Archive for category: Uncategorized

To clarify the various revisions in the American Psychiatric Association’s fifth edition of theDiagnostic and Statistical Manual (DSM-5)relating to gambling disorders,the National Center for Responsible Gaming (NCRG) authored a white paper, titled ‘The Evolving Defintion of Pathological Gambling in the DSM-5.’ Below is an excerpt of that white paper that outlines the specific changes. For a free download of the white paper, visitwww.ncrg.org/resources/white-papers.

CHANGES FOR PG IN DSM-5

Reclassification: From Impulse Control Disorder to Addiction

In the DSM-IV, pathological gambling (PG) was classified under the section titled, “Impulse Control Disorders Not Elsewhere Classified,” along with Compulsive Hair Pulling (Trichotillomania); Intermittent Explosive Disorder; Kleptomania; and Pyromania. TheDSM-5work group proposed that PG be moved to the category Substance-Related and Addictive Disorders.

The rationale for this change is that the growing scientific literature on PG reveals common elements with substance use disorders. Many scientists and clinicians have long believed that problem gamblers closely resemble alcoholics and drug addicts, not only from the external consequences of problem finances and destruction of relationships, but, increasingly, on the inside as well.According to Dr. Charles O’Brien, chair of the Substance-Related Disorders Work Group for DSM-5, brain imaging studies and neurochemical tests have made a “strong case that [gambling] activates the reward system in much the same way that a drug does.” Pathological gamblers report cravings and highs in response to their stimulus of choice; it also runs in families, often alongside other addictions. Neuroscience and genetics research has played a key role in these determinations.

Internet addiction was considered for this category, but work group members decided there was insufficient research data for it to be included. Another so-called behavioral addiction, “sex addiction,” also was not included because the work group found no scientific evidence that “reward circuitry is operative in the same way as in addictive areas.”

Renaming: From PG to Gambling Disorder

Officially changing the name to “Gambling Disorder” is a welcome revision for many researchers

and clinicians who have expressed concern that the label “pathological” is a pejorative term that

only reinforces the social stigma of being a problem gambler.5

Renaming: From PG to Gambling Disorder

Officially changing the name to “Gambling Disorder” is a welcome revision for many researchers and clinicians who have expressed concern that the label “pathological” is a pejorative term that only reinforces the social stigma of being a problem gambler.

Changes in Diagnostic Criteria and Lowering of Threshold for a Diagnosis

One major change in the DSM-5’s clinical description of gambling disorders is the elimination of the criterion “has committed illegal acts such as forgery, fraud theft or embezzlement to finance gambling.” The rationale for this change is the low prevalence of this behavior among individuals with gambling disorder. In other words, no studies have found that assessing criminal behavior helps distinguish between people with a gambling disorder and those without one. Studies suggest that its elimination will have little or no effect on prevalence rates and little effect on diagnosis. However, although committing illegal acts will no longer be a stand-alone criterion for diagnosis, the text will state that illegal acts are associated with the disorder. In particular, the criterion related to lying to others to cover up the extent of gambling will be described to include specific mention of illegal activities as one potential form of lying.

Other changes in the criteria are as follows:

• “Is preoccupied with gambling” will be “Is often preoccupied with gambling” to clarifythat one need not be obsessed with gambling all of the time to meet this diagnostic criteria.

• “Gambles as a way to escape from problems” will be “Gambles when feeling distressed.”

• In the text accompanying the criteria, “chasing one’s losses” is clarified as the frequent,and often long-term, “chase” that is characteristic of gambling disorder, not short-term chasing.

TheDSM-5work group observed that several empirical studies have supported lowering the threshold for a more accurate diagnosis of a gambling disorder from five to four criterion. For example, Stinchfield found that a cutoff score of four made modest improvements in classification accuracy and, most importantly, reduced the rate of false negatives. Anotherrecent study conducted in France found that theDSM-5criteria (the DSM-IV criteria without the illegal acts criterion and with a cutoff of four symptoms) performed better than theDSM-IVcriteria alone, the DSM-IV criteria without the illegal acts criterion and a new instrument based on theDSMcriteria for substance abuse.

