Good afternoon everybody. I'm Antoine Douai. I'm going to be presenting today on gambling disorder and other related disorders. This is some of the information about me. I'm a professor of psychiatry and medicine at the University of Pittsburgh School of Medicine. I'm an addiction psychiatrist and I've done patient care and continue to do patient care education dissemination science advocacy and research in the field of addiction and psychology of change. Today we're going to be reviewing the gambling disorder and the focus will be on that. These are my disclosures and research grants from funding that I get from NIDA, NIMH, SAMHSA, HRSA, CDC, AFSP and also I get royalties for academic books that were published by Oxford University Press, PSI Publishing and Springer and also royalties from Oakstone CME. Learning objectives. At the conclusion of this presentation the participants will be able to, there's going to be a few objectives here that we're going to try to meet here. Define and better understand gambling behaviors and gambling disorder, GD. I'm going to refer to that on a regular basis and learn about the epidemiology of GD. Summarize the etiology and risk factors related to GD. Describe the genetic and neurobiological changes implicated in the pathophysiology of GD. Identify the co-occurring psychiatric disorders with GD and how to screen and assess for gambling problem and diagnose GD based on DSM-5 criteria. And I will be reviewing also the pharmacological as well as psychosocial interventions for gambling disorder and also briefly discuss and recognize the non-substance-related conditions or behavioral addictions. What is gambling? So let me start with a little bit of a context here to what our presentation is going to be and just to give some definitions here and some really context as I mentioned. Gambling itself is an activity in which something of value is risk on the outcome of an event when the probability of winning and losing is less than certain. Totally uncertain probability. Gambling disorder GD is a term that is used in the fifth edition of the Diagnostic and Statistical Manual of Psychiatric Disorders, the DSM-5, to define a particular persistent and recurrent pattern of gambling, very compulsive in nature, that is associated with significant distress, impairment, and negative consequences. And if you look at older studies and the definition of GD was really started out early on in the third and fourth edition of the DSM as pathological gambling. And this is really interesting because we have really evolved determining more the pathological gambling as really more of a gambling disorder. Pathological gambling has that sort of really pejorative connotation too. So in DSM-5, the pathological gambling was moved to the substance-related and addictive disorders to acknowledge that it is associated with alcohol and drug addictions. So there are some commonalities that you can see with alcohol and drug addiction. That's why they ended up moving the pathological gambling into the substance-related and addictive disorders. Gambling has recreation. It has different forms. It's been a part of the history of the world. I mean, very old. The 48 states have some sort of legalized recreational gambling. And I'm not sure even now there are more than 48 states, but it's presented in the form of bingo, lottery, racetracks, slots, poker, table games, sports betting, and e-sports. This is really exploding. And you see it a lot with younger people. And so we need to keep that in mind. The expansion, when it comes to the online gambling, which also has expanded exponentially too, it's unregulated. And in fact, technically restricted and under contention in the US. And the regulations obviously are changing rapidly, as you can see, for example, with the legalizing marijuana. Some of the states have passed legislation to allow online gambling, while in-state and the sports betting. All right, to go back here. And the sports betting is now legal in 37 states, probably Washington, D.C. So the gambling, and this is fascinating also from the psychology of the gambling itself, the gambling ambivalence and distortion. I mean, if you look at some, I mean, these are some numbers that I wanted to share with you about really the mathematical odds of getting dealt. The Royal Flush, you know, is like one in 649,000. You know, the mathematical odds of becoming president of the U.S., one in basically 10 million, you know. And just to give you an idea about that, you know, there is that sort of a distortion that people, you know, believe, you know, that they're gonna be eventually winning, you know. And, but if you look at the differences in terms of chances of being murdered, one in 18,000, you know, and the chances of winning a Mega Millions lottery is really so slim, so slim. And recreation, and again, the word recreation is a little bit also pejorative in nature, but I'll tell you, like maybe gambling behaviors would be better than recreation, but I kept using, you know, kept reading kind of the recreation word here, you know, terms, you know, that are used. 80s doesn't mean it's not without risk. You know, 85% of U.S. adults have gambled at least one in their lifetimes. Three to 5%, depends on the studies and methodological challenges, you know, have a GD. You know, it goes from 0.12 to 5.8, you know. I mean, obviously it fluctuates, but it's around that range. It's believed that most people can