The importance of cognitive factors in increasing the risk to develop and maintain the pathological gambling in adolescents. Implications in therapy

Pathological gambling is currently one of the problems most serious young people are facing. It is characterized by an impulsive discontinuation associated with compulsiveness, manifested by the use of gambling behavior that leads to disfavor in personal, family, school and / or professional life.

The onset of this condition is in adolescence. Dependence circumscribes behavioral changes such as the need to increase gambling to satisfy sensation, resistance associated with irritability and anxiety, preoccupation with gambling and gambling problems [1,2].

Children and adolescents represent the segment of the population most at risk of developing impulse control disorder. This can have devastating consequences for those concerned due to the increasing availability, accessibility and diversity of gambling in the current society. Pathological gambling is currently one of the most serious problems faced by children and adolescents.

It is obvious that adolescents and children are increasingly playing due to the availability, affordability and variety of games in the environment. Studies conducted in recent years around the world have indicated that about 10% of adolescents have gambling problems such as gambling related lies, social relationships, excessive concern and the lack of detachment to stop their practice, repeated loans and / or theft of money to be able to continue playing, school absenteeism due to games [3].

Pathological gambling is defined in DSM-IV (APA, 1994) and DSM-IV-TR (APA, 2000) as an “inadvertent, persistent and repetitive practice of the game, satisfying at least 5 of the 10 proposed criteria inclusion, provided they do not appear in a manic episode [4]. In DSM 5 (2013), pathological gambling was introduced as a single disorder in the category of “addictive and substance-related disorders,” the subcategory “substance-free disorder” [5].
4 criteria of 9 are sufficient for diagnosis. The item was dropped: “committing illegal acts to continue the game”.
The social consequences can be as severe as in the case of drug addictions (alcohol or heroin):
-Expulsion
-Loss of family or relationships with friends and colleagues
-Financial difficulties

Numerous studies have concluded that early exposure in childhood and adolescence to gambling is a major risk factor for pathological gambling in adulthood (Burge et al., 2006).

There are high-risk games such as sports betting, card games (eg black-jack, poker) as well as the use of electronic gaming machines that creates the young players the illusion of controlling and mastering the game, which leads to exaggerated involvement in the game. Young people’s beliefs and attitudes about the game are important to understanding the mechanisms involved in persistent play. There are 2 types of control:
a) the illusion of control;
b) internal control of the “locus of control”.

Children and adolescents believe that skill and luck play an important role in winning the game. These age segments are twice as vulnerable because they have developed skills in the use of technology that allows access to all types of gambling, and on the other hand because they are developing, they have a psychological vulnerability. In view of these considerations and the fact that prevalence studies show an alarming increase in the rate of gamble between 11-19 years of age, primary prevention measures are needed [6].
Gamblers develop a perception of illusory control over gambling and money, overestimating the win possibilities.

Cognitive factors that lead to increased risk for developing pathological gambling are:
– The eronate perception of skill and luck in the game;
– Control illusion [7,8,9];
– Superstitions and rituals – the wrong assignment of the cause-effect relationship between two events occurring at random [10,11,12,13];
-The wrong pitch between independent games.

A relevant example is the following:
George, 24, a student in the last year at a college in Cluj-Napoca, had problems with betting and sexuallydangerous behavior, becoming acquainted with different females on the Internet, with whom he then met, spending big amounts of money. In this context, he almost neglected his college obligations despite the fact that he had a very good cognitive potential. He answered affirmatively 16 of the 20 questions of the Gamblers Anonymous . and also met the DSM-IV-TR and ICD-10 criteria for pathological gamble. To him, the idea of
illusory control of the game was obvious, in the sense that, although he was very intelligent, he did not distinguish between “betting sessions”. Thus, at a certain moment, he bet on a very large sum: 10,000 RON for 14 sporting results, of which he was 13. The last result he was expecting online on the Internet meant a match NBA basketball. He had a team that led the score to the last few seconds, but had been equalized by the opposing team, following extensions. These extensions were won by the team he was betting, but in the field of sports betting, this result was recorded as being equal, so he lost the big win with which, of course, he could have paid all his accumulated debts. Despite these situations, he was very excited and sure that next time he would win the “big pot” because he was so close.

In the cognitive-behavioral psychotherapy that took place over 12 sessions, we insisted greatly on irrational gambling cognitions and especially the illusion of the possibility of correlating the results of two successive games. In fact, the two sessions have no connection and every time theoretically there is the same chance of winning. In parallel, Carbamazepine therapy also followed. 200 mg, 3×1 tb / day, 6 months. We also approached the issue of sexual risk behavior, discussing all its implications [1].

