Understanding Pathological Gambling: Diagnosis and Epidemiology
Pathological gambling, characterized by the inability to resist the urge to gamble despite severe consequences, is a progressively worsening disorder. This text discusses the diagnostic criteria for pathological gambling, its positive diagnosis according to DSM-IV-TR, and epidemiological data on the prevalence of problem gambling in Romania, focusing on adolescents.
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Cocea Eduard-Natanael medic rezident an II
Date generale Jocul de noroc patologicestecea mai frecventa tulburarede control al impulsurilor,caracterizata prin esecul recurentde a rezista impulsului de a juca,in ciudaconsecintelor negative severe si devastatoare in plan personal,profesional,familial. Este o tulburare progresivacaracterizata prin pierderea continua sau periodica a controlului asupra jocului de noroc,preocuparea pentru jocuri de norocsi pentru obtinerea banilor,in scopul de a juca,gandirea irationala si continuareacomportamentului in ciuda consecintelor negative.
Diagnostic pozitiv Criteriile DSM IV TR Joc de noroc maladaptativ persistent si recurent indicat de cinci(sau mai multe) din urmatoarele: 1)Este preocupatde jocurilede noroc(de ex: preocupatde retrairea experientelortrecutede joc,schemede handicapuri sau planuirea urmatoarei sesiuni ,sau se gandeste la modurilede a obtine bani pentru a juca); 2)Trebuiesa joace sumede bani din ce in ce mai mari pentru a realiza excitatia dorita; 3)A facut in mod repetateforturi lipsite de succesde a controla,reducesau incetasa mai joace; 4)Este nelinistit sau iritabil atunci cand incearcasa reduca sau sa incetezesa mai joace; 5)Jocul este un mod de a se inteparta de problemesau de a inlatura o dispozitie disforica(de ex: simtaminte de neajutorare,vinovatie,anxietate,depresie); 6)Dupace pierde bani la joc,adeseori se intoarcea doua zi ca sa isi ea revansa(isi haituieste pierderile); 7)Ii minte pe membrii de familie,terapeut,pealtii,pentru a ascundegradul de implicare in jocurile de noroc; 8)A comis acte ilegale,cum ar fi falsuri,fraude,furtsau delapidare pentru a avea bani de joc; 9)A periclitat sau a pierduto relatie semnificativa,slujba sau o oportunitateeducationala sau din cariera din cauza jocurilorde noroc; 10)Se bazeaza pealtii ca sa-i dea banii cu care sa iasa dintr-o situatie financiara disperata cauzata de joc;
epidemiologie Datele legate de prevalenta jucatorilor patologici in randul populatiei din Romania nu sunt foarte numeroase 1032 de adolescenti ; varstecuprinse intre 11-19 ani:65.7% sex masculin 34,43% sex feminin Subiectii au fost impartiti in 3 grupuri: nejucatori/jucatori ocazionali:753 subiecti(72,96% din total):316 sex feminin si 437 sex masculin jucatori de noroc problematici:243 de subiecti=23,54 43 de sex feminin si 200 de sex masculin 3.jucatori de noroc patologici=36 de subiecti -3,48% din totalul subiectilor dintrecare 3 de sex feminin si 33 sex masculin 1. 2.
Jucatorii de noroc patologici Numarsubiecti:36 Varsta medie= 16,48 ani. Diferenta pe sexea fostsemnificativa -subiectii de sex masculin: 91,66% -sex feminin 8,33%. Jocuri practicate:pariurile sportive si "pacanelele -36,11% lotosi casino online au urmatcu 25% ruletasi black-jackul cu 22,22%. Din acestia 66,66% consumau alcool, 33,32% droguri legale sau ilegale .Doar 16% consumau tutun.
Scopul acestei prezentari este de a realiza o sinteza a multiple studii dublu orb, controlate placebo a diversilor agenti farmaceutici utilizati si a efectelor acestora.Am folosit studii efectuate in perioada 2004-2014.Studiile pe care le-am luat in considerare pentru aceasta prezentare includ antidepresive, antagonisti opiozi, timostabilizatoare,antipsihotice atipice, si agenti glutamatergici . In ciuda impactului personal i social al dependen ei de jocuri de noroc, nu exista inca un consens in privinta unei medicatii clare in jocul de noroc patologic.Am analizat 18 studii ale agentilor farmacologici enumerati anterior si multe dintre aceste studii sugereaza ca anumite terapii medicamentoase pot fi benefice in tratarea tulburarii.