Finally, to diagnose a gambling disorder, the critiera that are displayed among the individualmust occur within a 12-month period, unlike theDSM-IVwhich did not provide a time period for symptoms. In other words, if the person had two symptoms years ago and two symptoms in the past year, he or she would not qualify for a diagnosis.

References

American Psychiatric Association. DSM-IV: Diagnostic and Statistical Manual of Mental Disorders. Fourth ed.Washington, DC: American Psychiatric Association; 1994.

Holden C. Behavioral addictions debut in proposed DSM-V. Science. 2010;327(5968):935.

Potenza MN, Xian H, Shah K, Scherrer JF, Eisen SA. Shared genetic contributions to pathological gambling and major depression in men. Archives of General Psychiatry. Sep 2005;62(9):1015-1021.

Strong DR, Kahler CW. Evaluation of the continuum of gambling problems using the DSM-IV. Addiction. 2007;102(5):713-721.

Petry NM, Blanco C, Auriacombe M, et al. An Overview of and Rationale for Changes Proposed for PathologicalGambling in DSM-5. J Gambl Stud. 2013.

Stinchfield R. Reliability, validity, and classification accuracy of a measure of DSM-IV diagnostic criteria forpathological gambling. Am J Psychiatry. 2003;160(1):180-182.

Denis C, Fatseas M, Auriacombe M. Analyses related to the development of DSM-5 criteria for substance userelated disorders. An assessment of Pathological Gambling criteria. Drug Alcohol Depend. Apr 1 2011;122(1-2):22-27.

NCRG staffIn the NewsDSM-5gambling disordersresearch

Do you know a pioneer in the field of research on gambling disorders? Each year, theNational Center for Responsible Gaming(NCRG) recognizes outstanding contributions to the field of research on gambling disorders with theNCRG Scientific Achievement Award.This year’s award will be presented during theNCRG Conference on Gambling and Addictionin Las Vegas, taking place Sept. 22-24, 2013

Nominations may include:

• Research investigators at any stage in their career—early stage, mid-career or senior– whose research has made significant contributions to the knowledge base about gambling disorders;
• Educators who have successfully mentored young investigators in the field or have excelled at promoting public awareness and education about gambling disorders and responsible gaming; and/or
• A recent publication in a scientific, peer-reviewed journal that represents seminal work in the field.

The nomination package must include the following:

• Letter of recommendation: A detailed letter of recommendation describing the worthiness of the nominee, specifying his or her contribution to the field of gambling research or the significance of the publication nominated.
• Curriculum vitae (CV): For individual nominees, include an up-to-date CV.
• For research investigators, include a comprehensive bibliography of the nominee’s publications.
• Publications: For research investigators, submit no more than five scientific publications representative of the nominee’s work. In the case of a nomination of a publication, include a copy of the published version of the article. The publication must have been published in the same year as or the year prior to the nomination.

Submit nomination materials in PDF format to NCRG Senior Research Director Christine Reilly (creilly@ncrg.org) by Aug. 1, 2013. The selection committee, composed of distinguished scientists in the addictions field, will select one recipient to receive the 2013 award.

Each NCRG Scientific Achievement Award winner has an intriguing story to tell, and last year’s winner was no exception.Watch Randy Stinchfield, Ph.D., L.P.P., of the University of Minnesota, receive the 2012 NCRG Scientific Achievement Award for his contributions to research on youth gambling. You can also visit theaward websitefor a list of past recipients.

NCRG staffConference on Gambling and AddictionNCRG ConferenceNominationsscientific achievement award

The debut of thefifth editionof theAmerican Psychiatric Association’s(APA)Diagnostic and Statistical Manual of Mental Disorders (DSM)at the upcoming APA annual meeting might be regarded as the year’s most anticipated event in the mental health field. Its release has been covered in the media, including theWashington PostandThe New York Times,andexperts have weighed in with their viewof how this publication will impact clinicians, researchers and those diagnosed with mental disorders. However, an initiative underway for several years at theNational Institute of Mental Health(NIMH) could have more far-reaching effects on the diagnosis and treatment of mental health disorders and addiction.

