Decision making, cognitive distortions and emotional distress: A comparison between pathological gamblers and healthy controls
Introduction
Gambling disorder has been defined as a “persistent and recurrent problematic gambling behavior leading to clinically significant impairment or distress” (American Psychiatric Association, 2013, p.585). The negative consequences arising from gambling (e.g., occupational, relationship, and/or financial problems) do not necessarily deter problem gambling. In fact, counter intuitively, many individuals with a gambling disorder are typically unable to cease the problematic behavior and are prone to chasing losses in an attempt to recover the money lost (Lesieur, 1979, Linnet et al., 2006). Furthermore, it has been empirically demonstrated that problem gamblers show a foreshortened time horizon, since they are likely to consider the immediate consequences rather than the long-term outcomes (Ciccarelli, Malinconico et al., 2016, Cosenza et al., 2016, Nigro et al., 2016).
Although the etiology of gambling disorder is complex and multifaceted, several studies have identified poor decision making (Wiehler & Peters, 2015), cognitive distortions (Goodie & Fortune, 2013), and emotional distress (Lorains, Cowlishaw, & Thomas, 2011) as among the most critical factors associated with problem gambling. However, no study to date has taken into account the interplay of these factors when examining gambling disorder. A large body of research has indicated that problem gamblers perform more poorly than healthy controls in behavioral decision making tasks (see Wiehler & Peters, 2015 for a review), such as the Iowa Gambling Task (IGT; Bechara, Damasio, Damasio, & Anderson, 1994). The IGT is a laboratory task that mimics real-life decisions in conditions of reward and punishment, as well as decision making under uncertainty.
Originally, the IGT was developed to capture decision making fallacies in patients with ventromedial cortex damage (Bechara et al., 2005, Bechara et al., 1994). These patients showed a compromised ability to experience and/or to express appropriate emotions, as well as impaired decision making ability, while preserving a normal intellect. Starting from these observations, Damasio, Tranel, and Damasio (1991) formulated the somatic marker hypothesis (SMH; Damasio, 1994). The SMH states that emotions are important features in choice processing as they can guide or bias (consciously or unconsciously) decision making behavior. The SMH postulates that decision making process can be assisted by somatic markers (i.e., specific types of feelings expressed through somatic states). The somatic markers are represented and regulated in the ventromedial prefrontal cortex, which associates the implicit representations of affects with the explicit representations of potential actions and outcomes. In this way, the somatic markers influence decisions, acting as alarms for bad choices or incentives for good choices (Damasio, 1994).
Similarly to ventromedial prefrontal patients, gamblers appear unable to consider long-term benefits, probably due to a lack of response flexibility or chasing losses (see Goudriaan et al., 2005, Kertzman et al., 2011, Linnet et al., 2006). According to other authors, poor decision making stems from a decreased reward sensitivity (Goudriaan, Oosterlaan, de Beurs, & van den Brink, 2006), an excessive response to cues predicting immediate and large monetary rewards (Brevers, Bechara, Cleeremans, & Noël, 2013, p. 9; see also Lakey, Goodie, & Campbell, 2007), an anomalous reward processing (Lorains et al., 2014), or disrupted basic emotional processing (Brevers et al., 2012).
Cognitive distortions concern misbeliefs about gambling outcomes and the likelihood of influencing them (Clark et al., 2013, Goodie and Fortune, 2013, Griffiths, 1994, Jacobsen et al., 2007), such as skill misperceptions, illusion of control, superstitious beliefs, selective memory for wins, and interpretative biases (Toneatto, 1999).
Converging evidence from studies examining the association between cognitive distortions and problematic gambling have demonstrated that gamblers tend to misattribute cause-and-effect relationships to unlinked events, and believe they can influence gambling outcomes (e.g., Cosenza and Nigro, 2015, Joukhador et al., 2004, Myrseth et al., 2010). Interestingly, several studies suggest that the appropriate use of mathematical and probabilistic rules in daily life do not appear to be a protective factor from gambling (Benhsain and Ladouceur, 2004, Delfabbro et al., 2006, Sévigny and Ladouceur, 2003). However, even though non-problem gamblers are unable to profit from the knowledge of probabilistic rules (e.g., Joukhador, Maccallum, & Blaszczynski, 2003), many aspects differentiate them from problematic gamblers in terms of quantity (e.g., Ciccarelli, Griffiths et al., 2016, Miller and Currie, 2008) and quality of distorted beliefs (e.g., Källmen, Andersson, & Andren, 2008). However, arguably the most relevant aspect regards the insensitivity to disconfirming evidence (Ladouceur, 2004).
