Gambling Motives and Drinking Motives in Pathological ...

Gambling Motives and Drinking Motives in Pathological ...

Sub-typing Gamblers on the Basis of Affective Motivations for Gambling: Implications Dr. Sherry H. Stewart, Matching for Treatment Departments of Psychiatry & Psychology, Dalhousie University, CIHR Investigator, Killam Research Professor Funding Ontario Problem Gambling Research Centre (OPGRC) Nova Scotia Gaming Foundation (NSGF) Collaborators

Dr. Sean Barrett Dr. Joel Katz Dr. Raymond Klein Dr. David Hodgins Dr. Anne-Marie Wall Dr. Martin Zack Pamela (Loba) Collins Fofo Fragopoulos Adrienne Girling Meghan Kirsch Melissa Mohan Sarah Stuart

Background: Motivational Theories Motivational models of addiction argue that people engage in addictive behaviors to obtain desired outcomes (e.g., Cooper, 1994) Many such theories point to desires for mood alteration as motivating addictive behavior (e.g., Cox & Klinger, 1988) Theories abound regarding contributions of motivations involving emotional self-regulation in etiology and maintenance of pathological gambling Desire for tension-/dysphoria-reducing effects (e.g., Beaudoin & Cox, 1999) Desire for euphoric consequences (e.g., Hickey et al., 1986)

Background: DSM-IV-TR Criteria for Pathological Gambling A. Persistent and recurrent maladaptive gambling behavior as indicated by five (or more) of the following: (1) is preoccupied with gambling *(2) needs to gamble with increasing amounts of money in order to achieve the desired excitement (3) has repeated efforts to control, cut back, or stop gambling (4) is restless or irritable when attempting to cut down or stop gambling Background: DSM-IV-TR Criteria for Pathological Gambling (5) gambles as a way of escaping from problems or of * relieving a dysphoric mood (6) after losing money gambling, often returns another day to get even ("chasing" one's losses) (7) lies to family members, therapist, or others to conceal the extent of involvement with gambling

(8) has committed illegal acts such as forgery, fraud, theft, or embezzlement to finance gambling (9) has jeopardized or lost a significant relationship, job, or educational or career opportunity because of gambling (10) relies on others to provide money to relieve a desperate financial situation caused by gambling Background: Heterogeneity Increasing recognition of the heterogeneity of gamblers (e.g., Ferris, & Wynne, 2001) Cluster analytic studies suggest subtypes For example, Blaszczynski & Nower (2002) suggest three clusters: Antisocial impulsivist gamblers Emotionally vulnerable gamblers Behaviorally-conditioned gamblers

Previous Sub-Typing Schemes Researchers Lesieur (2001) (2 of 3) McCormick (1987) Blaszczynski et al. (1990) Blaszczynski & Nower (2002) (2 of 3) Grant (2007 yesterdays talk) Proposed Subtypes Impulsive Impulsive Escape Seekers Action Seekers Recurrently Chronically Depressed Under-Stimulated

DepressionBoredomProne Prone Emotionally Antisocial Vulnerable Impulsivist Anxious/ Pleasure/Urge & Depressed/ General Impulsivity Obsessional Need for Stimulation Background: Sub-typing Substance Abusers Our previous work in the alcohol/drug abuse area involves sub-typing substance abusers according to underlying motives for substance use (Conrod et al., 2000a) This sub-typing predicts:

Substance use patterns/preferences Co-morbid psychopathology Response to matched interventions (Conrod et al., 2000a,b, 2006; Watt et al., 2006) Matching brief interventions to motivational profiles Random assignment to 1 of 3 90-minute interventions: (1) Motivation-matched cognitive-behavioral training (N=94) (2) Motivation-mismatched cognitive-behavioral training (N=97) (3) Film control (N=52)

(Conrod, Stewart et al., 2000; Psych of Addictive Behaviors) Procedure: Follow-up Assessment at 6-months post-treatment Telephone interview Interviewer blind to subtype and intervention Several substance-related outcomes assessed Six-months Remission Rates 60 % remitted 50 40 30

20 10 0 Matc hed Mis matc hed Film 5 4 symptoms Reduction in dependence Reduction in Dependence Symptoms 3 2 1 0 Matc hed Mis matc hed

Film abstinent from alcohol % reporting >60 days Lengthy Abstinence from Alcohol 25 20 15 10 5 0 Matc hed Mismatc hed Film Our New Proposal: What about sub-typing gamblers according to motivations for emotional regulation?

