Understanding Gambling Disorder: Screening and Diagnostic Assessment
Dr. Kirk Christie, a Consultant Psychiatrist, delves into the world of gambling disorder, exploring definitions, neurobiology of addiction, screening instruments, DSM-V criteria, and harmful alcohol usage. Discover the differences between nondisordered, social, and problematic gambling behaviors, along with the characteristics of Gambling Disorder and its impact on individuals' lives.
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GAMBLING DISORDER: SCREENING AND DIAGNOSTIC ASSESSMENT Dr. Kirk Christie Consultant Psychiatrist Director of Female & Addiction Services, S.R.C. Gambling Addiction & Awareness Symposium Church of God Auditorium 31stOctober, 2018
Objectives DEFINITIONS NEUROBIOLOGY OF ADDICTION SCREENING INSTRUMENTS DSM V CRITERIA GAMBLING DISORDER HARMFUL & HAZARDOUS ALCOHOL USAGE SUMMARY SLIDE REFERRAL PROCESS
Quotes I want people to understand, gambling is not a bad thing if you do it within the framework of what it s meant to be, which is fun and entertaining Michael Jordan If you must play, decide upon three things at the start: the rules of the game, the stakes, and the quitting time ..Chinese Proverb
Quotes The best throw with the dice is to throw them away ..........................Anonymous Gambling: The sure way of getting nothing for something Wilson Mizner So are the ways of every one that is greedy of gain; which taketh away the life of the owners thereof Proverbs 1:19
Definitions Nondisordered Gambling: professional and social gambling; risks are limited and discipline is central. Social Gambling: typically occurs with friends and colleagues and lasts for a limited period of time, with acceptable loss. There may be problems associated with gambling i.e. short- term chasing behaviour and loss of control but criteria for GD is not met
Definitions-contd Gambling : greater value. risking something of value in the hopes of obtaining something of Gambling Disorder: Substantial impairment related to gambling behaviours. Persistent and recurrent maladaptive gambling behaviour that disrupts personal, family, and or vocational pursuits. Bailout behaviour: turning to family or others for help with a desperate financial situation that was caused by gambling Chasing one s losses: urgent need to keep gambling often with placing big bets or taking of greater risks) to undo a loss or series of loss. The chase is often frequent and long-term in GD. Gambling Behaviours: Individuals lie to family members & therapists to conceal the extent of involvement with gambling; deceit may include forgery, fraud , theft or embezzlement to obtain money with which to gamble
Gambling Disorder Gambling behaviours activate the reward systems in the brain similar to those activated by drugs of abuse and produce some behavioural symptoms that appear comparable to those produced by substance use disorders
Neurobiology of Addiction The Brain Reward System implicated in the development of Addiction is composed of key elements in the basal forebrain, including the ventral striatum and the extended amygdala and its connections Neuro-pharmacologic studies in animal models of addiction have provided evidence of decreases in specific neurochemical mechanisms in specific brain reward neurochemical systems in the ventral striatum and amygdala There is recruitment of brain stress systems i.e. CRF & NE and dysregulation of brain antistress systems i.e. Neuropeptide Y , that provide the negative motivation state associated with drug abstinence and similarly with abstinence from engaging in gambling behaviours
EVALUATION OF THE PATIENT THINK OF IT SCREENING TEST ASK THE RIGHT QUESTIONS
Screening Tools for Problem Gambling Gamblers Anonymous 20 questions South Oaks Gambling Screen (SOGs) NORC DSM Screen for Gambling Problems (NODS) Lie/Bet Brief Biosocial Gambling Screen (BBGS)
Gambling Disorder- Diagnosis (DSM-V) Persistent and recurrent problematic gambling behaviour leading to clinically significant impairment or distress, as indicated by the individual exhibiting four or more of the following in a 12 month period. 1. Needs to gamble with increasing amounts of money in order to achieve the desired excitement 2. Is restless or irritable when attempting to cut down or stop gambling