Finally, research has indicated that problem gambling is frequently associated with negative affective states, such as negative mood (Griffiths, 1995, Matthews et al., 2009) and/or anxiety disorders (e. g., Kessler et al., 2008, Petry et al., 2005). More specifically, some epidemiological surveys suggest that nearly half of all problem gamblers suffer from mood disorders (e.g., Kim et al., 2006, Lorains et al., 2011), and that pathological gamblers undergoing treatment report severe depression (Ladouceur et al., 2006). Other studies have provided evidence that individuals may use gambling for mood modification, that is to find relief from negative states and to increase arousal when bored (e.g., Nower and Blaszczynski, 2010, Stewart et al., 2008, Wood and Griffiths, 2007, Wulfert et al., 2005). Gee, Coventry, and Birkenhead (2005) found higher levels of anxiety during and after gambling and concluded that gambling could result in mood modification. Finally, experimental studies attempting to clarify the causal relationship between mood and gambling severity have highlighted differences in mood before and after gambling, but have failed to find effects of induced mood on gambling (e.g., Hills et al., 2001, Mishra et al., 2010).
Given that no study to date has ever examined the relationship among decision making, cognitive distortions, and negative affective states in pathological gambling, the aim of the present study was to investigate the interplay among these variables by comparing pathological gamblers and healthy controls. It was hypothesized that compared to healthy controls, pathological gamblers would show (a) poorer decision making ability, (b) higher levels of cognitive distortions, and (c) higher levels of emotional distress. It was also hypothesized that there would be strong correlations between these variables and gambling severity.
Section snippets
Participants
The sample comprised 108 males aged 24–65 years (mean age = 41.56 years; SD = 10.94). Of these, 54 were pathological gamblers (PGs) with a DSM-5 (APA, 2013) diagnosis of gambling disorder, and recruited from Local Health Trusts. The pathological gamblers were matched with 54 healthy controls (HCs) recruited from the community. No pathological gamblers had comorbid mental disorders, neurological and/or medical illnesses, or were undergoing any pharmacological treatment. Healthy controls had no
Results
Zero-order correlations revealed significant positive associations between all measures and problem gambling severity, as well as between IGT and GRCS scores (Table 1).
For analyzing the profile of the IGT performances of the two groups per block, a 2 × 5 repeated measures ANOVA was run, with group (HCs versus PGs) as a between-subjects factor and scores on the five subsequent IGT blocks as dependent variables. The analysis revealed a significant within-subjects effect of block (F4, 103 = 8.27; p
Discussion
The present study addressed an identified gap in literature regarding the relationship between pathological gambling, decision making, cognitive distortions, and emotional factors (i.e., depression, anxiety and stress). This was achieved in an experimental task comparing a group of confirmed pathological gamblers with a group of healthy controls, and determining which of these factors most accounted for gambling disorder. As expected, a negative correlation between IGT scores and problem
Conclusions
The present study is the first ever to simultaneously examine the relationship between decision making, cognitive distortions, and emotional distress in a confirmed sample of pathological gamblers (compared to healthy controls).
In line with previous literature, the present study demonstrated that pathological gamblers showed deficits in decision making processes, and reported more irrational beliefs and higher levels of anxiety and depression compared to healthy controls. Additionally, the
Declaration of interest
All other authors declare that they have no conflicts of interest.
Role of funding organizations
No funding was provided for this study.
References (88)
- et al.
Decision-making and addiction (part I): Impaired activation of somatic states in substance dependent individuals when pondering decisions with negative future consequences
Neuropsychologia
(2002) - et al.
Insensitivity to future consequences following damage to human prefrontal cortex
Cognition
(1994) - et al.
The Iowa Gambling Task and the somatic marker hypothesis: Some questions and answers
Trends in Cognitive Sciences
(2005) - et al.
The Italian version of the Depression Anxiety Stress Scales-21: Factor structure and psychometric properties on community and clinical samples
Comprehensive Psychiatry
(2015) - et al.
Decision making under ambiguity but not under risk is related to problem gambling severity
Psychiatry Research
(2012) - et al.