Antidepresivele au fost una dintre primele clase de medicamente folosite pentru a trata jocul de noroc patologic, avand la baz asocierea jocului de noroc patologic si a compulsivitatii, date care arata o disfunctie serotoninergica in jocul de noroc patologic,posibilitatea de a folosi clomipramina de a trata jocul de noroc patologic si folosirea fluvoxaminei pentru a trata cumparatul compulsiv, o tulburarece face parte din spectrul tulburarilor obsesiv-compulsive. Cercet rile ulterioare s-au axat pe similitudinile dintre simptomele clinice ale jocului de noroc patologic si utilizarea de substante psiho-active, precum: -lipsa de control -cresterea tolerantei -continuarea implicarii intr-un anumit comportament in ciuda consecintelor negative si caile neurologice similare pentru jocul de noroc patologic si adictia de substante psiho-active care a dus la explorarea antagonistilor opiozi ca optiune de tratament. Mai multe studii recente au eviden iat existen a unor subtipuri de joc de noroc patologic i alte aspecte relevante pentru aceasta tulburare cum ar fi comorbiditatile si antecedentele psihiatrice ale membrilor familiei ce a dus la examinarea stabilizatorilor de dispozi ie, antipsihoticelor atipice, agen ilor glutamatergici si antipsihoticelor atipice ca terapii farmacologice eficiente.
antidepresive Paroxetina:doza initiala 20 mg/zi, crescuta cu 10 mg/saptamana pana la 60 mg/zi S1:-8 s pt m ni -45 subiecti - 61% dintre subiec i au prezentato ameliorare la paroxetina fata de doar 23% la placebo. S2:-16 saptamani -76 subiecti - 59% dintre subiec i au prezentato ameliorare la paroxetinasi 48% la placebo(diferenta nu este una semnificativa in favoarea proxetinei) -rata ridicata de raspuns la placebo
antidepresive Fluvoxamina S1:-207 mg/zi -16 saptamani -15 subiecti -rezultate:eficientasemnificativa in tratarea tulburarii S2:-200 mg/zi -6 luni -32 subiecti -rezultate nesemnificative;
antidepresive S:-sertralina 95 mg/zi -6 luni -60 subiecti -rezultate o dpdv statistic S:-bupropiona -12 saptamani -39 subiecti -rezultate o dpdv statistic
Antagonisti opiozi Avand in vedere capacitatea lor de a modula transmisia dopaminergica in calea mezolimbica, antagonistii receptorilor opiozi au fost investigati in tratamentul jocului de noroc patologic. Naltrexonaeste un medicament folosit in principal pentru tratamentul dependentei de alcool, in reducerea intensitatii nevoii de a juca, gandurile si comportamentul legat de jocurilede noroc.
Naltrexona S1:-11 saptamani -45 subiecti -rata de raspuns 75% fatade 24% in grupul placebo -cei cu o intensitate mai mare a dorintei de a juca au raspuns mai eficient la tratament S2:-18 saptamani -77 subiecti - reduceri semnificativ mai mari in dorinta de a juca jocuri de noroc si comportamente legate de jocurile de noroc comparativ cu subiectii din grupul placebo - La sfarsitul studiului 39,7 % din cei cu naltrexona au putut s se ab in de la toate jocurile de noroc pentru cel pu in 1 luna fatade numai 10,5 % din cei cu placebo
Antagonisti opiozi Nalmefena S1:-16 saptamani -207 pacienti -59% au aratat reduceri semnificative ale dorintei, gandurilor si comportamentelor legate de jocurile de noroc comparativ cu 34% in randul celorcu placebo S2:-dozavariabila:20 si 40 mg -16 saptamani -233 subiecti -rezultatesuperioare in randul celorcare primeau 40 mg/zi fatade cei cu 20mg/zi sau placebo - dozajul agentului farmacologic poate fi important in controlul simptomelor.
Antagonisti opiozi Avand in vedere ca doua studii dublu orb controlate placebo ale naltrexonei si 2 studii ale nalmefenei sugereaza eficacitatea antagonistilor opiozi in reducereadorintei de a juca, gandurilorsi comportamentelor asociate jocurilor de noroc, aceasta clasa de medicamente ar trebui considerata prima linie de tratament in jocul de noroc patologic. Un studiu de follow-up realizat la 6 luni dupa, a constatat ca majoritatea celor care au raspuns la naltrexona au mentinut raspunsul si dupa intreruperea mediatiei.
Timostabilizatoarele S:-Carbonatde litiu cu eliberare prelungita -10 saptamani -40 de subiecti(tulburari din spectrul bipolar si joc de noroc patologic) -rezultate imbunatatiresemnificativa: 83% pt Carb. de litiu fatade 29 % din grupul placebo S:-Topiramat -14 saptamani -42 subiecti -rezultate -nesemnificative
Antipsihotice atipice Olanzapina:5-10 mg/zi S1:-12 saptamani -42 subiecti -rezultate o dpdv statistic S2:-7 saptamani -21 subiecti -rezultate 0 dpdv statistic
limitari numar redus de subiecti durata limitata grupuri clinice nereprezentative
Concluzii Cercet rile privind tratamentul farmacologic al jocului de noroc patologic par promi toare, n special n cazul antagoni tilor opioizi.Totusi cercetatorii si clinicienii ar trebui sa fie constienti de limitarile cunostintelor noastre in aceasta privinta. Cercetarea ulterioara ar trebui sa asigure un numar mai mare de subiecti cu joc de noroc patologic, pe perioade mai mari de timp si care sunt evaluate longitudinal pe o perioada de cativa ani .
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