Pathological gambling: an update on neuropathophysiology and pharmacotherapy

The pharmacological management of gambling disorder: if, when, and how

INTRODUCTION

Gambling disorder (GD) consists of a persistent, recurrent pattern of gambling that is associated with substantial distress or impairment. The etiology is multifactorial. GD frequently co-occurs with other psychiatric disorders and is often untreated. Different psychosocial interventions, particularly cognitive-behavioral therapy, are useful in the treatment of GD. Pharmacological therapy may also be helpful . No formal guidelines exist, and the management of the disease is often guided by few clinical elements.

AREAS COVERED

A literature search was performed using PubMed, Scopus, and Web of Science databases about treatment options for GD, considering both psychosocial treatments and available pharmacological ones.

EXPERT OPINION

The authors address whether and when it is appropriate to initiate pharmacological treatment for GD. They focus on providing clinicians with guidance on how to approach patients with GD in those situations where pharmacological therapy may be necessary. The reasons for the clinician to start thinking about a medication are examined. As specific traits in the psychopathology of GD may be managed with a strategic choice of the pharmacologic agent, the different available options are analyzed on the basis of their potential usefulness in GD. Issues that remain open about the pharmacological management of GD are summarized.

Habitual versus affective motivations in obsessive-compulsive disorder and alcohol use disorder

OBJECTIVE

To (1) confirm whether the Habit, Reward, and Fear Scale is able to generate a 3-factor solution in a population of obsessive-compulsive disorder and alcohol use disorder (AUD) patients; (2) compare these clinical groups in their habit, reward, and fear motivations; and (3) investigate whether homogenous subgroups can be identified to resolve heterogeneity within and across disorders based on the motivations driving ritualistic and drinking behaviors.

METHODS

One hundred and thirty-four obsessive-compulsive disorder (n = 76) or AUD (n = 58) patients were assessed with a battery of scales including the Habit, Reward, and Fear Scale, the Yale-Brown Obsessive-Compulsive Scale, the Alcohol Dependence Scale, the Behavioral Inhibition/Activation System Scale, and the Urgency, (lack of ) Premeditation, (lack of ) Perseverance, Sensation Seeking, and Positive Urgency Impulsive Behavior Scale.

RESULTS

A 3-factor solution reflecting habit, reward, and fear subscores explained 56.6% of the total variance of the Habit, Reward, and Fear Scale. Although the habit and fear subscores were significantly higher in obsessive-compulsive disorder (OCD) and the reward subscores were significantly greater in AUD patients, a cluster analysis identified that the 3 clusters were each characterized by differing proportions of OCD and AUD patients.

CONCLUSIONS

While affective (reward- and fear-driven) and nonaffective (habitual) motivations for repetitive behaviors seem dissociable from each other, it is possible to identify subgroups in a transdiagnostic manner based on motivations that do not match perfectly motivations that usually described in OCD and AUD patients.

[Problematic gambling and criminal responsibility]

OBJECTIVES

In total, 14% to 30 % of individuals with gambling disorder engage in illegal acts to finance such behavior. This clinical situation could be explained by higher gambling severity, associated substance use disorder, antisocial personality disorder and economic factors (debts, financial problems). The present work focuses, more broadly, on criminal responsibility of problematic gamblers.

METHODS

We will discuss this question through different typical situations that medical experts of criminal responsibility may have to face. We will address each of the following cases: 1) isolated problematic gambling; 2) problematic gambling associated with antisocial personality disorder; 3) problematic gambling associated with a manic episode; 4) problematic gambling associated with substance use disorders; and 5) problematic gambling associated wiht dopamine agonist treatment.

RESULTS

Isolated problematic gambling, (not associated with any psychiatric or addictive disorder): it seems consensual that individuals committing infractions in this case are criminally responsible. However, impeded ability to action control and possible sentence attenuation could be discussed in case of severe gambling disorder. Problematic gambling associated with antisocial personality disorder: if the penal offence reports solely to personality disorder, criminal responsibility would be attributed. However, if illegal or violent acting is directly linked to co-cocurrent delusional symptoms, it could be a cause of criminal non-responsibility. Problematic gambling associated with manic episode: manic episode related offence could lead to negation of criminal responsibility, while a hypomanic episode may provide grounds for sentence reduction. Problematic gambling associated with substance use disorders: in France, addiction is not considered to remove nor to impede a person's ability to understand or control his actions and is excluded from criminal non-responsibility causes. However, substance induced delusional or confusional episodes could abolish a subject's discernment or his ability to control his actions yielding to penal non-responsibility. Problematic gambling associated with dopamine agonist treatment: Criminal responsibility for dopamine agonist induced gambling related illegal acts is still controversial. Nevertheless, people committing an infraction linked to associated dementia or dopamine agonist induced mania should be considered as criminally non-responsible.

