Behavioral Addictions in the Setting of DSM-5: NYU Silver's Spring Seminar Series Tackles Gambling Disorder
On Friday, February 13, the NYU Silver School of Social Work presented “Behavioral Addictions in the Setting of DSM-5: Biological and Clinical Considerations,” the first installment of its Spring 2015 Seminar Series on Behavioral Disorders. Eileen Wolkstein, director of the Office of Global and Lifelong Learning, made opening remarks to a sold-out crowd of social workers, and presented an overview of the diverse array of continuing education program offerings slated for the spring.
Dr. Marc Potenza, the instructor of this seminar, serves as director of the Center of Excellence in Gambling Research at Yale University. His research interests focus on pathological gambling and impulse control disorders. He structured the three-hour presentation around the changing role of gambling within the context of the DSM-5 and current opinions on the best evidence-based modalities for treating gambling addiction. Potenza encouraged an open format for the seminar and engaged with the audience to field questions and comments about the implications of behavioral addictions on clinical practice and their reclassification in DSM-5.
In the latest edition of the DSM, gambling addiction, previously known as “pathological gambling,” has been reclassified as “gambling disorder” and is now categorized as an addictive disorder within the category of “behavioral addictions.” Internet gaming disorder, another addictive behavior considered for inclusion, was ultimately placed in Section III of the manual as a topic for future research. By creating these discrete categories, the DSM-5 makes a distinction between behavioral and substance addictions. Potenza said, “This distinction is somewhat problematic because all addictions involve behaviors, and while each of the addictions has as somewhat different pattern of withdrawal, they all have biological elements.”
Potenza addressed the role of the Internet in behavioral addictions. Pathological gambling rates, he shared, may be correlated with the changing technological landscape of the 21st century. The advent of computers, smart phones, and Internet technology has increased the number of gambling platforms available to consumers, as well as access to them. Advertisements and social media have proliferated online gambling, and the constant onslaught has proven especially potent for high-volume Internet consumers such as adolescents.
Behavioral addictions do not exist in a vacuum. Research has shown that with increasing problem gambling severity, one also sees increasing odds for other axis I disorders (especially major depressive disorders) and substance abuse disorders in both men and women. Severity of pathological gambling behavior, Potenza related, was also statistically significantly linked to the severity of comorbid axis I disorders. Potenza also shared a National Epidemiologic Survey on Alcohol and Related Conditions study that found a robust correlation between pathological gambling severity and rates of axis II disorders (personality disorders).
In addition to the correlation between behavioral addictions and mental health diagnoses, Potenza noted the high rate of co-occurrence of pathological gambling in tandem with tobacco, alcohol, and marijuana use.
Potenza then steered the seminar toward the field of impulse control disorders, a class of psychiatric disorders characterized by impulsivity. The DSM-5 classifies pyromania, intermittent explosive disorder, kleptomania, sexual compulsion, Internet addiction, and compulsive shopping as categories of impulse control disorders, but substance-related disorders (including gambling disorder) also deal heavily with an individual’s ability to resist temptations, urges, and impulses. In differentiating between addictive behaviors and compulsivity, Potenza shared, it’s helpful to “view it as the disorder realm vs. trait/feature realm.”
Potenza urged clinicians when screening individuals for impulse control disorders to be mindful of the higher likelihood of non-disclosure among this population due to shame, guilt, and/or an unwillingness or ambivalence about changing behaviors. When treating individuals with impulse control disorders or gambling addiction, the most effective modalities include cognitive and other behavioral therapies, imaginal desensitization, and motivational interviewing. Dopamine agonist medications such as Naltrexone (a nutraceutical) have also been found to be effective in the treatment of symptoms of pathological gambling and impulse control disorders; however, no pharmaceuticals are currently FDA approved for the treatment of behavioral addictions. And Potenza, utilizing a biopsychosocial framework, cautioned that “etiology may be multifactorial—environmental, individual, and biological factors also play a big role.”