gamble without necessarily negative consequences, but with the onset of online gambling, more people are exposed than before, and the risk is not totally clear at this time. Okay, so what are the characteristics of low-risk gambling? You know, the low-risk gamblers know that over time, nearly everyone loses, and the benefit is in the social and entertainment activity, you know, not the expectation of financial gains, and it has limit on frequency and duration. It's predetermined, acceptable, limits for losses as in the acceptable and affordable cost of an entertainment activity. So people are able to really, in a sense, you know, do it in an acceptable range, and they preset, and they predetermine for themselves. So the question is, what are the odds of having gambling disorders? You are now using the word odds, you know, and it's hypothesized to be very much of a complex interplay that has been caused by really multiple components involving following risk factors, neurobiological, genetic, psychological, and social. So it's a very complex, very multifactorial, you know, multidimensional. There is evidence of associations between GD and a variety of neurotransmitters that I'll talk about in a little bit, like norepinephrine, serotonin, glutamate, dopamine, endorphins, which kind of really, in a sense, let a lot of the research that we see in the field to explore, you know, medications that would manipulate these neurotransmitters. So what do we know about the risk factors for GD? And this is really important. There are more and more studies looking at that, you know, and whether risk factors, vulnerable populations, I'll talk about it in a second, too. The accessibility and the awareness, you know, and this is kind of these, there are theories that are related to exposure and adaptations. Early exposure is very risky, lack of community awareness of the dangers, the social acceptance, social-cultural acceptance, family history of addiction and or illegal activity, competitive home environment, family history of gambling activity and attitudes, and poor impulse control. Who would be considered as vulnerable populations, you know, that put them at really high risk of developing, you know, gambling disorder? Close to 3% to 8% of adolescent and college students exhibit problem and, again, problem, you know, gambling, you know, and gambling disorder. You know, I'm talking about really some kind of behaviors that do not necessarily meet gambling disorder. Student athletes are particularly vulnerable. It affects all races. Differences are found in the type of games that are played, beliefs about the money, finance, and self-worth, but it's all races. There's disproportionate number of people who smoke, have substance use disorders, psychiatric disorders, you know, that put them at really kind of in the category of vulnerable populations. See more men than women. The people come from low income and socioeconomic status, a high school education or less, and single young male or married for less than five years is really kind of fits under the category of the vulnerable population. You can ask me why. I mean, it's not totally really clear. So in terms of the vulnerable populations, the adolescents, 5% to 6% meet the criteria. Older adults, adolescent and young adults, older adults, there's an increase in gambling and retirement, harder to recoup financial losses. In the military, all branches run overseas slots for recreation to make money, also for social events and the casino workers, you know, and there's always a question of the chicken or the egg, you know, which is really fascinating. I wanna really point out, I'm gonna repeat that over and over again. I mean, talk about the smoking or tobacco use in general. You know, people who smoke heavily early on usually report that they began smoking in adolescence. I mean, tobacco use is sort of considered like a pediatric illness in a sense. The people who have gambling problems often report that they began also gambling in adolescence. So there is some sort of similarities here, and there's a possible links between the smoking and gambling among youth. So in terms of the early smoking and gambling onset, among those who reported smoking regularly, those who reported at risk or problematic gambling were more likely to have been smoking daily earlier. They also tended to smoke more cigarettes per day, you know, more kind of from the moderate and heavy side of the tobacco use disorder. And those at risk for problems with gambling were more likely to have tried smoking at least once in the past. So the other learning objective now that we want to review is the genetics and neurobiology of GD. So in terms of the neurobiology, I mean, this is really fascinating. It's evolving, you know, and really the field is really moving along at the same time. You know, we still got a lot of things that we do not really know about the neurobiological mechanism that really would explain the pathophysiology of gambling disorders. Implicated brain regions include the ventral prefrontal cortex, you know, cortices, including the medial and lateral orbitofrontal, you know, parts of it, the medial prefrontal cortex and the adjacent anterior cingulate cortex, the striatum, you know, plays a role, amygdala, the whole kind of really amygdala, which is really kind of includes different parts, you know, of the brain, hippocampus and insula. So you see that there's a lot of