CONCLUSIONS

Some clinical dimensions such as craving intensity, compulsivity, disorder's severity, volitional control might be forensic targets to assess criminal responsibility.

Clustering of treatment-seeking women with gambling disorder

BACKGROUND

The prevalence of gambling disorder (GD) in women has increased, but, to date, few studies have explored the features of clinical GD subtypes in female samples.

AIMS

The aim of this study is to identify empirical clusters based on clinical/sociodemographic variables in a sample of treatment-seeking women with GD.

METHODS

Agglomerative hierarchical clustering was applied to a sample of n = 280 patients, using sociodemographic variables, psychopathology, and personality traits as indicators for the grouping procedure.

RESULTS

Three mutually exclusive groups were obtained: (a) Cluster 1 (highly dysfunctional; n = 82, 29.3%) endorsed the highest levels in gambling severity, comorbid psychopathology, novelty seeking, harm avoidance, and self-transcendence, and the lowest scores in self-directedness and cooperativeness; (b) Cluster 2 (dysfunctional; n = 142, 50.7%) achieved medium mean scores in gambling severity and psychopathological symptoms; and (c) Cluster 3 (functional; n = 56, 20.0%) obtained the lowest mean scores in gambling severity and in psychopathology, and a personality profile characterized by low levels in novelty seeking, harm avoidance, and self-transcendence, and the highest levels in self-directedness and cooperativeness.

DISCUSSION AND CONCLUSIONS

This study sheds light on the clinical heterogeneity of women suffering from GD. Identifying the differing features of women with GD is vital to developing prevention programs and personalized treatment protocols for this overlooked population.

An Ecological Approach to Electronic Gambling Machines and Socioeconomic Deprivation in Germany

In Germany, gambling research has primarily focused on the broader population in prevalence studies, neglecting the importance and influence of the local socioeconomic context in the development and maintenance of gambling disorders. To analyze the interplay between contextual and compositional factors in the market for electronic gambling machines (EGMs) in Germany, we assessed the EGM densities and socioeconomic deprivation in 244 local communities within Baden-Wuerttemberg. Our results suggest that EGM density is statistically associated with 3 socioeconomic determinants: The shares of migrants, unemployed, and high-school-educated people in the communities are statistically significant variables in our linear regression model, whereas younger age, male gender, and marital status exhibit no statistical associations with EGM density. The share of unemployed people is the only variable of statistical and practical significance. Our analysis advocates area-based policy measures to minimize gambling-related harm. By decreasing EGM densities in communities with high levels of unemployment, we expect to protect at-risk population strata that are most vulnerable to gambling exposure.

Interventions for comorbid problem gambling and psychiatric disorders: Advancing a developing field of research

Despite significant psychiatric comorbidity in problem gambling, there is little evidence on which to base treatment recommendations for subpopulations of problem gamblers with comorbid psychiatric disorders. This mini-review draws on two separate systematic searches to identify possible interventions for comorbid problem gambling and psychiatric disorders, highlight the gaps in the currently available evidence base, and stimulate further research in this area. In this mini-review, only 21 studies that have conducted post-hoc analyses to explore the influence of psychiatric disorders or problem gambling subtypes on gambling outcomes from different types of treatment were identified. The findings of these studies suggest that most gambling treatments are not contraindicated by psychiatric disorders. Moreover, only 6 randomized studies comparing the efficacy of interventions targeted towards specific comorbidity subgroups with a control/comparison group were identified. The results of these studies provide preliminary evidence for modified dialectical behavior therapy for comorbid substance use, the addition of naltrexone to cognitive-behavioral therapy (CBT) for comorbid alcohol use problems, and the addition of N-acetylcysteine to tobacco support programs and imaginal desensitisation/motivational interviewing for comorbid nicotine dependence. They also suggest that lithium for comorbid bipolar disorder, escitalopram for comorbid anxiety disorders, and the addition of CBT to standard drug treatment for comorbid schizophrenia may be effective. Future research evaluating interventions sequenced according to disorder severity or the functional relationship between the gambling behavior and comorbid symptomatology, identifying psychiatric disorders as moderators of the efficacy of problem gambling interventions, and evaluating interventions matched to client comorbidity could advance this immature field of study.