TheNIMH’s Research Domain Criteria(RDoC) project was born of the inability of previous editions of theDSMto achieve both of their ultimate scientific objectives: produce areliable diagnostic codefor clinicians to use, and prove that these diagnoses arevalid(i.e. the measure to which the DSM accurately diagnosis what it claims to diagnose).¹On the one hand, theDSM-IIIandDSM-IVachieved the first objective of insuringreliabilityof the diagnostic constructs across different research and clinical settings through the use of diagnostic criteria, providing a “common language” among clinicians and ensuring “that a diagnosis is both accurate and consistent; for example, that a diagnosis of schizophrenia is consistent from one clinician to another, and means the same thing to both of these clinicians, whether they reside in the United States or other international settings.”²

On the other hand, the objective of establishing thevalidityof the diagnostic categories has not been achieved.¹Unlike definitions of medical illness, such as heart disease or AIDS, “theDSMdiagnoses are based on a consensus about clusters of clinical symptoms, not any objective laboratory measure,” such as found in genetics and brain imaging research.³

Consequently under the leadership of NIMH DirectorThomas Insel, M.D., the institute concluded that a new strategic framework was essential for generating research–unconstrained by theDSMcategories– that will eventually enable health care professionals to diagnose mental disorders as precisely as identifying strep throat by a throat swab. To achieve this goal, the NIMH will place a priority on collecting the imaging, genetic, physiologic and cognitive data on mental disorders–not just the symptoms–and see how they relate to treatment.³In other words, the emphasis will be on the causes of the disorder, not the symptoms.⁴

In this light, the utility of neuroscience and genetic studies on disordered gambling for developing treatment strategies becomes clearer. As Dr. Insel has noted, “Symptoms alone rarely indicate the best choice of treatment.”³For example, a study of the brain’s circuitry rather than a focus on symptoms might suggest which areas of brain are implicated in the impulsivity and poor decision-making of disordered gambling and, therefore, offer a region at which drug treatment can be targeted.^5,6

One critique of RDoC is that the research base has not developed fully enough to supply the data needed to transform diagnosis and treatment. In response to Dr. Insel’s blog about RDoC andDSM-5,David Kupfer, M.D., chair of APA’sDSM-5Task Force, argued that although “efforts like the National Institute of Mental Health’s Research Domain Criteria [RDoC] are vital to the continued progress of our collective understanding of mental disorders,’ the RDoC vision of a system based on biological and genetic markers ‘remains disappointingly distant’ and ‘cannot serve us in the here and now.’⁷It ‘merely hand[s] patients another promissory note that something may happen sometime.”⁷

What do you think of the RdoC approach? Please leave your thoughts or comments in the section below.

The National Center for Responsible Gaming (NCRG) will also be at the APA Annual Meeting from May 17 to 22 as theDSM-5is released. NCRG staff members Christine Reilly, Nathan Smith and Amy Kugler will be live blogging and updating the NCRG’s Facebook and Twitter pages with news and insights. The NCRG will also be at Booth #2128 in the APA Exhibit Hall. Please follow us online or in person as the events unfold at the APA Annual Meeting!

References

1. DSM-5 and the NIMH Research Domain Criteria Project – Psychiatric Times. 2011. Available at: http://www.psychiatrictimes.com/blog/dsm-5/content/article/10168/1842906. Accessed May 6, 2013.

2. American Psychiatric Association. DSM-5 Development. 2010. Available at: www.dsm5.org.

3. Insel T. NIMH Director’s Blog.Transform. Diagn.2013. Available at: http://www.nimh.nih.gov/about/director/2013/transforming-diagnosis.shtml.

4. Belluck P, Carey B. Psychiatry’s New Guide Falls Short, Experts Say.The New York Times. http://www.nytimes.com/2013/05/07/health/psychiatrys-new-guide-falls-short-experts-say.html. Published May 6, 2013. Accessed May 7, 2013.

5. Balodis IM, Kober H, Worhunsky PD, Stevens MC, Pearlson GD, Potenza MN. Diminished frontostriatal activity during processing of monetary rewards and losses in pathological gambling.Biol. Psychiatry. 2012;71(8):749–757. doi:10.1016/j.biopsych.2012.01.006.

6. Potenza MN. Pharmacological approaches to treating pathological gambling. In:What Clinicians Need to Know about Gambling Disorders.Vol 7. Increasing the Odds: A Series Dedicated to Understanding Gambling Addiction. Washington, DC: National Center for Responsible Gaming; 2012:52–60. Available at: http://www.ncrg.org/resources/monographs. Accessed April 30, 2013.