complexity of how many really systems, you know, and how many regions are involved. The dysfunction in these brain regions have been proposed to be associated with disruptions to or differences in several processes and functions such as sensitivity to reward, excitement, the low loss chasing behavior that we see obviously in gambling disorder, stress dysregulation, social emotional problems, they are all really linked together and tied together. And it's kind of fascinating when you look at the neurobiology of PD, there are some variations of volume and activity of certain brain regions related to learning, stress management and report. And these are some of the studies that have demonstrated that there is decreased activity in the decision-making area, the left ventral medial prefrontal cortex. The orbitofrontal cortex is affected, which is reprocessing of rewards, dealing with uncertainty inhibiting responses. The anterior cingulate which is also part of the decision-making, the ventricular, the ventral striatum, which is the NAC and the limbic system. So the question is on brains or people with GD are different. So more and more of studies demonstrated that people who have GD exhibit lower reading kind of activity in the prefrontal cortex. And with neurocognitive testing, people who have GD showed similar dysfunction in the prefrontal cortex as people with methamphetamine use disorders. And this is the reasons why the pathological gambling and then the gambling disorder was moved to really that category of non-substance related in the sense that because of the similarities between gambling disorder and addictions. Okay, so how do we explain the links between GD and psychiatric conditions? This gives you an idea about data from the National Coordinated Study. You know that there is a high prevalence, you know, of co-occurring psychiatric disorder with depression, anxiety, I'm gonna talk about it more and more here. And more than 60% of individual with GD have at least three psychiatric disorders. Studies have also found that people who have GD have high rates of personality disorders, mood disorders, anxieties. These are the over-represented disorders are the personality disorder, mood disorder, anxiety disorder as well as co-occurring substance use disorders. And this is from Fifi Cox and Serene. I said, it's rare to observe a disordered gambler. I know it's a little bit of a kind of, you know, stigmatizing language here without a co-morbid condition. And it's often the co-morbid condition that ultimately leads the individual to treatment. So the depression, the anxiety, initiate really kind of is more the catalyst for people getting into treatment. And then throughout the whole evaluations, you know, we will find out, you know, that people have gambling disorders. And so this is just to give you an idea about what I mentioned earlier, the increase in the major risk for major depression, antisocial personality and phobias. With SUD, you know, the GD and SUD, you know, that is a very high link here that people have GD are 5.5% more likely to have had a substance use disorder. 75% alcohol, mostly the alcohol use disorders. We talk about the tobacco use disorder, 38%. The drug use disorder. The recreational gamblers smoke at same rate as general populations, 60 to 80% of people with GD smoke. I cannot really talk about the GD without really discussing also the suicidality piece. And the suicidality is really very much important to assess while we're assessing people who have gambling problems. The GD is associated with suicidal ideation as well as attempts, risk factors, financial difficulties, mostly losses, depression and legal problems. Gives you an idea about the prevalence of the suicidality. 20% of individual with problem gambling will attempt suicide, this is very high. About two times the rate of suicide attempts compared to other addictions. And suicide attempts in those who have gambling disorder and other concurrent disorders is much higher. Talk about co-occurring, you know, depression, anxiety, and wellness. So, it's progression and other problem, you know, that we see that gives you an idea about really, from a psychological point of view, you know, the phases that people who gamble go through. You know, obviously there's the winning phase, you know, resulting in unreasonable optimism, belief that you can continue winning. Losing phase, they start really bragging and think about past wins, secretly gambling, and begin to chase the losses. Desperation phase, gambling increases in time, frequency, and amount. A lot of guilt, shame, remorse, alienation, and problem increase. And there's the hopeless phase, where the gambler no longer believes there is a hope and they would be at high risk for suicide at that time. Other really problems that could be associated with that is intimate partner violence, let's not forget that one. And, you know, the research has consistently shown that high rates of GD&Ts, whose parent gambled too much. You know, and this is really important to also, the children of parents with GD have been shown to have higher levels of the following compared to peers, you know, tobacco, alcohol, and drug use as well as over eating. So in terms of the next learning objective, the screening tools for GD, we start with the screening. Brief screens, this is the most commonly used for the, you know, and I'll talk about it, you know, in a second. But it's so crucial to