Pathological Gambling Associated With Aripiprazole or Dopamine Replacement Therapy: Do Patients Share the Same Features? A Review

BACKGROUND

In the last 10 years, dopamine replacement therapy (DRT) has become a well-known risk factor for developing an impulse control disorder, such as gambling disorder (GD). Another medication, aripiprazole (ARI), has been more recently identified as another risk factor. Dopamine replacement therapy and ARI share a dopamine agonist action. Our work aimed at comparing patients with PG according to their treatment with DRT or ARI.

METHODS

Two methods were combined-a systematic review concentrated on case reports and the analysis of a French disordered gamblers cohort focused on patients using ARI or DRT at inclusion.

RESULTS

We reported 48 cases of GD possibly due to DRT and 17 cases of GD possibly due to ARI. Because of their standardized assessment, only the EVALJEU patients could be compared. Two clinical patterns emerged. Patients in the ARI group were young, impulsive, and high novelty seekers and had a history of substance misuse. Their first gambling experience occurred during adolescence. Conversely, patients in the DRT group were old, and they began gambling late in life. They showed low levels of gambling-related cognition.

CONCLUSIONS

Patients in the ARI group seemed to be more severe pathological gamblers than patients in the DRT group. Aripiprazole is a partial D2 receptor agonist, whereas DRT includes full D2 receptor agonist. The trigger mechanism of PG development is complex and cannot only be attributed only to the pharmacodynamic effects of dopaminergic drugs. Indeed, individual vulnerability factors and environmental factors need to be considered.

Pharmacotherapy and group cognitive behavioral therapy enhance follow-up treatment duration in gambling disorder patients

BACKGROUND

Longer treatment duration is important for the successful treatment of gambling disorder (GD). This retrospective study investigated the factors and interventions that might enhance treatment duration in GD patients in South Korea.

METHODS

A total of 758 outpatients with a primary diagnosis of GD, who were treated in a clinical practice from 2002 to 2011, were assessed by retrospective chart review. We compared the treatment duration according to pharmacotherapy and group cognitive behavioral therapy (CBT).

RESULTS

Pharmacotherapy contributed to a longer duration of treatment maintenance, despite the patients' gambling severity (p < 0.001). Participation in group CBT (p < 0.001) and antidepressants (p = 0.009) were associated with a longer treatment duration after adjusting for age, depression, and gambling severity. The treatment maintenance duration was the longest in those receiving combined antidepressant pharmacotherapy and group CBT (F = 35.79, p < 0.001).

CONCLUSIONS

Group CBT and antidepressants seem to enhance treatment follow-up duration in GD patients. Additional studies are needed to advance GD prevention and treatment strategies.

Anger in pathological gambling: clinical, psychopathological, and personality correlates

The aim of this study was to explore the association between pathological gambling (PG) and anger by assessing whether psychopathology and personality are related to PG and to evaluate gender differences. The sample comprised 71 PGs and 37 healthy controls. Anger, psychopathology and personality were assessed with the STAXI-2, SCL-90-R and TCI-R respectively. Gender did not affect anger expression after stratifying by diagnostic condition (p > .05). Among PG patients, anger, psychopathology and personality measures were correlated with good effect-size (r > .30). Scores in the Anger Temperament (B = 0.21, p = .038) and Anger External-Expression (B = 0.27, p = .029) scales were positively associated with PG severity scores. Anger expression in PG should be considered in future treatment programs.

Obsessive-compulsive aspects and pathological gambling in an Italian sample

INTRODUCTION

Gambling behaviour appears as repetitive and difficult to resist and seems to be aimed at neutralizing or reducing negative feelings such as anxiety and tension, confirming its similarities with the obsessive-compulsive spectrum. Aims. Estimating the prevalence of gambling behaviour in an Italian sample and assessing the effects of sociodemographic variables and the correlations between gambling behaviour and obsessive-compulsive features.

METHODS

A sample of 300 Italian subjects was evaluated based on gambling behaviours and obsessive-compulsive attitudes. The assessment was carried out in small centers in Italy, mainly in coffee and tobacco shops, where slot machines are located, using the South Oaks Gambling Screen (SOGS) and the MOCQ-R, a reduced form of Maudsley Obsessional-Compulsive Questionnaire.

