Impulsivity profiles in pathological slot machine gamblers
Introduction
Gambling Disorder (GD) is characterized by persistent and recurrent maladaptive behavior that disrupts personal, family or vocational pursuits and is classified in the DSM-5 as an Addictive Disorder, due to similarities in etiological, biological, clinical terms and treatment outcomes with Substance-Related Disorders [1]. Indeed, high impulsivity is considered as an indicator of vulnerability for both disorders [2,3]. In a recent review, Grant and Chamberlain [4] concluded that there were similarities between substance abuse and GD on the cognitive and neurological components of impulsivity. In a prospective community-based study of 958 births analyzing the association between impulsivity at age 7 and the development of GD in adulthood, Shenassa et al. [5] found that children with impulsive behavior were three times more likely to develop GD in adulthood than non-impulsive children.
Impulsivity has been associated with various psychopathological disorders such as addiction, compulsive buying, problem gambling, attention deficit and hyperactivity disorders, eating disorders, aggressiveness, antisocial conduct, limit and antisocial personality disorders or risky sexual behaviors [6]. Although impulsivity has been widely used in mental health, its definition remains controversial [7,8]. It is a complex and multi-dimensional concept composed of different dimensions (i.e., cognitive, emotional and behavioral), which result in individual differences in its distribution and its degree of severity [8,9]. More than a criterion for a specific diagnosis, impulsivity could be considered a trans-diagnostic trait [10].
High impulsivity has also been associated with GD [2,[11], [12], [13], [14], [15]]. Whiteside and Lynam [15] described a multi-dimensional model of impulsivity and confirmed its heterogeneity. The four-factor model of impulsivity they developed was named the “Urgency-Premeditation-Perseverance-Sensation seeking model” (UPPS model). Negative urgency was defined as the tendency to act rashly as a result of intense negative affect; Lack of premeditation refers to the tendency to act without considering the potential consequences, without planning or adequate consideration of potential outcomes prior to action; Lack of perseverance as the inability to maintain involvement or persist in long, boring or difficult tasks; and Sensation seeking, defined as the tendency to enjoy and pursue exciting activities and openness to trying new experiences. Later, a fifth facet named, Positive urgency, defined as the tendency to act rashly or maladaptively in response to positive mood states, was added by Cyders et al. to create the UPPS-P model [2].
These five dimensions of the UPPS-P model have been empirically associated with different parameters of addictive behavior. Negative urgency has been associated with tobacco craving, severity of stimulant addiction, pathological gambling, compulsive purchases, as well as Internet abuse and risky sexual behavior. Lack of perseverance and lack of premeditation have both been linked with problematic use of substances (e.g., alcohol, cocaine and amphetamines). Sensation seeking has been associated with the frequency of drug use, alcohol consumption and pathological gambling. Finally, Positive urgency has been linked to the recreational use of alcohol and drugs and risky sexual behavior [7,16].
In GD, although some studies have established impulsivity as a predictor of GD severity, treatment outcomes and dropouts, they did not consider its multi-dimension nature [9,[17], [18], [19], [20]]. Some studies using the UPPS-P Impulsive Behavior Scale have found that pathological gamblers showed high impulsivity with a larger effect for both Positive and Negative urgency [[21], [22], [23]]. Considering the relationship between impulsivity and GD, a better understanding of the implications of impulsivity for the treatment and prevention of GD is essential. However, it is worth mentioning that gambling is not a single homogeneous activity, and although the chance of winning something of greater value than the amount invested is a common feature of the various forms of gambling activities, different types of gambling present different attributes [24]. Since lotteries, bingo, sport betting, or slot machines offer diverse experiences to gamblers, the motives for participating in particular forms of gambling probably vary from person to person [25]. Indeed, several studies have pointed out that certain forms of gambling are more likely to develop into problem behavior (e.g., slot machines, casino games, online gambling) than others (e.g., weekly lotteries, instant lottery tickets) [24,[26], [27], [28]]. Moreover, of all types of gambling, slot machines are the most addictive; in Spain they cause more gambling problems than any other type and require more specialized psychological treatment [29]. Therefore, including different types of gamblers in one study may introduce excessive variance, whereas focusing on one specific type of gambling may obtain more homogeneous results and a rapid understanding of its distinguishing features. Consequently, the main objective of the present study is to obtain an empirical classification of slot machine gamblers with GD based on their impulsivity. We also aimed to compare the resulting groups in terms of sociodemographic and clinical variables and gambling behavior.
Section snippets
Participants
The study population was derived from a prospective single-center registry of consecutive outpatients attended at a Pathological Gambling Unit between 2013 and 2016. Patients older than 18 years, diagnosed with GD and having problems only with slot machines were included. Patients with any other behavioral addiction (i.e., compulsive buying, internet addiction, sex addiction) or with addiction to other types of gambling were excluded. Illiterate subjects, those with difficulties in
Results
Based on the UPPS-P data, the cluster analysis showed two groups. The first cluster (cluster 1, n = 86) included subjects with the highest scores on all the UPPS-P scales, whereas the second cluster (cluster 2, n = 40) included those with high scores on Negative Urgency and Lack of Premeditation scales and low scores on the other scales. Negative Urgency, Positive Urgency and Sensation Seeking scales showed the highest differences between the two clusters (Table 1).
Participants in the two
Discussion
The results of our study demonstrate that individuals with slot machine GD do not represent a homogeneous population but differ in terms of impulsivity, one of the central aspects of addictive behavior. We identified two distinct clusters of slot machine gamblers depending on their impulsivity. Using the UPPS-P model [15], we found a group of pathological gamblers with higher impulsivity scores and with high scores on all scales of the UPPS-P questionnaire (cluster 1), and another group of
Conflict of interest
The authors have no conflicts of interest to declare.
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