Gambling Disorder 3. Has made repeated unsuccessful efforts to control, cut back or stop gambling 4. Is often preoccupied with gambling (persistent thoughts of reliving past gambling experience, handicapping or planning the next venture, thinking of ways to get money with which to gamble 5. Often gambles when feeling distressed (helpless; guilty, anxious, depressed)
Gambling Disorder 9. Relies on others to provide money to relieve desperate financial situations caused by gambling 10. The gambling disorder is not better explained by a manic episode Mild: 4-5 criteria met Moderate: 6-7 criteria met Severe: 8-9 criteria met
Comorbidities Tachycardia and angina; poor medical health Substance Use Disorders (Alcohol, Nicotine) Depressive Disorders Anxiety Disorders Personality Disorders
To Assess for Problematic Alcohol Use - Ask! Unless you are in a context of low alcohol use, ask at least one question about alcohol use! For example Do you drink alcohol? If the answer is yes, you need to ask more questions (see next slide)
Establish Communication and Build Trust Address the person's immediate expectations What problem or concern has prompted the person to come to the health service today? Listen carefully and with respect Manage the person's expectations, if they are unreasonably high Be honest about what you can and cannot do Assess the impact of substance use on the person's life The healthcare worker should ask everyone about alcohol use How have their home and work life been affected
Establish Communication and Build Trust Look for common ground There is a shared interest in improving the person's health Do not judge Challenge misconceptions but avoid confrontation Use good communication skills Start by asking open questions Remain neutral Explain your understanding of the situation to the person Always be honest Expect that it will take multiple appointments to build trust
Identify the Pattern of Alcohol use Which patterns should be identified? Hazardous Harmful Dependence How should they be identified? Ask questions of the person and carer (with consent) Listen and look for further information Do a physical examination and request further investigations
There is Hazardous use if the Person says Yes to any of the following Questions Consumed 5 or more standard drinks on any given occasion in the last 12 months? Drink on average more than two drinks per day? Drink every day of the week? Do you drink when driving or operating machinery? considering pregnancy? contra-indicated medical condition is present? using certain medications, such as sedatives, analgesics and selected hypertensives? 1. 2. 3. 4.
What is Harmful Alcohol Use? Harmful use is a pattern of alcohol use which is causing harm to health a physical or mental health problem caused by alcohol, or they are pregnant AND continued alcohol use despite this health problem/situation
CAGE QUESTIONNAIRE C- Have you ever felt you needed to CUT down on (reduce) your drinking? A Have people ANNOYED you by criticizing your drinking? G Have you ever felt GUILTY (or ashamed) about drinking? E Have you ever felt you needed a drink first thing in the morning (EYE opener) to steady your nerves or to get rid of a hangover?
SUMMARY Don t be dismissive of the warning signs of Problem Gambling and Gambling Disorder THINK of the possible associated problems Use Brief Screening Instruments Conduct a diagnostic assessment (DSM-V) Refer the person/s for appropriate management of their problems
Referral Process FAMILY PHYSICIAN---------------------------CONTACT FOR CONSULTATION CCAC---------------------------------------------------323-3295/6 SRC OUTPATIENT CLINICS-------------------------364-9600 FAMILY ISLAND-------------------------------------DISTRICT MEDICAL OFFICER PSYCHIATRISTS ACCESS IN PRIVATE PRACTICE----------SEE TELEPHONE DIRECTORY/YELLOW PAGES
REFERECENCES CITED MhGAP 2012 presentation on Alcohol Use and Alcohol Use Disorders Anthony J, 2002. Into the World of Illegal Drug Use, American Journal of Epidemiology, Vol. 155, No. 10 : 918 925 Diagnostic and Statistical Manual of mental disorders: DSM-5-5th edition Galanter, Marc, Kleber, Brady. Textbook of Substance Abuse Treatment, fifth edition, 2015. American Psychiatric Publishing The National Institute of Drug Abuse online website www.drugabuse.gov.NSDUH Survey 2013. I