really basically, you know, evaluate, sorry, screen for the mental health substance use as well as any other really occurring problems. And this can help identify and intervene and refer or treat patients to specialized programs with GD. And the treatment can be incorporated into existing substance use and mental health problems, which is what we have in our clinic, which is dual recovery clinic, that mostly treat patients who have psychiatric disorders and substance use disorders. You know, the co-occurring disorders, but also, you know, gambling disorders and other really behavioral addictions. So what is the screen that we usually use, you know, and it's a very, very simple, very easy. It's an online questionnaire. Two questions surveyed, valid and reliable, to determine if a longer screening tool should be used in diagnostics. If the answer is yes to one or both, then you need to do a formal evaluation and assessment. These two questions are, have you ever felt the need to bet more and more money? Have you ever had to lie to people important to you about how much you gambled? Very simple, very easy. There is another one debriefed by a social gambling screen that also a yes to any of the questions. These are the persons at risk for developing a gambling problem. These are the three questions that we have there. During the past 12 months, have you become restless and irritably anxious when trying to stop and cut down on gambling? Yes or no. And this evaluates for the past 12 months. Have you tried to keep your family and friends from knowing how much you gambled? During the past 12 months, did you have such a financial trauma as a result of your gambling that you had to get help with the living expenses from family, friends, or welfare? Any yes answer would trigger the importance of a full evaluation assessment. Other basically tools that are used in terms of assessments. So we talked about the screenings and now talk about the assessment. Is the South Oaks gambling screen, SOGS. And the diagnostic screens, obviously you use the DSM-5 criteria. For the SOGS, you know, there is 20 item, multiple choice instrument, introduced to help identify individuals with gambling disorders. Zero, no problem. One to four, some problem. Five or more probable pathological gambler. Obviously that was the old term because that's at the time when the assessment was there, but this means gambling disorders. And it's been kind of criticized for high false positive rates. And there has been a version that has been modified for adolescents. So the diagnosis, and you know, and again, for the gambling disorder, you know, talking about the DSM-5 diagnosis, the DSM-5 diagnosis, you can really use, you know, that has to be a part of really the whole really assessment here. And once you really identify, you know, that there is a, you know, from the screen, you know, that there is a concern about potential gambling disorder. You know, there is a commonalities, you know, and similarities between GD and substance use disorders. Remember we talked about few of those. Commonalities include loss of control, death compulsivity, and preoccupation, urges, pathological wanting, cravings, associated highs, negative impact on major areas of life. Same thing with SUDs. And major impacts on mood, judgment, and insight. There's a tolerance and withdrawal. The hereditary nature. And similar treatment success with 12-step program, the Ambulance Anonymous, and CBT. And we'll talk about it in a bit. So these similarities and differences, immediate gratifications, addictive behaviors, the compulsion, the craving, urges, the, I mean, this is the old terminology of denial, which I don't like to use it anymore. Prefer to use the word more ambivalence, you know. And, you know, but this is what's been identified, the depression, anxiety, the blackouts, dissociating mechanisms for escape, and dysfunction of the family, which becomes very present and sometimes very severe. The differences is that the gambling is more hidden, and impossible to overdose on gambling. No ingestion of chemicals, unless there's a co-occurring substance use disorder. Labile financial situations. More unpredictable outcome. Not perceived as an illness, not perceived as a medical condition, you know, or a psychiatric condition. Fewer resources for people with GD. And faster progression. Remember, I talked about, really, that when you're diagnosing using the DSM-5 criteria, you know, versus the DSM-4. The DSM-4 used the language of pathologic gambling now is gambling disorder, impulse control disorder not otherwise classified. This is what it was in the DSM-IV. Now substance-related and addictive disorders, you know, classification because of the similarities with alcohol and drug addictions. Five or more criteria in the DSM-IV here, four or more criteria in the past 12 months. And in the pathological gambling, they used to really talk about the illegal activities. You know, as you know, this is the same thing with legal problems with substance use that was dropped, that criterion was dropped in the DSM-IV. So the criteria, you know, in terms of diagnosing, you know, putting it all together, there are the A and B here. A is a persistent and recurrent problematic gambling behavior leading to clinically significant behavioral distress. Remember, I mentioned four or more of the following over the course of one year, 12 months period. Needs to gamble with increasing