Might be a theoretically- and clinically-useful way of understanding diversity among pathological gamblers and those at risk. Study 1: Sub-Typing Problem Gamblers Who Drink When Gambling on Affective Motives for Gambling Background: Gambling and Alcohol High co-morbidity between pathological gambling and alcohol use disorders (Ciarrocchi, 1993; Crockford & el-Guebaly, 1998; Griffiths, 1994; Stewart & Kushner, 2003). Theories explaining co-morbidity include:

Pathological Gambling Alcohol Abuse (Zack et al., 2005) Alcohol Abuse Pathological Gambling (Ellery et al., 2005) Common Third Variable For example, common underlying motivations for gambling/drinking Purposes Test the validity of a gambler subtyping scheme that classifies gamblers on their primary emotion regulation motives for gambling Test the degree of overlap in specific motives for gambling and for drinking among problem gamblers who drink when gambling

Do those who use gambling to cope with negative emotions also use drinking for the same reason? Do those who use gambling to enhance positive states also use alcohol for the same reason? Hypotheses (1) At least two clusters or subtypes of pathological gamblers would emerge using gambling situations as indirect measure of motives those gambling in response to negative contexts (e.g., unpleasant emotional states) COP gamblers. those gambling in response to positive contexts (e.g., pleasant emotional states) ENH gamblers. (2) Clusters of gamblers identified using the Inventory of Gambling Situations (indirect) would be validated using Gambling Motives Questionnaire (direct).

(3) The ENH gamblers would evidence greater gambling behavior than other cluster(s) (4) The COP gamblers would evidence greater gambling problems than other cluster(s) Hypotheses (continued) (5) We expected to observe associations between gambling motives and drinking motivations on the Drinking Motives Questionnaire (6) We hypothesized that the ENH gamblers would show higher quantities of drinking, and more alcohol related problems on the Brief Michigan Alcoholism Screening Test, than other cluster(s) Method - Participants

A sample of 158 gamblers (77%M; mean (SD) age = 36.0 (10.7) years) was recruited from the community using newspaper and television advertisements. All were probable pathological gamblers (scoring > 5 on the SOGS). All reported consuming alcohol at least 50% of the times when they gamble. All were 19 years of age or older Results: Hypothesis 1a Pattern Matrix from Principal Components Analysis of subscale scores from the Inventory of Gambling Situations (IGS; Turner & Littman-Sharp, 2006) following Oblique Rotation (n = 158) IGS Subscale Unpleasant Emotions Worried Over Debt Conflict With Others Testing Personal Control Winning and Chasing Losses Factor 1

Negative Situations .976* .945* .938* .886* .764* Factor 2 Positive Situations -.029 -.072 -.034 .032 .202 Communality .918 .812 .840 .821 .821 Pleasant Emotions Social Pressure Need for Excitement

Confidence in Skills -.105 -.036 .246 .173 .930* .899* .757* .678* .751 .768 .872 .639 Urges and Temptations .603* .423* .873

Note: A two-factor solution was selected based on Kaisers rule. Salient loadings (> .40) are indicated with an asterisk (*). Results: H1b: Cluster Analysis 3 cluster solution Cluster 1 high positive situation scores/low negative situation scores labeled Enhancement (ENH) gamblers (n = 94) Cluster 2 high negative/high positive situation scores, but particularly high negative scores labeled Coping (COP) gamblers (n = 36) Cluster 3 low negative/low positive situation scores labeled Low Emotion Regulation (Low ER) gamblers (n = 28) Results: H2: Factor Scores on Gambling Motives