RESULTS

A negative correlation between SOGS and MOPQ-R, with reference to the control and cleaning subscales, was evidenced in the majority of the examined subjects. Both evaluating instruments showed reliability and a good discriminative capacity.

CONCLUSIONS

Our study evidenced that the sample of gamblers we analysed did not belong to the obsessive-compulsive disorders area, supporting the validity of the model proposed by DSM-5 for the classification of PG. These data confirm the importance of investing in treatments similar to those used for substance use disorders.

The latest achievements in the pharmacotherapy of gambling disorder

Gambling disorder (GD) is becoming increasingly prevalent both among adults and adolescents. Unfortunately, this disorder is largely underestimated, while it can still lead to serious social and personal consequences, including criminal behavior or suicide attempts. In the past, the only means of treating gambling were psychobehavioral therapies. Nowadays, this disorder could also respond to many drugs from different classes such as opioid antagonists, serotonin selective reuptake inhibitors, mood stabilizers, atypical antipsychotics or glutamatergic agents. This review presents current pharmacological strategies and the results of clinical trials evaluating the efficacy of pharmacotherapy for GD. It also discusses the importance of distinguishing different pathological gambler subtypes such as impulsive, obsessive-compulsive and addictive subtypes as this may have serious pharmacological implications.

Differences between early-onset pathological gambling and later-onset pathological gambling: data from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC)

AIMS

To examine differences between early-onset versus later-onset pathological gamblers in socio-demographic characteristics, rates of Axis I and II disorders, preferred type of gambling and rates of treatment-seeking in a large nationally representative survey of adults in the United States.

DESIGN

Data were collected from face-to-face interviews using the Alcohol Use Disorder and Associated Disabilities Interview Schedule DSM-IV version IV (AUDADIS-IV). SETTING AND MEASUREMENT: The study drew on data from the United States' National Epidemiologic Survey on Alcohol and Related Conditions (NESARC).

PARTICIPANTS

All individuals with a DSM-IV diagnosis of pathological gambling (PG). To be consistent with prior studies, age of onset of PG was dichotomized as 25 years and younger (early-onset) versus 26 years and older (later-onset).

FINDINGS

Individuals with early-onset PG were more likely than individuals with later-onset PG to be male [odds ratio (OR) = 2.86; 95% confidence interval (CI) = 1.20, 6.82], never married (OR = 3.51; 95% CI = 1.39, 8.84), to have income below US$70 000 (OR = 0.09; 95% CI = 0.01, 0.61), to belong to younger cohorts (OR = 0.93; 95% CI = 0.89, 0.97) and to have a cluster B personality disorder (OR = 4.11; 95% CI = 1.77, 9.55), but less likely to have a mood disorder (OR = 0.42; 95% CI = 0.19, 0.94). There were no differences between individuals with early- and later-onset PG regarding rates of treatment-seeking (OR = 0.71; 95% CI = 0.20, 2.43) or preferred type of gambling (OR = 2.00; 95% CI = 0.55, 7.3). All results remained significant after adjusting for age, sex and race, except the difference in the prevalence for mood disorders, which was no longer significant.

CONCLUSIONS

Individuals with early-onset versus later-onset pathological gambling differ in several socio-demographic and clinical characteristics, but not in their preferred types of game. Individuals from more recent cohorts appear to be at significantly increased risk for developing early-onset pathological gambling.

Professional and pathological gamblers: similarities and differences

Although much recent research has focused on the gambling practices and psychosocial functioning of pathological gamblers, few investigations have examined the characteristics of professional gamblers. The current project sought to address this gap in the literature by conducting a quantitative comparison of professional and pathological gamblers. Pathological gamblers were recruited and balanced with professional gamblers on demographic variables and preferred gambling activity. A total of 22 professional gamblers and 13 pathological gamblers completed an extensive self-report battery including instruments assessing demographics, gambling behaviors and problems, other psychiatric disorders, current psychosocial functioning, recent stressful events, personality characteristics, and intelligence. Pathological and professional gamblers reported similar rates of gambling frequency and intensity and types of games played. Pathological gamblers endorsed poor psychosocial functioning, whereas professional gamblers reported a rate of psychiatric distress within a normative range. Pathological gamblers also reported lower gambling self-efficacy, greater impulsivity, and more past-year DSM-IV Axis I disorders than professional gamblers. The results of the present study shed light on the unique circumstances of professional gamblers, as well as underscore important differences between such individuals and pathological gamblers that could prove fruitful in future research and intervention and prevention efforts.

