Problem Gambling and Mental Health | Addiction Counseling Skills

This episode was pre recorded as part of a live continuing education webinar on demand. CEUs are still available for this presentation through all CEUs register@allceus.com counselortoolbox. Hi everybody. I'm Dr. Donnelly Snipes and welcome to this episode on gambling and mental health. In this presentation, we're going to talk about post traumatic stress symptoms in pathological gambling and potential evidence of something called an anti reward process. And I'll explain what that is when we get there. We'll talk about problem gambling in people with bipolar disorder. We'll explore alexthymia and pathological gambling, food addiction in gambling disorder and gambling, domestic violence and trauma. Believe it or not, all of these are really strongly correlated to gambling disorder. And finally, we'll stop or end with understanding stigma. Let's start with post traumatic stress and gambling. There was a study that looked at the number of traumatic events that somebody went through and controlled for those and found that individuals with pathological gambling disorder had significantly higher scores on post traumatic stress than individuals that didn't have pathological gambling disorder or gambling disorder when those events were controlled for. So Sally could have three traumas in her life and John can have three traumas in his life. Both of them have the trauma. But if John also has gambling disorder, John likely had significantly higher post traumatic stress scores. This is important for us to recognize that if we have somebody with gambling disorder, we also do need to be assessing for post traumatic stress. Anti reward is a term that we use when somebody gets momentary relief from their symptoms, from their post traumatic stress. But the behavior that they use to get that relief contributes to their spiraling distress cycle. We see it a lot in addictions people use in order to numb the pain. And then that works for a little while, but as soon as they sober up, things have gotten worse. They're getting more and more distressed, a lot more problems, problems are creeping up. So what do they do they use again in order to get some more momentary relief? We see the same thing in gambling. Gambling can help people get this momentary relief, but the expenses and the losses often contribute to a worsening of everything else in their life. In a study of pathological gamblers, gambling behavior significantly decreased upon completion of PTSD treatment. That's interesting to realize. So it reinforces this notion that gambling may be being used in some cases by people to cope or escape from post traumatic stress symptoms like hypervigilance. When they went through the PTSD treatment and they had resolved their PTS issues, then their gambling behavior normalized or significantly Decreased. If you're working with somebody who does have gambling disorder, it would be imperative then to assess for post traumatic stress and treat that post traumatic stress in order to assist in the recovery of the gambling problem. People with a history of trauma should be counseled about their increased risk for developing gambling problems. People who met criteria for bipolar one, now remember that's when somebody actually has a full blown manic episode, not hypomanic. People who met Criteria for bipolar 1 and pathological gambling were identified. Out of a group of thousands of people in the general population, 3.8% of people could be diagnosed with problem gambling. Now remember, problem gambling doesn't quite meet the criteria for gambling disorder, but it is posing a problem. Obviously, in the group with bipolar disorder there was an 11.6 prevalence of problem gambling. That's almost three times as many people in the group with bipolar disorder. Of all the psychiatric categories examined, people screening positive for a manic episode had the highest risk of pathological gambling. This is common sense. We know that in a manic episode people are often engaging in high risk, potentially high reward behaviors. That is sort of the very definition of gambling. So it's not a surprise they have found that selective serotonin reuptake inhibitors may be effective for some patients with pathological gambling. But big but red warning sign here, selective serotonin reuptake inhibitors or SSRIs can trigger a manic episode in people with bipolar disorder. So a lot of psychiatrists will not prescribe SSRIs for people with bipolar disorder in order to prevent triggering a manic episode. Sometimes you'll see it in conjunction with a mood stabilizer, but most of the time you will not see people with bipolar disorder on an ssri. What's the option? People with bipolar disorder do have options, and one of them is sustained release lithium. It appears to produce significant positive results in both gambling behaviors and affective stability over eight to 10 weeks. That was a really positive finding. Unfortunately, the sample size was kind of small. I think it was 46. And the FDA still has not approved any medication for the treatment of gambling disorder. So I do want you to recognize that this is not saying that the FDA is approving sustained release lithium for the treatment of gambling disorder. I'm just saying, in a study there were significant positive effects after the person had been on sustained release lithium for eight to ten weeks. Alexthymia is something else that is a common co occurring issue in people with gambling disorder. Individuals with high levels of alexthymia become prone to addictive behavior because of Their emotional dysregulation. They have difficulty describing their feelings. They have difficulty distinguishing their feelings from bodily sensations. So I want you to think for a second. How do you feel when you're scared? How do you feel when you're angry? How do you feel when you are different feelings? A lot of times, especially scared and angry, Sometimes they can feel very similar because they're both excitatory, they're both fight or flight sort of feelings. So people may not know how they feel, which means if they don't know how they feel, they may not know what's causing it. If they don't know what's causing it, then they're going to have difficulty addressing it. Therefore, they may just try to numb it out in order to make it stop. People with alexthymia tend to have restrictive imaginative processes and a stimulus dependent externally