Questionnaire (GMQ) by 1.2 Subtype 1 0.8 0.6 coping motives enhancement motives 0.4 0.2 0 cluster group x subscale interaction (F (2, 151) = 3.44, p < .05) -0.2 -0.4 ENH COP

Low ER Results: H3: Number of Lifetime Gambling Activities (SOGS) by a a b Subtype 10 9 8 7 6 5 # activities 4 3 cluster group effect (F (2, 155) = 19.90, p < .001)

2 1 0 ENH COP Low ER Results: H4: Gambling Problems on DSM-IV-Based Measure by b a c Subtype 20 18 16 14 12 10 gambling problems

8 6 cluster group effect (F (2, 151) = 33.23, p < .001) 4 2 0 ENH COP Low ER Results: H5: Factor Scores on Coopers (1994) Drinking Motives Questionnaire (DMQ) 1.5 by Subtype 1 0.5 coping motives enhancement motives

0 cluster group x subscale interaction (F (2, 151) = 7.42, p < .005) -0.5 -1 ENH COP Low ER Results: H6a: Drinking Quantity (drinks per occasion) by a b a Subtype 10 9 8

7 6 5 drinking quantity 4 3 cluster group effect (F (2, 150) = 7.57, p < .005) 2 1 0 ENH COP Low ER Results: H6b: Drinking Problems by Subtype b

a b 14 12 10 8 B-MAST scores 6 4 cluster group effect (F (2, 147) = 13.13, p < .001) 2 0 ENH COP Low ER

Some Remaining Questions Do the clusters represent trait-like subtypes or stages? Do the clusters simply reflect correlates of gambling problem severity? Are the sub-typing findings specific to pathological gamblers who drink when gambling? Study 2: The Relationship of Gambler Subtypes to Gambling Expectancies in Regular Gamblers

Background: Expectancies Expectancies = beliefs about consequences of engaging in a specific behavior If-then statements making connections between behavior and expected outcome (Goldman et al., 1999) Distinct from motives (Birch et al., 2004) Many domains, but two higher-order Reward Relief (Birch et al., 2004) Background: Expectancies In addictions field, expectancies exert powerful influence on addictive behavior

e.g., expectancies about effects of alcohol strong determinants of heavy and problem drinking (Goldman et al., 1999) Surprisingly, little research on expectancies in gambling area Purposes Replicate typology of gamblers identified in Study 1, with sub-typing on the basis of gambling situations (inferred motives) Determine if gambler subtypes differ in gambling outcome expectancies on a new mood-regulation Gambling Expectancies Questionnaire (GEQ) modeled after a similar alcohol outcome expectancies measure (Birch et al., 2004; Singleton et al., 1994) Relief expectancies (e.g., I would feel less irritable

if I gambled now) Reward expectancies (e.g., It would be great to gamble now) Hypotheses (1) Three clusters or subtypes of regular gamblers would emerge on basis of IGS positive and negative situation factors: Pure enhancement gamblers (ENH) Primarily coping gamblers (COP) Low emotion-regulation gamblers (LOW ER) (2) Gambler subtypes would differ in moodregulation gambling outcome expectancies on the GEQ

Reward expectancies: ENH = COP > LOW ER Relief expectancies: COP > ENH = LOW ER Method - Participants A sample of 181 regular gamblers (56% M; mean age = 37.7 years) was recruited from the community using newspaper and television advertisements. Approximately half recruited in Halifax (n=84) and the other half in Toronto (n=97) No restrictions regarding SOGS scores or alcohol consumption; M SOGS = 3.88 (4.23) Results: Hypothesis 1a Pattern Matrix from Principal Components Analysis of subscale scores from the IGS following Oblique Rotation (n = 179) IGS Subscale Conflict With Others

Worried Over Debts Testing Personal Control Unpleasant Emotions Need To Be In Control Factor 1 Negative Situations .938* .904* .794* .786* .775* Factor 2 Positive Situations -.093 -.100 .130 .144 .141 Communality .789 .724 .766