amount of money in order to achieve the desired excitement. Restlessness, irritability, when attempting to cut down or stop gambling. Repeated unsuccessful effort to control, cut back or stop gambling. And is often preoccupied all the time, you know, in a sense, majority of the time beyond today with gambling. A lot of thoughts of reliving past gambling experiences, handicapping, or planning the next venture, or thinking ways of different ways to get money which to gamble. Often gamblers were feeling distressed when they are helped as hopeless, guilty, ashamed. Just after losing money gambling, often returns another day to get even. It's what we call the chasing one's losses. Did people lie to conceal the extent of involvement with gambling? Not being truthful, basically. Has jeopardized or lost a significant relationship, job, educational, career opportunity because of the gambling. And rely on other to provide money to relieve separate, sorry, relieve desperate financial situation caused by gambling. So the B is very important. It is not better accounted for by a manic episode. These are the specifiers. Episodic, persistent, early remission, sustained remission. The severity is based on mile four to five, moderate six to seven, criteria, severe eight to nine. So these are the episodic or persistent. You know, obviously, you know, GDP may occur at any one or more points in people's lives. And sometimes there are some episodes, periods of time when it is not there. So the next learning objective is the treatment. And here, this is really fascinating because, you know, the treatments, you know, I'm gonna start with the psychosocial intervention and mutual support groups. If you look at the studies, you know, that have been done, with the psychosocial interventions, mostly, you know, that what we've seen with short-term benefits and positive outcomes are with cognitive therapies. I'm talking about particularly with CBT cognitive behavioral therapy. So, you know, with the long-term effects, there's less evidence, so it's mostly the short-term benefits and effects. Motivational interviewing has been looked at with some benefits limited to short-term, no more effective than CBT, and it has not been really very well assessed and studied for the long-term. The GA, which is really what most people get involved in, which is a mutual support group, and it can be incorporated with psychosocial treatments. So, with professional care, that it can produce good outcome. People are more likely to achieve absence than those who do not participate in GA. So, GA is crucial, you know, when it comes to really as a big resource and a support system when it comes to addressing, you know, the gambling disorder. There's a large randomized controlled trial found people with GD, they use the DSM-IV criteria, who attended the GA and completed either cognitive therapy or a CBT workbook had a better outcome at six and 12 months compared to those referred to GA alone. So, you see that, in a sense, the combination has really worked the best. And the recent systematic review and meta-analysis showed that face-to-face delivered intervention has the strongest evidence for CBT. So, we would want people to come in now, you know, with a lot of that stuff that has been done on a more, you know, virtual basis, you know, like telehealth and all the stuff we wanna have. People basically come in, you know, and face-to-face seems to really work much better when it comes to CBT. So, in terms of pharmacotherapy, you know, first of all, there is a lot of the stuff that I'm gonna be re-discussing here. It's basically off-label and there is no FDA approved pharmacotherapy, you know, for a GD. Some benefits of particular medications like the opioid receptor antagonist, naltrexone, nalmethine. In fact, we did a trial with nalmethine, but it's just all for, you know, opioid withdrawal, you know, and it's not really used very often. You know, naltrexone showed some promise. Particularly, two categories of medications that could be potentially beneficial are the monoaminergic drugs and the clitamatergic drugs, and I'll mention some about that. So, obviously, as you've seen from my conversation earlier, that when you combine, you know, psychotherapeutic approaches with the GA, they work very well. So there's always the question whether if you combine pharmacotherapy, you know, with whatever we have available that could potentially be helpful to work in psychotherapy, you know, maybe it could really provide more, you know, better rates, you know, in a sense, you know, more positive outcomes, you know, when it comes to patient retention. You wanna keep people engaged and engaged in care, and you wanna do whatever you can to really ensure it's gonna happen. The co-morbidities, as you know, the co-occurring substance use disorder, other psychotic disorders, need to be addressed, and if we talk about particularly mood disorders and depressive, you know, disorder, anxiety disorders, using the mood stabilizers and SSRIs. So the pharmacotherapy, you know, when you think about it, you know, it's kind of, in a way, fascinating because, you know, that the improvement is very, you know, more in the severity of the symptoms. It might not eliminate totally the, you know, the gambling manifestations, and it's all short-term improvements. I mean, you would think that we would find something at this point in time that would potentially be very helpful in