disorder are more impulsive and usually suffer from severe disorder types (Harvanko et al., 2013). In addition, impulsiveness is a risk factor for developing alcohol addiction, prolonging alcoholism, and causing relapse. Alcoholics display reduced impulse control and distorted decisionmaking skills. In other words, impulsive behavior accompanied with distorted decision-making can present a vulnerability factor for alcoholism; it usually precedes alcoholism, although it can be caused by longterm alcoholism (Lawrence et al., 2009; Spoelder et al., 2015) due to the fact that regular alcohol consumption diminishes the individual’s experience-based learning ability (Spoelder et al., 2015). Alcoholics with earlier onset in alcoholism are more impulsive, manifest a greater desire for sensations, show aggressive behavior, and seek immediate rewards (Harvanko et al., 2013). However, alcohol abuse is a risk factor, regardless of impulsiveness, for the progression of a gambling disorder and the tendency towards serious gambling types in men, while alcohol abuse in females is a risk factor for progression of gambling disorder only in the case of an equally present high impulsiveness rate (Barnes et al., 2002; Messerlian et al., 2007). Impulsiveness is a significant risk factor for developing a gambling disorder in both sexes, regardless of alcohol intake, as well as being a risk factor for developing alcoholism. Higher impulsiveness rates are evident in gamblers addicted to alcohol
and also in gamblers with comorbidity alcoholism than in persons who are either alcoholics or gamblers, which corroborates with impulsiveness being a mutual risk factor for developing a gambling disorder and alcohol addiction (Barnes et al., 2002; Florez et al., 2016; Stewart & Kushner, 2005). In alcoholics and gamblers, impulsiveness is at the root of the tendency toward short-term rewards. If regular alcohol use or gambling reoccur during a longer time period, learning mechanisms based on rewards develop into compulsive behavior (Choi et al., 2014), and it is possible that addictive pathology includes progression from impulsiveness to obsessive compulsiveness (Choi et al., 2014). In gamblers with very high impulsiveness rate, alcohol fosters riskier gambling, influences the amount of average stakes, and leads to quicker money loss (Cronce & Corbin, 2010).
Emotion Regulation Apart from impulsiveness, emotion regulation can also be one of the factors which contributes to the development of alcohol addiction and a gambling disorder (Jauregui et al., 2016). Executive function can be divided into cognitive and affective component. The cognitive aspect of executive function is dominant in situations which demand abstract information manipulation and, consequently, carries no reward or punishment. Affective executive function is prevalent in situations which demand the regulation of emotions and motivations, and actions are based on reward and punishment. Daily decision-making involves cognitive aspects, such as impulse control and flexible and responsive responses to cognitive strategies. Nevertheless, in rare occasions, decisions are made without affective or motivational influence, which can interfere with the implementation of the cognitive aspects. (Kully-Martens et al., 2013). Gamblers have difficulties with emotion regulation, and emotion regulation is in direct relation to alcohol abuse. Gambling is connected to the expectation of a positive effect or with diminishing a negative effect, while drinking alcohol soothes negative emotions, reduces stress, increases positive impact, and diminishes desire. Negative emotional states along with bad self-control can lead to impulsive behavior, such as gambling and drinking alcohol, which helps negative emotion regulation (Jauregui et al., 2016).