Another significant example we noticed is another case that lost within 2 months 60000 Euro and which considers that the loss would be due to a frog that would have jumped in front of him when entering the playground and which canceled his luck.

The importance and specificity of cognitive disorders is a very current field of investigation. Ladouceur et al. (1996) were the first to study the dysfunctional thoughts of players by the “verbalizing” method, in which the player expresses out loud all the thoughts that went through his mind during the game. Considering the classification of irrational thoughts proposed by Ladouceur et al. (2004), several authors, such as Walker (1992), Griffiths (1994), Coventry and Norman (1998), Delfabbro and Winefield (2000), found more than 70% irrational thoughts [10,14,15,16].

Among these, there are some superstitions or some rituals that were considered by the players to increase their chances of winning, such as rubbing the car or blowing the lever, wrongly attributing a cause-andeffect relationship between two events [10,11,12,13], the illusion of control (overestimation of the degree of contingency between actions and outcomes) [7,8,9], the minimization of the hazard, the certainty of earning money without taking into account losses, the certainty that the continuation of the game would increase the chances of winning.

Children and adolescents believe that skill and luck play a role in winning the game.
We conducted a study on 1032 participants, Cluj and Harghita counties, 65.57% male and 34.43% female selected by convenience criterion. The participants were ages 11 to 19 [17].
Adolescents completed 20 GA-RAs (Gamblers Anonymous-Revised for Adolescents) and 20 other questions. The first 20 questions in GA-RA refer to gambling behavior and its consequences, and the other 20 questions relate to age, gender, family description, family income, school, class, school results, absenteism, the reason why they were playing, drug use, favorite and frequented gambling, the maximum amount bet on a gambling session [17].

Of all participants 72.96% plays occasionally without any problems. The gender gap was as expected, with male sex being more involved in pathological play (91.66% of the pathological gamblers) more than female sex (8.33% of the pathological gamblers).
The study made it possible to divide the sample into 3 groups according to the results obtained at 20 GA-RA (Table I):
– Level 1 – 0-1 points – non-occasional players / players
– Level 2 – 2-6 points – gamblers gamble
– Level 3 – ≥ 7 points – Pathological gamblers

As we can see, half of the questioned adolescents about the perception of control in the game say they can control the results of the game, and so much so that the chance has no importance in the game.

In another study we analyzed the risk factors for gamble play in adolescents in Romania, on a group of 231 high school and vocational school students aged 14-18, from the counties of Cluj, Satu-Mare and Argeş [18].

The research design was represented by an anonymous questionnaire which included the risk factors: unfavorable family environment (physical abuse, physical and / or educational neglect), social mobility (resources and / or social relationships), family situation (number of brothers, cohesion family, divorce, conflict, parental education level), physical or psychological traumas, or serious family injuries, physical or psychological trauma or serious injuries suffered by the subject, affective factors (the recent rupture of an amorous relationship), and “The 20 questions of Gamblers Anonymous “to establish the diagnosis. A change has been made on item ranking by including subclinical diagnostic categories more informative of the frequency and magnitude of gambling disorder.  

The most significant risk factors for this type of addiction were: divorce / separation of parents, serious physical illness of a family member, death of a family member, discontinuation of an affective relationship, a serious mental illness of a family member, the presence of a serious accident in the past. In 14% of the pathologists, co-morbidity with the use of illegal drugs was found. Sexual abuse of puberty and adolescence has also been found to be a major risk factor for pathological play. There are two robot portraits of adolescent pathological players:
1) A 15-16 year old teenager from a family and socially unfavorable environment where he faces various stressors and traumas, ranging from neglect to physical and sexual abuse. In this context, we can interpret the addiction to play as a mechanism for coping with chronic stress;
2) 15-16 year old teenager from a family and a favorable social environment, with an average income, where the reason for adolescent neglect is the parents’ most frequent program. In this case, gambling seems to be a way of to fill their free time and to attract their attention [19].

The results showed that 34% of the subjects do not attend games or occasionally attend them-level 1; 54% are problem-level 2 players; and 12% are thirdlevel pathologists.

In the case of the problem game – Level 2, the most important risk factors were: home change (61%), the presence in a family member’s history of a mental illness (60%), or severe physical (59%), death a family member (57%), the presence of a severe physical illness (55%), the single parent situation (50%).

For the level 3 pathological gambling, the most important risk factors were: the history of a serious accident, the psychological or somatic illness of a family member, the termination of an affective relationship, the death of a family member or the divorce of the parents. Subjects identified as pathological players were significantly higher (29%) among those who suffered a serious accident than those who did not experience such an event (10%), or even the sample group (12%).