terms of a pharmacological agent, you know, because we know more and more about the neurobiological, really, mechanisms, you know, and, you know, of gambling disorder, but we don't. We don't have anything that has been well-established with randomized controlled trial and the other stuff, but if you look at antidepressants and opioid receptor antagonists and mood stabilizers, they were associated with an improvement in the GD relative to placebo or no treatment with an overall effective size of 0.78. I mean, this is kind of fair and reasonable. You know, I mean, would we wanna use these medications? We could use them, but using them without psychosocial treatments as well as support groups like the GA might not really be as beneficial. But when I mentioned about the opioid receptor antagonists, again, off-label, naltrexone and dalmaphene, they may indirectly influence the immunogenic neurons in the mesolimbic system, and we don't know clearly how it works, basically, you know, when it comes to GD. The mono-immunogenic drugs, it's related to the proposal of serotonin with respect to the impulse control, but we're talking about really the disorder that has a compulsive and impulsive components, particularly the compulsive components. Some of them, you know, that I'm referring to is the SSRI, bupropion and olanzapine. So obviously, you know, some of the antipsychotics could be potentially helpful too, but again, we don't have, you know, a clear sense of really, you know, how it works, you know, and what the dose is, and how it could be approached, you know, and obviously using it without really the psychosocial treatments might not be helpful at all. The glutamatergic drugs, and they looked at in terms of the glutamate transmission receptors and the reward reinforcement and the relapse. He says, you know, we're talking about the NAC, you know, N-acetylcysteine, the combination with CVT as well as motivation to the elements, and what we call the imaginal desensitizations in the study that looked at 28 individuals who have tobacco use disorder. And so again, you know, it could potentially be beneficial to combine some of these treatment approaches from ecological approaches, but there's no guarantee that anything is going to make any much of a difference. So that's why it's so crucial, you know, that using the person-centered approach, you know, and really negotiating with the patient about what the potential options would be and what to expect from these options. And you want to be careful, you know, to be very transparent and very clear with the patients about what these medications could do. In terms of the mood-stabilizing drugs, there are mixed results when it comes to the GD in study using mood-stabilizing medications such as lentimortepyramid. You know, I mean, here we go again, you know, it's the same kind of challenge that we want to be very clear with the patients about what the expectations could be. And again, honestly, we cannot determine, you know, what's going to work, what's not going to work, you know. And again, how do you titrate the dose? What is the dose that could be potentially optimal or beneficial? And there is no clear answer to that at this point in time. So which kind of, you know, makes people more inclined towards really considering, you know, the psychosocial treatments as well as a support group. In fact, the GA has been the mostly used, you know, in solid treatment approach, mostly used, you know, support group that helps people, you know, with the fellowship piece, you know, and focus on, you know, really the GD, you know, and their experiences with GD and how they can rely on the, you know, other patients who are really struggling with it and what they learned in terms of what works and what doesn't work. What we call here a warning program, you know, first of all, routinely screening for gambling problems, which is not really done on a regular basis. We don't, there's so much of a stigmatizing aspect to it and also kind of downplaying it. And that play, that kind of in a sense, similar to how people who struggle with gambling disorder, you know, approach it is by not acknowledging that this is an illness that requires, you know, involvement in treatment, you know, that could get better, that, you know, and so in a sense, you know, the healthcare system, you know, and practitioners can, they end up basically colluding also with that sort of an approach that really does not really screen routinely in a way for potential gambling problems. And if the screen is positive, to follow through with the full evaluation. And you can use a lot of the evidence-based prevention, assessment and treatments, and existing mutual support groups, such as the GA. You know, the GA is really very crucial. You know, as I mentioned, you know, particularly as you've seen from the study that I just showed you is that in combination with other really therapeutic approaches. And this has to be done, that screening, questioning psychiatric treatment programs or substance use assessments themselves. So you assess for substance use, you assess also for gambling. And the assessment has to be very comprehensive. It has to incorporate also asking about suicide, hopelessness, access to really firearms and all this, you know, whether people have experienced any kind of, you know, suicidal tendencies that they don't know how to cope with, and whether they consider any crimes, you know, as a