TREATMENT PROBLEMS In the treatment of patients who are alcoholics with a gambling disorder comorbidity, the complexity of the psychopathology—which is manifested in multiple psychiatric disorders, which besides alcohol addiction
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KEY FACTS
and gambling disorders, are personality disorders, depressive, and anxiety disorders—needs to be taken into consideration (Cowlishaw & Hakes, 2015). Previous experience shows that a small number of patients are being treated and that around 75% have never asked for treatment. The biggest obstacles when entering treatment are the belief that they can resolve their problems on their own, experiencing shame, fear of stigmatization, poor adaptation to program rules, lack of social support, low personal motivation, poor insight into the severity of problem, and a negative opinion of the treatment efficacy. Stigma and shame are barriers which are usually identified in alcoholics and gamblers (Dabrowska et al., 2017). In gamblers there is a negative relation between alcohol abuse and treatment response (Jimenez-Murcia et al., 2016). The treatment of these patients which has proven to be effective includes integrated strategies for resolving gambling problems in comorbidity with alcohol, accompanied with intensive psychotherapy. A therapeutic approach aimed at gambling issues mostly includes modified treatment modalities which are already being used in alcohol addiction such as motivational interviewing, CBT, and relapse prevention. Patients with a gambling disorder in comorbidity with alcoholism will greatly benefit from motivational interviewing (Josephson et al., 2016). Brief interventions aimed at reducing gambling can also be helpful (Jimenez-Murcia et al., 2016). Using a pharmacological approach, there have been attempts of introducing naltrexone in the treatment of comorbidity of alcohol addiction and gambling disorder. However, treatment with naltrexone has not proven to be more efficient than a placebo in reducing drinking alcohol or with a reduction of gambling in alcoholics with a gambling disorder (Toneatto et al., 2009). It has been noted that methylphenidate in patients with ADHD improves decision-making processes and decreases the tendency towards risky behavior, and, given its beneficial effect on the executive function disorders in ADHD patients, it would be justified to consider this kind of treatment for gambling and alcohol addicts (DeVito et al., 2008; Goudriaan et al., 2006). An additional problem is comorbidity with other psychiatric disorders, such as personality, depressive, and anxiety disorders. In such cases, pharmacological treatment of comorbidity states according to existing guidelines for the treatment of psychiatric disorders is used (Babi´c, 2016).
CONCLUSION Alcohol drinking and gambling are mutually connected activities and the comorbidity of alcoholism
and a gambling disorder is more of a rule than an exception. Apart from the fact that one disorder can precede the other, and vice versa, alcoholism and gambling disorders share mutual genetic vulnerability, they are influenced by similar neurodevelopmental factors and personality traits, and entail similar brain changes. Comorbidity of alcoholism and a gambling disorder is by far a more serious clinical and social problem than the individual disorders. Comorbidity is stigmatized, and often is concomitant with a lack in treatment cooperation with resulting unsatisfactory outcomes in many cases. It is indicative to perform further research for the purpose of finding appropriate treatments for these patients.
MINI-DICTIONARY OF TERMS Behavioral addiction Addiction to a behavior like gambling rather than to a drug. Comorbidity The simultaneous presence of two chronic conditions in a patient. Reward system The reward system is a group of neural structures responsible for positive emotions. Impulsiveness Tendency to act without consideration of consequences. Compulsive behaviors Actions that people feel driven to do that they cannot resist or control. Cognitive behavior therapy This psychotherapy method combines the techniques of cognitive psychotherapy and behavior therapy. Relapse Recurrence of alcohol abuse in an individual who has previously achieved and maintained abstinence for a significant period of time beyond withdrawal. Lifetime prevalence The proportion of individuals in a population that at some point in their lives have experienced a disease or a negative/destructive behavior. Positive reinforcement The presentation of a stimulus that increases the future likelihood that a behavior will occur.
KEY FACTS Alcohol and Gambling Disorder • The comorbidity of alcoholism and gambling disorder is more a rule than an exception. • One disorder can precede the other, and vice versa. • Alcoholism and gambling disorders share mutual, genetic vulnerability. • The mesolimbic reward system is deficient in both disorders. • Structural and functional disorders of the prefrontal cortex and deficient executive functioning are found in both disorders. • Impulsivity is a significant personality trait in both disorders.
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SUMMARY POINTS • Alcohol abuse usually precedes the development of a gambling disorder. • Comorbidity of alcohol addiction with a gambling disorder is more prevalent in men. • The severity of a gambling disorder is related to the amount of alcohol consumed and the age when the drinking began. • Possible variables which may contribute to pathogenesis of these disorders are: • genetic vulnerability • prenatal alcohol exposure • mother’s alcohol abuse during childhood • conduct problems in childhood • impulsive and compulsive behaviors • deficit emotion regulation • dysregulation of the dopamine reward system • defects in the prefrontal cortex • deficient executive functioning • Comorbidity between gambling disorder and alcoholism is related to poor response to treatment.
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