.768 .745 Pleasant Emotions Social Pressure Need for Excitement Confidence in Skills -.201 .029 .192 .205 .952* .750* .725* .704* .727 .588 .720 .702 Urges and Temptations Winning and Chasing Losses

.403* .448* .580* .500* .766 .707 Note: A two-factor solution was selected based on Kaisers rule. Salient loadings (> .40) are indicated with an asterisk (*). Results: Hypothesis 1b Gambling situation factor scores of the three clusters of regular gamblers 1.5 1 0.5 0 Negative Situations Positive Situations -0.5

-1 -1.5 Cluster 1ENH (n=68) Cluster 2LOW ER (n=63) Cluster 3COP (n=48) Results: Hypothesis 2 GEQ factor scores as a function of gambler subtype 1 0.8 0.6 0.4 0.2 0 -0.2 Relief Expectancies

Reward Expectancies -0.4 -0.6 Cluster 1ENH Cluster 2LOW Cluster 3COP (n=67) ER (n=61) (n=46) cluster group x expectancy domain interaction (F (2, 171) = 25.80, p < .001) STUDY 2 Cluster 1 ENH Cluster 2 LOW ER Cluster 3 COP

Age (yrs) 33.57 (14.54)b 41.02 (14.02)a 39.88 (9.03)a SOGS 2.99 (2.45)b 1.41 (2.12)c 8.48 (4.79)a Gambling 2.40 freq (per wk) (1.96)a

1.57 (1.02)b 2.84 (1.96)a B-MAST 4.28 (5.70)b 2.40 (3.97)c 7.58 (6.34)a Drinking Onset (yrs) 14.91 (2.90) 15.42

(2.67)b 14.00 (2.62)a Study 3: Validity of SubTyping Undergraduate Gamblers on Affective Motives for Gambling Purposes Test the validity of a gambler subtyping scheme that classifies gamblers on their primary emotion regulation motives for gambling, as applied to undergraduate gambling behavior Does the three subtype scheme hold in undergraduate gamblers? Do the subtypes vary as expected on gambling behaviors and gambling problems?

Method - Participants A sample of 168 regular gamblers (58% M; mean age = 20.3 years) was recruited from the undergraduate student population Approximately half recruited at Dalhousie University (n = 82) and the other half recruited at York University (n = 86) No restrictions regarding gambling problems or alcohol consumption Results: Hypothesis 1a Pattern Matrix from Principal Components Analysis of subscale scores from the IGS following Oblique Rotation (n = 168 university student gamblers) IGS Subscale Factor 1 Positive Situations

Factor 2 Negative Situations Pleasant Emotions Social Pressure Confidence in Skills Need for Excitement 1.101* .818* .796* .790* -.234 .025 .025 .146 Conflict with Others Negative Emotions Worried about Debt Testing Personal Control -.071

.044 -.027 .241 .982* .900* .886* .761* Urges and Temptations Winning and Chasing Losses .597* .580* .456* .401* Note: A two-factor solution was selected based on Kaisers rule. Salient loadings (> .40) are indicated with an asterisk (*). Results: H1b: Gambling Situation Factor Scores of the 3 Clusters of Gamblers Gambling Situation Factors Scores for the Three Clusters of Regular Undergraduate

Gamblers 4 positive situations negative situations 3 Mean 2 1 0 -1 -2 1 2 3

1=cop/enh, 2=enh, erER (n=81) 1 = COP (n=22); 2 = ENH (n=65);3=low 3 = Low STUDY 3 Cluster 1 COP Cluster 2 ENH Cluster 3 Low ER Age (yrs) 22.32 (4.93)a 19.88

(1.96)b 20.08 (2.38)b Gender (% male)* 81.8% 61.5% 48.2% Money Spent 50.20 When (70.04)a Gambling ($) 37.22 (46.86)a 17.82 (21.46)b