oriented cognitive style. External locus of control is what we often call this looking for outside reasons for something to happen. They're not seeing what's going on inside them. They often also have challenges in emotional processing and coping with stressful feelings and emotion regulation. Alexthymic individuals attempt to regulate their emotions through compulsive behaviors. They start feeling a certain way, you know, their belly starts to get all tied up or they feel like they want to punch a wall or something. And they try to regulate these emotions through compulsive behaviors like gambling or taking drugs or eating or whatever it is they do. They often have addictive behaviors due to their lack of self knowledge and insight. Again, they're using the addictive behaviors in order to try to make that unpleasant feeling stop because they don't understand what it is, where it's coming from, or how else to stop it. Emotional dysregulation has been measured and I love this scale. I use it in practice. You can use the Difficulties in Emotion regulation scale and you can just google that and it will come right up. In order to identify clients who have difficulties with emotion regulation, we know that is one of the things that dialectical behavior therapy is so amazing at helping people address. So if you identify a client who has difficulties in emotion regulation with or without gambling disorder, then you can start intervening because if they have these problems, then they are at much greater risk for the development of addictive disorders and gambling disorder. Difficulties in emotion regulation and alexthymia are positive significant predictors of pathological gambling. Gambling is also highly associated with domestic violence. Think about it. If somebody's gambling, especially if they're in a losing phase and they're draining their accounts, they're probably being secretive. They're trying to figure out how to replace the money that they lost. They're probably hiding. They're being dismissive of their family. They're spending too much time out for long periods and not talking about where they've been. There's a lot of conflict and chaos in the house. There's a lot of stress. That person is under a whole lot of stress. We know when those things add up. It can create the perfect storm for domestic violence. 20 to 50% or even more of spouses of compulsive gamblers or people with gambling disorder have been abused. 25 to 50% or more of spouses of compulsive gamblers have been abused. Just let that sink in. That's a huge number. The odds of intimate partner violence increased 10.5 times if the partner was a problem gambler. That doesn't mean that the person met the criteria for gambling disorder necessarily. They just met the criteria for being a problem gambler. And that increased their risk of domestic violence 10.5 times. Children of problem gamblers are 2 to 3 times more likely to be abused by the parent. Interesting little fact, though. For many women, gambling venues are a refuge from violence, and gambling may become a method of escape. I didn't realize that. I wouldn't have thought of that. Family violence and addiction have several common features, including loss of control, continuation despite adverse consequences, tolerance and withdrawal, involvement of the whole family, preoccupation or obsession, and defenses of denial, minimization, and rationalization. We see these characteristics in people with substance use disorders as well as with gambling disorder. There was a cool study that was done. It was a twin cohort study. So they looked at twins, and these are twins that who. Who had experienced traumatic events and those experiencing traumatic events had an increased risk of having a gambling problem by 453%. So if you have two twins, one has a trauma, the other one doesn't, the one with the trauma, even though they're living in the same environment, going to the same school, the one with the trauma was 453% more likely to develop a gambling problem. Problem gamblers are 620% more likely to develop PTSD. Again, I emphasize if you work with clients with PTSD, assess for gambling. If you work with gamblers, assess for ptsd. Soldiers who are returning from deployment tend to have a greater propensity for risk taking and often have experienced trauma, putting them at greater risk for the development of problem gambling. Recent research supports the notion that food may have addictive potential in Some individuals, due to the increased potency of certain nutrients. Palatability or natural reward. Food provides the building blocks for our body to make the neurotransmitters that it needs to make for us to feel happy, for us to feel scared, for us to feel motivated. So if we have increased potency of some of these nutrients, then we might have a increased response. If it's more palatable, it means it tastes better, then we may focus on that. And that could be a reward in and of itself. It just tastes so good, or it could just be a natural reward. Certain foods, especially high fat, high sugar foods, cause a release of dopamine and serotonin, which, which helps a lot of people feel more feel calmer. In today's society, where people are eating a lot of different types of diets and cutting out whole food groups, sometimes the body needs certain nutrients. So if they get an infusion, if you will, of those nutrients from something, it may trigger a stronger response. Palatable foods can mimic the neurophysiological and behavioral effects of addiction. Addictive drugs, not to the same level. You're not going to get the same effect from a brownie as you are from cocaine. But brownies do bring with them chocolate, which releases all kinds of neurochemicals and sugar and fat, which helps release dopamine and serotonin. It can help people calm down. Plus, brownies may also be associated psychologically with positive times in the past that bring people a feeling of comfort and happiness. Systematic reviews confirm commonalities between gambling disorder and other behavioral addictions, including food addiction. Similarities include impulsivity and compulsivity, structural and functional abnormalities of networks involved in reward processing and top down control. Fancy way of saying impulse control. Alterations in neurochemical and neuroendocrine systems. You may see hypocortisolism, you may see other alterations, but basically the neurotransmitters are not in the balance that we would expect to