result of all these financial issues, loss of relationships and all this. So the multi-modal approach include legal, financial, family issues. You can also help people from a legal point of view too. And also really, we need to really kind of always think about really where the research is going with that, keeping updated on that. So you remember, I mentioned about the concerns that a lot of patients would have about seeking help. And if they had negative experiences in the past, you know, that's gonna be limiting them from really reaching out. You know, that they have doubts about helping professionals themselves, you know, the lack of experience of being a problem gambler, you know, having a gambling disorder. You know, and, you know, the lack of knowledge. They don't know if, which in fact, very valid because, you know, a lot of practitioners do not have experience with that. Even, you know, addiction psychiatrists might not have experience in terms of really how to really treat patients who have GD. Confidentiality, trust issues, legitimacy and financial gain, you know, an expectation about treatment that they can be in this hopeless state where they kind of feel that they feel that it's not gonna really work. Oh, sorry. So, the threats to personal integrity would include the issues of stigma, pride, you know, embarrassment, shame, guilt, not wanting to be labeled. And that kind of stops people from really reaching out and really engaging with treatment. And the secrecy and the exposure, you know, and looking at it as a weakness and exposing the problems, you know, and having to rely on other people that rely on themselves. And the openness about talking about really deep intimate issues related to these gambling behaviors. So now, moving on to really what we know about other really, you know, non-substance related or called behavioral addictions. I know that addictions are a loaded term, you know, but a lot of the several conditions have been looked at and proposed, but there is little to no data validating any particular condition. Validating any particular diagnostic criteria. And if you think about diagnostic criteria, you know, similar to the substance use disorder, gambling disorders, excessive time spent in the behavior, you know, repeated attempts to cut down or stop the behavior, diminished control over the behavior, tolerance, withdrawal, continued behavior despite all these negative consequences. And so, not much really different from substance use disorder and gambling disorder. The internet gaming disorder, there is lack of sufficient research to classify it as a unique disorder. And potentially, it could be a condition for future research in SM-5. And also in 2017, been looked at as being a new condition in ICD-11, has already been recognized as a distinct disorder in South Korea and China because of the high prevalence. It may include gaming on any electronic device, but most people who have clinically significant problem, problems related to it, they engage in internet gaming. We see it a lot, basically, with young adults too, you know, let's put it this way, and less in young adults. You know, these are some of the proposed criteria. They need five or more within, again, the 12 months period, preoccupation with gaming, withdrawal symptoms, when gaming is taken away, not possible, the tolerance, spending more time gaming to satisfy the craving and the urge, inability to reduce playing, unsuccessful attempts to quit gaming, giving up other activities, loss of interest in other enjoyable activities due to gaming. Gaming takes over, basically, their lives. Continuing to game despite problems, deceiving family members, other losing, you know, basically important relationships, and the use of gaming to relieve negative moods such as guilt, hopelessness, shame, and the risk having jeopardized or lost a job or relationship to game. Other things that they consider behavioral addictions, you know, that are based on very much compulsive, you know, tendencies, they include basically, you know, they are overlapping in what a lot of established psychiatric disorders, but the particular behaviors are sex, related to sex, like sexual addiction, eating food, exercising, shopping, as we mentioned about the internet, and panic, for example, internet will consist in that. Treatments, so there are no formal diagnostic criteria, but when you think about the treatment, treatment program has been developed and claimed to treat behavioral addictions. You know, some example of the, you know, support groups, mutual support groups that really work well, that patients utilize very well, similar to the GA, is the SLAA, which is basically Sex Addicts Anonymous, Sex and Love Addicts Anonymous, you know, and there's a Sexual Compulsive Anonymous, you know, Sexaholics Anonymous, Sexual Recovery Anonymous, there are different type of really variations, you know. There's the Overeaters Anonymous, Shopaholics Anonymous, and Debtors Anonymous, you know, and there's a Computer Gaming Addicts Anonymous, and Online Gamers Anonymous. They have the same principles, same for, you know, when it comes to the fellowship itself, the working steps, you know, and the sponsorship. That's it, and these are the references. And I included some resources for the winning group. Thank you.

gambling disorder

psychiatry

addiction

screening tools

co-occurring conditions

treatment approaches

behavioral addictions

stigma