Sexual abuse was 3 times more frequent in pathological players than in problem gamblers and significantly more frequently than non-players. Concerning co-morbidity with other types of addiction, the most important was the correlation between pathological play and the use of illegal substances: 3% of non-players said they had used such substances at least once versus 14% in the case [20,21].

The most important identified consequences of gambling involve the deterioration of the relationship with parents. In a significantly higher proportion, the pathologists had frequent quarrels with their parents about gambling, and the game was forbidden by them.

In order to carry out a national prevalence study, we conducted a representative sample for the target population of the school population aged between 11 and 19 who were questioned (N = 2006), 48.3% were male and 51.7% female and 21.2% came from rural areas. The mean age of the study participants was 15.04 years with a standard deviation of 2.33years.

THE PERCEPTION OF GAMBLING
79% of gamblers or gamblers consider that they have gambled more than they have expected to in the last 12 months.
To the question “Do you consider the risk that you are more influencing the outcome of the game?” 3.8% (76) of the respondents considered that they are often the ones who determine the outcome of the game of chance. This is, in fact, one of the most powerful irrational cognitions that causes pathological gambler to continue, even if he loses or wins, and the reason why he/she often returns to recover the lost amount.

Of those at risk, 55.0% believe they control the outcome of the game of chance. This percentage becomes worrying, especially if this cognition remains unchanged.

Cognitive-behavioral psychotherapy of pathological play is recommended by associating individual and group therapy. An important aspect of therapy is represented by correcting erronated beliefs about the possibility of game control;

The intervention is based on correcting the misconceptions of the subjects as to the event.

This therapy has four components:
1. Understanding the concept of chance.
Pointing out that each round is independent and does not exist strategies to control the outcome, making it impossible to control the game.

2. Understanding the irrational beliefs of the player.

It explains how the illusion of control contributes to the maintenance of habits related to gambling and correcting irrational beliefs the player has.

3. Awareness of erroneous perceptions.
The player is informed that the game is predominant erroneous perceptions, and the distinction between verbalizations is explained appropriate and inappropriate.

4. Cognitive correction of wrong perceptions.
Therapist corrects inappropriate verbs and beliefs irrational, players try to control and predict the results games that are objectively uncontrollable. illusion control motivates them to develop strategies to gain more money.
The Canadian authors with great experience in this field, recommend cognitive-behavioral psychotherapy of pathological play by associating a therapy individual and group [22]. According to the cited authors, the therapy comprises 5 stages:
1) informing about the game;
2) correction of erronate beliefs about the possibility of control of game;
3) “training” to solve the game issue;
4) “training” of social skills;
5) prevention of relapses.

1. Information on the game
This initial phase aims at informing the player about which means a game of chance and money. This may seem surprising to most clinicians, but most players know relatively little about the substrate of these games.

It must be pointed out that hazard is the only thing that governs the game, that the different laps are totally independent, there is no strategy to favor the player in the long run, that the game can trigger illusory perceptions of control, and that the game is always perceived for the benefit of the casino (Establishment).

At this stage, the psychotherapist will write down the misconceptions of the player.
2. Correction of misconceptions

The subject will be invited to use the voice thinking method, which is to say out loud everything he says to himself [23]. Next, the clinician accompanies the client at a game session and records his words.
If in vivo experience is not possible, it can be used Directed imagery, as is the case with desensitization systematic. The psychotherapist shows (points out) the patient his misconceptions, the predominance of inappropriate verbalisation. The patient will need to identify at least 80% of inappropriate verbalisation. Then follow the correction and cognitive restructuring [24].
3. Training to solve the game problem pathologic
It is an extremely important phase that involves 5 steps:
a) general orientation on the game;
b) definition and formulation of the problem;
c) enumeration of potential solutions;
d) applying a solution;
e) verification of efficacy. The patient is taught to apply this approach when he is in delicate situations (D’Zurilla, 1986).

4. Social skills training
The player learns the role-playing, refusing to make some negative comments unfavorable to its peers and to develop a convenient social network convenient.

5. Prevent relapse
Most therapists claim that the most important phase in all this is the stage of maintaining abstinence and fighting against the problems of psychological addiction to the game.

In conclusion, cognitive factors contribute substantially increasing the risk of maintaining pathological gambling adolescents, which has major implications in therapy.