Hours per week Gambling 3.06 (2.74)b 2.00 (1.78)c 6.81 (6.95)a Results: Percentage High Risk Gamblers (on CPGI) as a function of Subtype Percent of Each Cluster Scoring Low and High on the CPGI 1=cop/enh, 2=enh, Cluster 3=low er 100.0% 1

2 3 Percentage of each cluster 80.0% 60.0% 40.0% 20.0% 0.0% low high CPGI group 1 = COP (n=22); 2 = ENH (n=65); 3 = Low ER (n=81) Study 4: Heart Rate Increase to Alcohol and VLT Play as a Function

of Gambler Subtype Background: Heart Rate & Reward Alcohol intake leads to resting heart rate increases (e.g., Conrod et al., 2001; Stewart et al., 1992) Positively related to feeling energized in regular drinkers (Conrod et al., 2001) Suggested marker for susceptibility to alcohol reward and reinforcement (e.g., Brunelle et al., 2003; Peterson et al., 1993) Background: Heart Rate & Reward

Heart rate increases may apply to a variety of addictive behaviours Heart rate increases have also been seen in gamblers when gambling (e.g., Coventry & Norman, 1997; Meyer et al., 2004) Two prior studies show heart rate increases to alcohol and gambling alone and in combination in regular gamblers (Stewart et al., 2005, 2006). Experimental Design 2 x 3 x 3 mixed model Between subjects factors:

Beverage condition: alcohol vs. placebo control Gambler subtype: COP vs. ENH vs. Low ER Within subjects factor Testing time: pre-drink vs. post-drink vs. VLT play (spinning reels) Participants 72 regular VLT players Recruited from the community Mean age: 35 years old 38 males; 34 females 47 NPG; 25 PPG (SOGS) Play VLTs 1.9 times per week, on average IGS Cluster Analysis

3 2.5 2 1.5 1 Negative Situations 0.5 Positive Situations 0 -0.5 -1 -1.5 ENH (N=36) LOW ER (N=31) COP (N=5)

Characteristics of Subtypes Enhancement (ENH) SOGS total scores Gambling frequency (per week) Drinking frequency (per week) Number of drinks per week Number of drinks while gambling p < 0.02 4.97 (3.84)* Low Emotion Regulation (LOW ER) 2.03 (1.85)* 2.26 (1.27)* 1.45 (.92)*

2.36 (1.51)* 1.56 (.79)* 11.98 (1.24)* 7.87 (1.34)* 4.60 (3.64)* 2.74 (2.61)* Heart Rate Analyses DV = % change from pre-drink (sober) baseline ANOVA revealed hypothesized three-way interaction (p = .036)

Beverage Condition X Subtype X Testing Time Follow-up simple effects analyses for heart rate response at Post-Drink and VLT play Heart Rate Percent Change from Predrinking Baseline VLT Play 16% 14% p p==.03 .03 12% 10% Placebo 8% Alcohol 6% 4%

2% 0% ENH LOW ER Studies 1-3: Conclusions Three subtypes of gamblers were consistently identified based on cluster analyses of IGS scores and validated with the GMQ: This subtyping scheme applies to

a group that gambles purely for positive reinforcement (pure enhancement; ENH) a group that gambles for both positive and negative reinforcement, but mainly for negative reinforcement (coping; COP) a group that gambles for neither positive nor negative reinforcement (low emotion-regulation; LOW ER) Pathological gamblers who drink when gambling Regular gamblers drawn from the community University student gamblers Similarities to Blaszczynski & Nowers (2002) and Lesieurs (2001) subtypes (and to those mentioned by Grant, 2007): ENH antisocial, impulsivist gamblers; impulsive action seekers COP emotionally vulnerable gamblers; impulsive escape seekers LOW ER behaviorally-conditioned gamblers; normal gamblers Previous Sub-Typing Schemes Researchers Proposed Subtypes