see. For the person to feel happy, there's an increased urgency, disinhibition and novelty seeking. And there's often a family history of addiction. In people who have gambling disorder or other behavioral addictions, there is a distinct type of gambling disorder. Patient described as the disorganized, emotionally unstable type. The co occurrence of food addiction in people seeking treatment for gambling disorder is related to poorer emotional and psychological states. If you've got somebody in treatment for food addiction, assess for gambling disorder. If you've got somebody in treatment for gambling disorder, assess for food addiction. Since there are so many similarities between the different types of addiction, if we don't treat all of them or address all of them, then people are going to do what's called substituting addiction. If they can't get their addiction of choice, they're going to go to something else. And then when their addiction of choice becomes available again, they're going to be more likely to go back to that addiction. A higher ratio of food addiction was found in women, Though men have other addictions that they may go to. And there's a higher risk of a food addiction diagnosis in patients with higher scores for harm avoidance. So those patients who tend to try to escape from pain and a dimension they called self transcendence, which means the person typically was unconventional, illogical, suspicious, and immature in their behaviors. If you've got a client who has these characteristics, Then you want to assess for food addiction. And they also tend to have lower scores in cooperativeness. My experience in working with people with addictions. Cooperativeness is not one of those characteristics that is often present in early recovery. Sometimes it is, But a lot of times, people in early recovery still are digging their heels in, and they want to do recovery their way. Finally, let's talk about stigma a little bit. As the result of stigma, people with gambling problems attract substantial negative stereotypes, Social distancing, emotional reactions and status loss, and discrimination. As a result of all that, people with gambling disorders or gambling problems Often don't seek treatment because they don't want to get that label. Stigmatizing. Attitudes held toward people experiencing problem gambling Include thinking that they're impulsive, irrational, irresponsible, untrustworthy, unproductive, greedy, antisocial. Now, while they're in their active addiction, Some or all of these may be true, but does that represent a behavior or does that represent the core of the person? And that's kind of what we need to look at. Is this person always irresponsible? Is this person always untrustworthy? Stereotypes of problem gamblers are socially constructed from transmitted cultural beliefs Rather than cognitively derived from. From direct interactions. Which again, is a fancy way of saying we assume we know what a problem gambler is like because of what we've seen on tv. Most of us have never knowingly interacted with somebody who was a problem gambler. Once we start to interact with somebody who has problem gambling or addiction or something else, we start to realize how much they are like us. They have the same hurts, they have hang ups. You know, they love things. Sometimes they want to be happy. They are very much like us. So when we are exposed to them and we recognize that they've got a problem with gambling, then we can start seeing commonalities and stop othering them, which means pushing them away, saying they're not like me, they're somebody else, they're somebody other than like me. Culturally constructed stereotypes are more resistant to contradictory evidence and education campaigns because it's ingrained in our culture, it's in our media, it's in everywhere. So increased contact with a stigmatized population seems to be the best way to reduce stigma and start changing these concepts and beliefs about people with gambling problems. Desired social distance increase with perceptions that problem gambling is caused by bad character, is perilous, non recoverable and disruptive, but decreased with perceptions that is due to stressful life circumstances or a chemical brain imbalance. Again, when we get people together, when we help them have direct interactions, then they can see that people with gambling problems are people first and they are probably going through something and really struggling. A lot of people have an attitude of compassion that comes out when they start recognizing there but by the grace of God go I. Individuals experiencing gambling problems have expressed aversion to being pitied and want instead to be treated like everybody else. They want to be empowered. They don't want to be pitied. The anti reward process or the immediate short term escape followed by the worsening of the condition is very common in people with post traumatic stress who gamble. People with pathological gambling disorder have higher post traumatic stress scores. Gambling is a high risk behavior that people with bipolar disorder may undertake to escape depressive mood states or for excitement during manic states. Time released lithium was found to improve gambling urges as well as emotional lability in people with bipolar disorder and people with alexthymia have difficulty identifying and therefore regulating their emotions. Gambling can provide an escape or numbing of unpleasant physiological or emotional states for people with alexthymia. Similar to other addictions, there's a high correlation between food addiction and gambling disorder. In families where someone has pathological gambling disorder, there are significantly higher rates of domestic violence and child abuse and stigma often causes people to refuse to seek help. Stigma regarding gambling appears to be largely culturally created and exposure to people who have pathological gambling disorder will help reduce othering in order to help reduce stigma in our communities. Thank you for being with me and I will talk to you on the next episode. If this podcast helps you help your clients or yourself, please support us by purchasing your ceus@allce.com or getting your agency to sponsor an episode. A direct link to the on demand ceus for this podcast is@allce.com podcastceus that's allceus.com podcastce ceus to sponsor an episode of Counselor Toolbox and reach over 50,000 clinicians per week, go to allce.com sponsor thank you.