Wagering the future: Cognitive distortions, impulsivity, delay discounting, and time perspective in adolescent gambling
Journal of Adolescence
(2015) - et al.
A comparison of individual and group cognitive-behavioural treatment for female pathological gambling
Behaviour Research and Therapy
(2007) - et al.
Decision making in pathological gambling: A comparison between pathological gamblers, alcohol dependents, persons with tourette syndrome, and normal controls
Cognitive Brain Research
(2005) - et al.
Psychophysiological determinants and concomitants of deficient decision making in pathological gamblers
Drug and Alcohol Dependence
(2006) - et al.
Risk-taking decisions in pathological gamblers is not a result of their impaired inhibition ability
Psychiatry Research
(2011)
Pathological gambling and mood disorders: Clinical associations and treatment implications
Journal of Affective Disorders
Perceptions among pathological and nonpathological gamblers
Addictive Behaviors
Group therapy for pathological gamblers: A cognitive approach
Behaviour Research and Therapy
The structure of negative emotional states: Comparison of the depression anxiety stress scales (DASS) with the beck depression and anxiety inventories
Behaviour Research and Therapy
An italian translation and validation of the consideration of future Consequences-14 scale
Personality and Individual Differences
Substance abuse, pathological gambling, and impulsiveness
Drug and Alcohol Dependence
Pathological gambling: A comprehensive review
Clinical Psychology Review
Reward-based decision making in pathological gambling: The roles of risk and delay
Neuroscience Research
Diagnostic and statistical manual of mental disorders
Diagnostic and statistical manual of mental disorders
Diagnostic and statistical manual of mental disorders
Cognitive distortions, anxiety, and depression among regular and pathological gambling online poker players
Cyberpsychology, Behavior, and Social Networking
Knowledge in statistics and erroneous perceptions in gambling
Gambling Research: Journal of the National Association for Gambling Studies
Anxiety and/or depression in the pathogenesis of addictive gambling
Substance Use and Misuse
A pathways model of problem and pathological gambling
Addiction
The association of alcoholism and anxiety
Psychiatric Quarterly
Iowa gambling task (IGT): Twenty years after-gambling disorder and IGT
Frontiers in Psychology
Decision-making, cognitive distortions and alcohol use in adolescent problem and non-problem gamblers: An experimental study
Journal of Gambling Studies
Reward preferences of pathological gamblers under conditions of uncertainty: An experimental study
Journal of Gambling Studies
Pathological choice: The neuroscience of gambling and gambling addiction
Journal of Neuroscience
Stress and anxiety as factors in the onset of problem gambling: Implications for treatment
Stress Medicine
Youth at stake: Alexithymia, cognitive distortions, and problem gambling in late adolescents
Cognitive Computation
Risk-taking, delay discounting, and time perspective in adolescent gamblers: An experimental study
Journal of Gambling Studies
Deciding with (or without) the future in mind: Individual differences in decision-making
Descartes' error: Emotion, reason, and the human brain
Somatic markers and the guidance of behavior: Theory and preliminary testing
It's not what you know, but how you use it: Statistical knowledge and adolescent problem gambling
Journal of Gambling Studies
Prevalence of psychiatric co-morbidity in treatment-seeking problem gamblers: A systematic review and meta-analysis
Australian and New Zealand Journal of Psychiatry
Longitudinal links between impulsivity, gambling problems and depressive symptoms: A transactional model from adolescence to early adulthood
Journal of Child Psychology and Psychiatry
Epidemiological associations between gambling behavior, substance use & mood and anxiety disorders
Journal of Gambling Studies
Psychosocial stress and its relationship to gambling urges in individuals with pathological gambling
The American Journal on Addictions
Cognitive distortions as a component and treatment focus of pathological gambling: A review
Psychology of Addictive Behaviors
Controlling the uncontrollable: Effects of stress on illusory perceptions of controllability
Journal of Personality and Social Psychology
Erroneous perceptions and gambling
Journal of Social Behavior and Personality
Cited by (86)
Association between endocrine and neuropsychological endophenotypes and gambling disorder severity
2024, Addictive BehaviorsTheorising Gambling Self-Exclusion Agreements: The Inadequacy of Procedural Autonomy
2023, Canadian Journal of Law and JurisprudenceThe Role of Irrational Beliefs on Psychological Distress among Female Office Workers in Bali
2024, Acta Medica Philippina