Stewart et al. (Studies 1-4) Lesieur (2001) (2 of 3) McCormick (1987) Blaszczynski et al. (1990) Blaszczynski & Nower (2002) (2 of 3) Grant (2007 yesterdays talk) Coping Gamblers Impulsive Escape Seekers Recurrently Depressed DepressionProne Emotionally Vulnerable Anxious/ Depressed/

Obsessional Enhancement Gamblers Impulsive Action Seekers Chronically Under-Stimulated BoredomProne Antisocial Impulsivist Pleasure/Urge & General Impulsivity Need for Stimulation Studies 1-4: Conclusions Contrary to hypothesis, no pure coping motivated gambler was identified

when coping-motivated gambling occurs, it occurs most often in combination with enhancement-motivated gambling, although coping appears the primary motivation Remains to be determined if therapy needs to focus on the primary motive, or both motives given both are elevated Unexpectedly, a third group emerged which was characterized by low levels of both positive and negative situation gambling More research needs to focus on understanding the underlying motives for gamblers in the Low EmotionRegulation cluster; external vs. internal motives (Cooper, 1994)? Studies 1-4: Conclusions Relations of Gambling Clusters to Motivations for Drinking (Study 1)

At least among problem gamblers who drink when gambling, the underlying motivations for the two behaviors are similar Consistent with third variable interpretation of high co-morbidity of alcohol gambling disorders Possibility of motives as traits Further evidence of utility of sub-types: Vary in expected ways in terms of reward vs. relief gambling outcome expectancies (Study 2) Varying expectancies may be a function of differing sensitivities to various reinforcing consequences of gambling (e.g., ENH gamblers more sensitive to reward consequences of alcohol plus gambling; Study 4) Clinical Implications (Studies 1-4) Results may be useful in designing sub-type specific

interventions for pathological gamblers aimed at level of underlying motives (cf. Conrod et al., 2000b) Study 1 results may also be useful in helping design interventions for co-morbid problem gamblers problem drinkers Evidence for consistency of motives across gambling and alcohol use suggests that the particular motives underlying both forms of addictive behavior should be a primary focus of treatment in a given co-morbid client. Gamblers in the Enhancement gambling cluster should have their underlying enhancement motives for gambling/alcohol use be a primary target of therapy. Gamblers in the Coping gambling cluster should have their primary coping motives for gambling/alcohol use be primary targets of therapy (at least).

Clinical Implications Study 2 results may also be useful in helping design content of matched interventions for gambler subtypes Gamblers in the Enhancement gambling cluster should have their reward gambling outcome expectancies be a focus of treatment using expectancy challenge techniques (Darkes & Goldman, 1993) Gamblers in the Coping gambling cluster should have their relief gambling outcome expectancies (at least) be a focus of treatment using expectancy challenge techniques (Darkes & Goldman, 1993) Need more information on the motivations for gambling in the Low Emotion-Regulation subtype before we can design effective interventions for their gambling; other types of gambling expectancies/other faulty cognitions in this group? Clinical Implications

Study 3 results Suggest treatment matching may also be useful in prevention / early intervention since similar subtypes evident even among young, relatively less experienced gamblers (see Conrod et al., 2006; Watt et al., 2006) Study 4 results Suggest the possible utility of naltrexone as a matched treatment for ENH gamblers (OMalley, 1996; Peterson et al., 2006) Consistent with suggestions by Grant (talk yesterday) Proposed Treatment Matching Study for

Gamblers Stewart, Barrett, & Hodgins (grant under review) problem gamblers COP ENH TAU + ENH Tx TAU Tx ENH Low ER COP Low ER ENH COP Low ER

TAU + COP Tx ENH COP Low ER TAU control Mismatched Matched pre TAU control Mismatched Matched post TAU control

Mismatched Matched F.U. Expected Results 1 16 14 12 10 pre post follow-up 8 6 4 2 0 control mismatched

matched Expected Results 2 TAU ALONE TAU + ENH Tx TAU + COP Tx 16 14 12 10 pre post follow-up 8 6 4 2 0 LER ENH COP LER ENH COP LER ENH COP

Gambler Subtype Questions?

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