Treatment of Gambling Problems in Asia: Comprehensive Review and Implications for Asian Problem Gamblers

Much research has been conducted in the treatment of gambling problems. However, very little is reported specifically on treating Asian problem gamblers. Thus, this article reviewed the general problem gambling treatment literature as well as the limited Asian problem gambling treatment literature to provide a discussion of interventions that can be used with Asian problem gamblers. The general literature showed that behavioral, cognitive, and combined cognitive behavioral treatments (CBT) have the most treatment outcome literature and appear to be the most effective in treating gambling problems. Although, pharmacotherapy also looks promising, it may be more suitable for problem gamblers with comorbid mood problems or impulsivity. Research on other forms of treatments also exists (e.g., 12-step and psychodynamic treatment approaches) but are not as robust. Only three studies have reported on the effectiveness of treatment with Asian problem gamblers. The first study is case study. The second study presents data from a treatment program for Asian problem gambling and the last one presents preliminary findings of a telephone delivered treatment program with eight Asian American gamblers. These studies support the general treatment literature in showing that CBT and pharmacotherapy have a role to play in treating Asian problem gamblers. Based on the general and Asian problem gambling treatment literature, a discussion of treatment of Asian problem gamblers is provided including the use of CBT and other forms of treatment, issues to address in treatment, and variables that can assist treatment.

Football gambling three arm-controlled study: gamblers, amateurs and laypersons

BACKGROUND

Football (soccer) betting, as a strategic form of betting, became one of the favorite wagers for pathological gamblers. Previous studies demonstrated the psychological and biological significance of the 'illusion of control' (personal control) and 'near miss' results in gambling. In our study, we explored whether knowledge and expertise of pathological sports gamblers can ensure a successful bet.

SAMPLE AND METHODS

Participants were divided into three groups of individuals - pathological gamblers, amateurs and laypersons - and were asked to predict in advance the general result and the exact result of football matches in the European Champions League Round of 16.

RESULTS

The 165 participants included 53 pathological sports gamblers (52 males and 1 female), 78 laypersons (45 females and 33 males) and 34 amateurs (all males). After a thorough statistical analysis, we found no significant differences between the groups, no matter what kind of previous knowledge they had acquired.

CONCLUSION

This study demonstrates that the 'illusion of control' of pathological gamblers, attained by knowledge of the game and its latest data and information (especially in a strategic gamble as football betting), has no factual background. Moreover, our study demonstrates without a doubt that there is no significant difference between the male pathological sports gamblers group and the male/female laypersons group.

Effect of executive functioning, decision-making and self-reported impulsivity on the treatment outcome of pathologic gambling

BACKGROUND

Impairments in self-regulatory behaviour reflect a deficit in executive functioning and decision-making, as well as higher levels of self-reported impulsivity, and may be involved in the development and maintenance of addictive disorders. We sought to explore the association between self-reported impulsivity and neurocognitive measures, and their association with treatment outcome in pathologic gambling.

METHODS

We assessed patients with pathologic gambling using executive functioning and decision-making tests and self-report measures of impulsivity. Patients underwent cognitive-behavioural therapy (CBT) for pathologic gambling.

RESULTS

We included 88 patients (8% women) in our study. High self-reported extravagance was associated with poor performance in the Iowa Gambling Task (IGT)-ABCD version. High impulsiveness, low disorderliness, high exploratory excitability (trend), poor backward block span and poor IGT-EFGH scores (trend) predicted dropout. We observed no self-reported or neurocognitive predictors of relapse or number of treatment sessions attended.

LIMITATIONS

Most participants were slot-machine gamblers seeking treatment. No follow-up data and no control group were included in the study. The missing sample (i.e., individuals who were recruited and assessed in the pretreatment stage but who chose not to begin treatment) had higher extravagance scores than the final sample.

CONCLUSION

Neurocognitive reward sensitivity was related to self-reported overspending behaviour. Self-regulatory impairments (especially rash impulsiveness and punishment sensitivity) and executive dysfunction predicted only dropout of CBT in participants with pathologic gambling. Different neurocognitive processes and personality traits might mediate treatment response to psychological therapy of pathologic gambling according to the specific target variable assessed.