BIBLIOGRAPHY :

1. Lupu, V. (2008). Jocul patologic de noroc la adolescenţi, Editura Risoprint, Cluj-Napoca.
2. Todirita (Lupu) Izabela Ramona(2014) Pathological gambling in children and adolescents measuring instruments, prevalence and prevention – summary – PhD Th esis. Babeș-Bolyai University Faculty of Psychology and Educational Sciences Department of Psychology Cluj-Napoca
3. Gupta R., Derevensky J.L., și Martin I.(2006). Clean Break, produced by International Centre for Youth gambling Problems&High – Risk Behaviors,McGill University,Montreal, Quebec,Canada).
4. Diagnostic and Statistical Manual of Mintal Disorders. 4th Edition (DSM-IV), (1994). American Psychiatric Association, Washington, DC.
5. Diagnostic and Statistical Manual of Mintal Disorders, DSM-5, 5th edition, (2013). Washington, DC, London, England.
6. Todiriţă, I.R., și Lupu, V. (2011). Profi laxie și intervenţie în jocul patologic de noroc, În A.I. Grădinaru (Coord.), De la intervenţie în psihologie, II, (pp. 102-118), București, România: Editura Universitară.
7. Langer, E. (1975). Th e illusion of control, Journal of Personality and Social Psychology, 32, 311-328.
8. Langer, E.J., și Roth J. (1975). Heads you win, tails it’s chance: the illusion of control as a function of the sequence of outcomes in a purely chance task, Journal of Personality and Social Psychology, 32, 951-955.
9. Delfabbro, P. (2004). Th e stubborn logic of regular gamblers: obstacles and dilemmas in cognitive gambling research, Journal of Gambling Studies, 20 (1), 1-21.
10. Walker, M. B. (1992). Irrational thinking among slot machine players. Journal of Gambling Studies, 8, 245-288.
11. Ladouceur, R., și Walker M. (1996). A cognitive perspective on gambling. In P. M. Salkovskis (Ed.), Trends in cognitive and behavioural therapies, 89-120. New York: John Wiley și Sons.
12. Toneatto T., Blitz-Miller T., Calderwood K., Dragonetti R., și Tsanos A. (1997). Cognitive distortion in heavy gambling. Journal of Gambling Studies,13, 253-266.
13. Joukhador, J., Blaszczynski, A., și Maccallum F. (2004). Superstitious beliefs in gambling among problem and non-problem gamblers: preliminary data, Journal of Gambling Studies, 20 (2), 171-180.
14. Griffi ths M.D.(1994): Th e role of cognitive bias and skill in fruit machine gambling. Br. J . Psychol.; 85: 351-369.
15. Coventry K., Norman.(1998): Arousal, erroneous verbalizations and the illusion of control during a computer-generated gambling task. Br. J. Psychol.89: 629-645.
16. Delfabbro P.H., Winefi eld A.H. (2000): Predictors of irrational thinking in slot-machine gambling.J. Psychol.134: 17-28.
17. Lupu V.,Todiriţã I.R. Updates of the Prevalence of Problem Gambling in Romanian Teenagers. J.Gambl. Stud.2013,29,1, 2936.
18. Lupu, V., Boros, S., Miu, A., Iftene, F. și Geru, A. (2001). Factori de risc pentru jocul patologic de noroc la adolescentii români. Revista SNPCAR, [Risk factors in pathological gambling in Romanian adolescents], SNPCAR Magazine, 4 (4), 33-38.
19. Lupu, V. (2009). Romania. In: G. Meyer, T. Hayer, M. Griffi ths, (Eds.): Problem Gambling in Europe. Challenges, Prevention, and Interventions. Editura Springer, New-York , 229-241.
20. Saiz-Ruiz, J., Moreno Oliver, I., Lopez-Ibor Alino, J.J. (2001). Pathological gambling: A clinical and therapeutic-evolutive study of a group of pathological gamblers. Actas Luso-Espanolas de Neurologia Psiquiatria y Ciencias Afi nes, 20, 189-197.
21. Lesieur H.R, Blume S.B.(1991): Evaluation of patients treated for pathological gambling in a combined alcohol,substance abuse and pathological gambling treatment unit using the Addiction Severity Index. Br. J.Addict.86(8):1017-1028.
22. Ladouceur, R., Ferland, F., Roy, C., Pelletier, O., Bussieres, E.-L., Auclair, A. (2004). Prévention du jeu excessif chez les adolescents : une approche cognitive. Journal de Th érapie Comportementale et Cognitive, 14, 3, 124-130.
23. Gaboury A., Ladouceur R. (1989): Erroneous perceptions and gambling. J. Soc. Behav. Pers., 4:411-420.
24. Blackburn I., Cottraux J., (1988): Th erapie cognitive de la depression. Masson, Paris.