Impulsivity, implicit attitudes and explicit cognitions, and alcohol dependence as predictors of pathological gambling
Introduction
Gambling is a popular recreational pastime. Annual episodes of gambling in some Western countries have been reported in up to 70−85% of the adult population (Toce-Gerstein et al., 2009). A small group of these gamblers will lose control and escalate into pathological or problematic gambling. The international prevalence of this problem varies between 0.2–5.3% (Hodgins et al., 2011).
In the 5th edition of the DSM “pathological gambling” was relabelled as “gambling disorder” and moved into the Substance–Related and Addictive Disorders section (APA, 2013) due to the underlying aetiology it shares with other addictions (Xavier, 2014).
Several factors are regarded as significant contributors to gambling disorder. Impulsivity is a central one (Blanco et al., 2015), not only for gambling disorder in particular, but also for addictions in general (Holden, 2010). Its standard scores significantly correlate with gambling disorder severity scores (Krueger et al., 2005), and also with vulnerability to the disorder (Leeman et al., 2014, Verdejo-Garcia et al., 2008). Gambling disorder seems to be more related to trait than state impulsivity (Lai et al., 2011), and also more related to choice impulsivity than response impulsivity (Robbins et al., 2012). Another important issue is that, in patients treated for pathological gambling, impulsivity is related to cognitive distortions so that an impulsive decision-making style might increase the chance of unquestioning acceptance of erroneous beliefs (Michalczuk et al., 2011).
Another important factor is the cognitive distortions that play a crucial role in the development and maintenance of gambling disorder (Goodie and Fortune, 2013). The most frequently detected distortions are the “illusion of control” and the “gamblers fallacy”, but others such as “overconfidence”, “trends in number picking”, “near-miss effects”, “self-serving bias” and “impaired control” have also been described (Goodie and Fortune, 2013, Spurrier and Blaszczynski, 2014). At first, the “thinking aloud method” was used to assess these cognitive distortions, but psychometrically validated instruments are now preferred as they have shown discriminant validity (Goodie and Fortune, 2013).
But cognitive distortions, which are explicit and therefore amenable to introspection and deliberate decision making, may not be so central for gambling disorder (Dickerson and Baron, 2000). Several studies suggest that implicit cognitions, which are activated in an automatic way by motivational and situational cues, may play a more important role in addictions, including gambling disorder (McCarthy and Thompsen, 2006, Ostafin et al., 2008, Ostafin and Palfai, 2006, Snagowski et al., 2015, Yen et al., 2011). The Implicit Association Test (IAT) is a tool for assessing implicit attitudes that comes from the social cognition field (Greenwald et al., 2003). This task is of special value when participants deny or are unaware of their true thoughts and feelings (Greenwald et al., 2003). It has been used in the addictions field, including gambling disorder, with promising results (De Houwer et al., 2004, de Jong et al., 2007, Ostafin et al., 2008, Ostafin and Palfai, 2006, Yen et al., 2011).
Finally, as previously mentioned, there is a clear aetiological relationship between gambling disorder and addictions (Blanco et al., 2015). It is no surprise that they have been found to frequently co-occur (Cowlishaw et al., 2014). In particular, alcohol use disorder, with a five to six times higher odds in disordered gamblers versus the general population, is the most common addiction – psychiatric disorder in these patients (Bischof et al., 2013). An association has been found between gambling severity and alcohol consumption (French et al., 2008). Higher levels of impulsivity are detected in alcohol-dependent pathological gamblers (Lister et al., 2015). Gambling, especially when winning, may become a conditioned cue for alcohol use, particularly in gamblers with severe alcohol problems (Zack et al., 2005). This is why an association between winning at gambling and alcohol use has been found using the IAT (Zack et al., 2005).
In light of the literature discussed above, it is reasonable to hypothesise that having a gambling disorder will correlate with impulsivity, explicit cognitive distortions and implicit attitudes related to gambling, as wells as alcohol abuse. This study is the first to examine the relation among these four factors in pathological gamblers.
Section snippets
Participants
The protocol was approved by the Pontevedra-Vigo-Ourense Local Research Ethics Committee (2014/453), and all participants provided written informed consent. The study was conducted in accordance with the Declaration of Helsinki. All participants were recruited as a convenience sample from a government-run out-patient addiction treatment center.
Inclusion criteria for the gambling disorder group were: meeting a lifetime DSM-5 gambling disorder diagnosis with a National Opinion Research Center
Results
Table 1 shows all baseline variables for both groups. The mean age of the control group was higher than the mean age of the gambling disorder group (43.20 (11.80) vs 50.33 (8.38), p =0.001). There were also statistically significant differences in employment status, as the proportion of pensioners was higher in the control group than in the gambling disorder group (13.64% versus 19%, p<0.001).
The IAT score was higher in the control group than in the gambling disorder group (0.75 (0.36) vs 0.51
Discussion
Our results demonstrated a positive relationship between pathological gambling and impulsivity, explicit cognitive distortions and implicit attitudes related to gambling, and to a lesser extent alcohol dependence. But the specific interaction seen among these four domains with pathological gambling, active pathological gambling, and pathological gambling plus alcohol dependence is of greater interest.
Impulsivity assessed with the BIS-11 clearly indicated a difference between pathological
Conflicts of interest
None.
Acknowledgements
This work was supported in part by the Instituto de Salud Carlos III, Centro de Investigación Biomédica en Red de Salud Mental, CIBERSAM.
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