Impulse control disorders: updated review of clinical characteristics and pharmacological management

Impulse control disorders (ICDs) are characterized by urges and behaviors that are excessive and/or harmful to oneself or others and cause significant impairment in social and occupational functioning, as well as legal and financial difficulties. ICDs are relatively common psychiatric conditions, yet are poorly understood by the general public, clinicians, and individuals struggling with the disorder. Although ICD treatment research is limited, studies have shown ICDs may respond well to pharmacological treatment. This article presents a brief overview about the clinical characteristics of ICDs and pharmacological treatment options for individuals with ICDs.

Acamprosate and Baclofen were Not Effective in the Treatment of Pathological Gambling: Preliminary Blind Rater Comparison Study

OBJECTIVES

Pathological gambling (PG) is a highly prevalent and disabling impulse control disorder. A range of psychopharmacological options are available for the treatment of PG, including selective serotonin reuptake inhibitors, opioid receptor antagonists, anti-addiction drugs, and mood stabilizers. In our preliminary study, we examined the efficacy of two anti-addiction drugs, baclofen and acamprosate, in the treatment of PG.

MATERIALS AND METHODS

Seventeen male gamblers were randomly divided into two groups. Each group received one of the two drugs without being blind to treatment. All patients underwent a comprehensive psychiatric diagnostic evaluation and completed a series of semi-structured interviews. During the 6-months of study, monthly evaluations were carried out to assess improvement and relapses. Relapse was defined as recurrent gambling behavior.

RESULTS

None of the 17 patients reached the 6-months abstinence. One patient receiving baclofen sustained abstinence for 4 months. Fourteen patients succeeded in sustaining abstinence for 1-3 months. Two patients stopped attending monthly evaluations.

CONCLUSION

Baclofen and acamprosate did not prove efficient in treating pathological gamblers.

Age of onset in pathological gambling: clinical, therapeutic and personality correlates

We aimed to explore the association between age of onset of gambling problems and current psychopathological and clinical status, personality profile and therapeutic outcome in a sample of pathological gamblers. A total of 904 consecutive pathological gambling patients were administered several instruments about gambling behavior, psychopathology and personality. They received a 4-month cognitive-behavioral group treatment. Information of dropouts and relapses during treatment was registered. Older age of onset of gambling problems was associated with higher general psychopathology (SCL-90-R Paranoid Ideation, Psychoticism, Depression; P < 0.015). Younger age of onset was related to greater severity of pathological gambling (P < 0.015), higher novelty seeking, and lower self-directedness (P < 0.015). No statistically significant association was found between age of onset and relapse and dropouts during treatment. Age of onset of gambling problems seems to influence the clinical presentation of pathological gambling but not treatment outcome.

Subtyping study of a pathological gamblers sample

OBJECTIVE

To classify into subgroups a sample of pathological gambling (PG) patients according to personality variables and to describe the subgroups at a clinical level.

METHOD

PG patients (n = 1171) were assessed with the South Oaks Gambling Screen; the Temperament and Character Inventory-Revised; the Symptom Checklist-90-Revised; Eysenck's Impulsivity Scales, a diagnostic questionnaire for the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) PG criteria; and the Structured Clinical Interview for the DSM-IV, Axis I disorders, substance use module. Clinical measures were collected through a semi-structured interview. We performed a 2-step cluster analysis based on the above-mentioned personality variables. Clinical data were compared across clusters.

RESULTS

Four clusters were generated. Type I (disorganized and emotionally unstable) showed schizotypic traits, high impulsiveness, substance and alcohol abuse, and early age of onset, as well as psychopathological disturbances. Type II (schizoid) showed high harm avoidance, social aloofness, and alcohol abuse. Type III (reward sensitive) showed high sensation seeking and impulsiveness but no psychopathological impairments. Type IV (high-functioning) showed a globally adaptive personality profile, low level of substance and alcohol abuse or smoking, and no psychopathological disturbances.

CONCLUSIONS

At least 4 types of PG patients may be identified. Two types showed a response modulation deficit, but only one of them had severe psychopathological disturbances. Two other types showed no impulsiveness or sensation seeking and one of them even exhibited good general functioning. The different personality and clinical configuration of these clusters might be linked to different therapeutic approaches.