7. American Psychiatric Association. Psychiatric News Alert.David Kupfer Md Responds Crit. Dsm-5 Nimh Dir.Available at: http://alert.psychiatricnews.org/2013/05/david-kupfer-md-responds-to-criticism.html?spref=tw. Accessed May 6, 2013.

NCRG staffResearch UpdateDr. InselDr. KupferDSM-5NIMHRDoC

By now, you’ve probably marked your calendar for the14^thannual NCRG Conference on Gambling and Addictionfrom September 22-24 in Las Vegas. We hope you’ll put one more date on your calendar: June 15 – the deadline to apply for scholarships for the NCRG Conference!

For the third year, the NCRG is offering the need-based scholarship program for anyone interested in attending this year’s NCRG Conference. This is a popular program, so it is best to turn your application in early! Insofar as we are able, it is the NCRG’s wish to provide fair access to the NCRG Conference to all interested stakeholders, especially those in academia and the clinical and public health sectors. In 2012, the NCRG supported almost 30 NCRG Conference attendees. This year, the NCRG will award scholarships to more than 15 individuals and a portion of these scholarships may also include travel assistance. Additional scholarship funds may be available at a later time thanks to the generosity of the NCRG Conference’s sponsors.

To apply for a scholarship, interested applicants must submit their application and registration form byJune 15, 2013,one of three ways:

1. Online at theNCRG’s Conference Scholarship website
2. By email to Christine Reilly (creilly@ncrg.org)
3. By fax, attention Christine Reilly, at 978-522-8452

Applicants must submit two pieces of information:

1. Answers to the following questions in the application document
2. Completed NCRG Conference registration form(Note: By filling out this form, you are not automatically registered for the NCRG Conference. NCRG staff members will give you instructions should you receive a scholarship.)

Applications will be reviewed and applicants will be notified about receipt of a scholarship no later than July 1.

We hope you’ll apply and share this information with interested colleagues around the nation. We look forward to seeing you in Las Vegas!

Questions or comments? Leave them in the comments section below or contact Christine Reilly atcreilly@ncrg.orgor 978-338-6610.

NCRG staffConference on Gambling and AddictionNCRG ConferenceScholarships

Earlier this year, theNCRGandAGAreleased the winter 2013 edition ofResponsible Gaming Quarterly. While developing this edition of RGQ, we had the opportunity to speak in depth with members from theEvergreen Council on Problem Gamblingin Washington state to learn more about the organization and their 2013 initiatives.

Led byExecutive Director Maureen Greeley, the Evergreen Council is dedicated to expanding the availability of services for those affected by gambling disorders and encouraging research and programs for education, prevention and treatment. The Evergreen Council serves as a connection hub for both counseling services and residential treatment options for individuals with a gambling disorder. Its website and the state helpline are resources for individuals and their family members to receive information about in-state counseling services for gambling disorders and other addictions.

Additionally, the council currently is the only source of funding for residential pathological gambling treatment. In order to give individuals the care that they need, the council pays to send patients to neighboring states to receive treatment at residential facilities.

For 2013, the organization also has expanded its contract with the state certification boards to offer more education opportunities for clinicians wanting accreditation to treat those with gambling disorders. Throughout the year, Greeley and her staff will organize two conferences and quarterly trainings that will be attended by mental health practitioners from across the state. (The NCRG partnered with the Evergreen Council for one of those trainings. More information about this will be including in an upcoming blog post).

The Evergreen Council also will host the27th annual conference for the National Council on Problem Gamblingon July 19 and 20.

The organization’s third goal for 2013 is to work with new partners to reach a wider audience with information about gambling disorders, ways to gamble responsibly and resources to use for help. In December 2012, the council launched a new initiative that expanded its prevention programs targeting youth and solicited the help of other non-profit organizations and radio personalities.(Read more about this two-part campaign in the winter 2013 edition of RGQ.)

If you are interested in learning more about the Evergreen Council,click here.

What are some of the initiatives your local organizations are doing to help problem gamblers and promote responsible gaming?

NCRG staffICRG NewsEvergreen Council on Problem Gamblinggambling disorderNCRG Partnerproblem gambling