Is gambling disorder associated with impulsivity traits measured by the UPPS-P and is this association moderated by sex and age?
Introduction
Pathological gambling (PG), previously classified as an “impulse control disorder not elsewhere classified”, has been renamed as Gambling Disorder (GD) and reclassified as a “substance-related and addictive disorder” in the fifth edition of the Diagnostic and Statistical Manual (DSM-5) [1]. The basis of this change lies on the growing scientific evidence from neuroscience, genetics and experimental psychology studies that reveal that GD and substance use disorder share some common substantial elements, such as impulsivity [2], [3]. Accordingly, the strong association between impulsivity and problematic gambling behavior has been widely studied and repeatedly reported as significant [4]. Furthermore impulsivity has been described as a risk factor for GD [5], [6], [7].
Impulsivity is a complex construct with multi-dimensional characteristics and its definition has been difficult to ascertain [8], [9]. At present, there are different theoretical and conceptual models of impulsivity. Among them, the Whiteside & Lynam [10] Five Factor Model of personality is of particular interest because it improved the assessment of impulsivity through the widely known UPPS Impulsive Behavior Scale. Originally, the UPPS was created and validated by Whiteside & Lynam [10] with 4 different sub-scales: Urgency (UR), Lack of Perseverance, Lack of Premeditation and Sensation Seeking. Later, the UR dimension (emotion-based disposition to engage in rash actions) was divided into two different personality traits: positive UR and negative UR [11]. Positive UR refers to the tendency to engage in impulsive actions in response to extreme positive emotions. Therefore impulsivity is associated with positive emotions and immediate positive reinforcement [12], [13]. Negative UR refers to impulsive actions due to the experience of negative emotional states, such as depression, boredom and stress. In this case, impulsivity is associated with negative emotions and negative reinforcement (avoidance behavior or relief seeking) [14], [15], [16], [17]. The UPPS-P Impulsive Behavior Scale assesses the five described personality dimensions for impulsive behaviors [18] observed in different addictive disorders or impulsive related disorders such as: eating disorders [19], substance use disorders [20], non-suicidal self-injury [21], among others. In fact, the UPPS-P has been proven as one of the most valid and appropriate impulsivity measures.
During the last decade several studies have concluded that UR is a key component of risky behaviors [22], [23] and among them problematic gambling behavior is highlighted [15], [24]. For instance, Whiteside et al. [25] studied a sample of patients with GD, borderline personality disorder, alcohol abusers and healthy controls; according to their results UR was both a predictor of GD as well as the most constant factor across all the dimensions (low premeditation, low perseverance and sensation seeking). Additionally, in a cross-sectional study conducted by Cyders & Smith [26], higher scores in positive UR among university students predicted increased risk of long term gambling behaviors. Negative UR on the other hand, has been linked to the urge to consume tobacco [22] as well as to binge-eating/purging symptoms in eating disorders [19], [27].
Three studies have been conducted with UPPS-P so far and GD in clinical samples [24], [28], [29]. Billieux et al. [28] described how GD individuals presented higher UR and lack of premeditation when compared to control individuals. Furthermore, Michalczuk et al. [24] reported that UR dimensions (i.e.: negative and positive UR) were strongly associated with gambling behaviors. Besides, differences were also found between GD participants and controls in all the other impulsivity dimensions with the exception of sensation seeking.
Thus, UR appears to be the impulsivity dimension most highly associated with emotion regulation in GD, with gambling behavior being a maladaptive mechanism for regulating positive (e.g.: euphoria, empowerment) and negative emotions (e.g.: stress, boredom or sadness) [30], [31], [32]. Finally, Grall-Bronnec et al. [29] reported a positive association between UR and GD severity as well as a strong association between impulsivity and psychopathology (e.g.: mood disorders, risk of suicide, alcohol use disorder and ADHD).
In spite of impulsivity being a well studied construct in GD samples with and without the UPPS-P measure [24], [28], [29], to our knowledge no previous studies have been conducted so far exploring impulsivity in a consecutively recruited and large GD clinical sample.
The main goal of the present study was threefold: 1) to explore the role of sex and age on impulsivity in GD patients; 2) to identify the relationship of the different impulsivity facets with comorbid psychopathology and other personality traits in GD patients and 3) to assess whether impulsivity is a predictor for the severity of GD.
Section snippets
Sample
Sample consisted of 406 GD individuals (359 male, 88.4%) with a mean age of 41.2 years old (SD = 13.0). All of them were outpatient consecutive referrals for the assessment and treatment of GD at a Gambling Disorder Unit in the Psychiatry Department of the University Hospital of Bellvitge, in Barcelona (Spain). Sample recruitment was conducted from March 2012 to November 2013. Many participants had primary (50.5%) or secondary (38.5%) education and 53.3% were unemployed. Civil status was
Impulsivity levels in GD patients
Table 1 shows the distribution of the UPPS-impulsivity scores for the sample. No statistical differences emerged based on participants' sex. Based on the groups of age, a negative linear trend was obtained for the lack of premeditation and sensation seeking scores (the higher the age the lower the impulsivity level) and a positive linear trend was obtained for the positive UR score (means tended to increase in this scale according to the patients' age) (Fig. 1).
Table 2 shows the results of the
Discussion
The present study widens the previous knowledge of the association between GD and impulsivity (measured by means of the UPPS-P). Specifically, it reports no sex differences in impulsivity among individuals suffering from GD and provides significant information about the role that psychopathology and personality traits play in impulsivity among the studied sample.
Accordingly, several studies report that impulsivity as a trait is a risk factor for both the onset and maintenance of the problematic
Conclusions
This study explores the association between impulsivity and GD and its findings are consistent with previous research on the field. No sex differences throughout the impulsive dimensions were confirmed. However, the age was negatively associated with impulsivity in patients with GD. Moreover, in our sample, several significant associations were found among impulsivity, personality traits and comorbid psychopathology. While many studies explore the impulsivity by means of UPPS-P in alcohol and
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Conflict of interest declaration: All authors declare that they have no conflicts of interest