Noradrenergic function in pathological gambling: blunted growth hormone response to clonidine

The noradrenergic system has been linked to impulsive behaviour in animals and humans, yet little data on noradrenergic system exist in specific impulse control disorders. To explore the role of the noradrenergic system in pathological gamblers (PG), we assessed neuroendocrine growth hormone (GH) response to the alpha2-adrenergic receptor agonist clonidine and placebo in PG and controls. The net effects of clonidine are a decrease in neurotransmission by depressing locus coeruleus activity and stimulation of GH secretion through activation of post-synaptic alpha2-adrenergic receptors in the hypothalamus. Twenty-nine PG subjects, free of other comorbid conditions, and 27 healthy controls received a double-blinded, placebo-controlled, single dose of oral clonidine (0.15 mg/kg). Data observed included GH, clonidine levels and levels of the main noradrenergic metabolite, 3-methoxy-4-hydroxy-phenylglycol (MHPG). The area under the curve for GH response to clonidine was significantly lower (separate variance t with 44.3 df = 2.626, P = 0.012, d = 0.58) in the PG group (199.6) than in the control group (426.3). PG had significantly blunted GH responses compared with controls at 120 and 150 min post-clonidine. These results are consistent with the idea that the subsensitivity of post-synaptic alpha-2 receptors is possibly attributable to higher-than-normal noradrenergic secretion in PG. This peripheral noradrenergic dysfunction could be consistent with attenuated cortico-frontal noradrenergic function as shown in positron emission tomography (PET) studies of PG.

Dopamine dysregulation syndrome: an overview of its epidemiology, mechanisms and management

Dopamine dysregulation syndrome (DDS) is a relatively recently described iatrogenic disturbance that may complicate long-term symptomatic therapy of Parkinson's disease. Patients with DDS develop an addictive pattern of dopamine replacement therapy (DRT) use, administering doses in excess of those required to control their motor symptoms. The prevalence of DDS in patients attending specialist Parkinson's disease centres is 3-4%. Amongst the behavioural disturbances associated with DDS are punding, which is a complex stereotyped behaviour, and impulse control disorders (ICDs), such as pathological gambling, hypersexuality, compulsive shopping and compulsive eating. We review the risk factors and potential mechanisms for the development of DDS, including personality traits, potential genetic influences and Parkinson's disease-related cognitive deficits. Impulsive personality traits are prominent in patients developing DDS, and have been previously associated with the development of substance dependence. Candidate genes affecting the dopamine 'D(2)-like' receptor family have been associated with impulsive personality traits in addition to drug and nondrug addictions. Impaired decision making is implicated in addictive behaviours, and decision-making abilities can be influenced by dopaminergic medications. In Parkinson's disease, disruption of the reciprocal loops between the striatum and structures in the prefrontal cortex following dopamine depletion may predispose to DDS. The role of DRT in DDS is discussed, with particular reference to models of addiction, suggesting that compulsive drug use is due to progressive neuroadaptations in dopamine projections to the accumbens-related circuitry. Evidence for neuroadaptations and sensitization occurring in DDS include enhanced levodopa-induced ventral striatal dopamine release. Levodopa is still considered the most potent trigger for DDS in Parkinson's disease, but subcutaneous apomorphine and oral dopamine agonists may also be responsible. In the management of DDS, further research is needed to identify at-risk groups, thereby facilitating more effective early intervention. Therefore, an increased awareness of the syndrome amongst treating physicians is vital. Medication reduction strategies are employed, particularly with regard to avoiding rapidly acting 'booster' DRT formulations. Psychosocial treatments, including cognitive-behavioural therapy, have been beneficial in treating substance use disorders and ICDs in non-Parkinson's disease patients, but there are currently no published trials of psychological interventions in DDS. Further studies are also required to identify factors that can predict those patients with DDS or ICDs who will derive benefit from surgical interventions such as deep brain stimulation.

Suicide, misappropriation and impulsivity

OBJECTIVE

To describe a patient who survived a suicidal act in which lethal means were used and who subsequently cooperated with psychiatric examination.

METHOD

Case report.

RESULTS

A 22-year-old man jumped from a bridge into the water 49 m below and survived. He was admitted to hospital for assessment. No psychiatric diagnosis could be made on either Axis I or II. He had misappropriated money and lost it gambling, and detection was imminent. He described his jumping as being the result of a sudden impulse. While he was falling he changed his mind and assumed an appropriate diving posture with the intention of preventing his death.

CONCLUSIONS

This is an example of a person performing a highly lethal suicide act, in the absence of Axis I or II disorder. Threat of disgrace and possible prosecution; and impulsivity were significant factors.