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Comparison of Craving Between Pathological Gamblers and Alcoholics
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  Comparison of Craving Between Pathological Gamblersand Alcoholics Hermano Tavares, Monica L. Zilberman, David C. Hodgins, and Nady el-Guebaly Background: Cravingisacentralphenomenoninaddiction.Temperamentfactorsarealsoimportantforpathologicgamblingandotheraddictions.Theaimofthisstudywastocomparecravingbetweenpathologicgamblers (PG) and alcohol-dependent subjects (ADS), correlating craving with personality. Methods:  Forty-nine PG and 101 ADS willing to start treatment were recruited. A trained psychiatristdiagnosed them according to DSM-IV criteria. To be included in this study, subjects had to be abstinent forat least five days and no longer than 21 days. Alcoholics should have no significant physical withdrawalsymptoms by the time of craving assessment. Subjects with current comorbidity with other addictions wereexcluded, except nicotine. ADS rated craving for alcohol and PG rated craving for gambling on the samequestions, respectively. Both answered a semistructured interview, the Temperament and Character In- ventory and the Beck Scales for anxiety and depression. Results:  Pathologic gamblers scored higher than ADS on craving measures (  p    0.001) and noveltyseeking (  p  0.01). ADS scored higher in harm avoidance (  p  0.01). Alcohol craving correlated positively with anxiety and novelty seeking and negatively with length of abstinence and persistence. Gamblingcraving correlated positively with depression and negatively with length of abstinence and reward depen-dence Conclusions: PathologicgamblersexperiencedstrongercravingsthandidADS.Thismaybeadisturbingexperience for PG and a potential cause for relapse. The higher scores on novelty seeking concur withprevious studies that associate PG and impulsivity. ADS higher scores on harm avoidance suggest anxiety vulnerability.Thepositiverelationbetweenalcoholcraving,anxiety,andharmavoidancesuggeststhatADSrely on alcohol to deal with a proclivity to negative emotions. The positive relation of gambling craving todepression and negative relation to reward dependence suggests that individuals who have a lesser suscep-tibility to experience positive emotions are the ones who most miss gambling when abstaining. Key Words:  Alcohol Dependence, Pathologic Gambling, Craving, Personality. S INCE THE 1980S, the focus on addiction diagnosis hasgradually shifted from the emergence of neuroadapta-tion signs (i.e., tolerance and withdrawal) to behavior andsubjective experience, namely, 1) craving; 2) loss of control;and 3) maintenance of behavior despite adverse conse-quences (Shaffer, 1999). Craving has received increasedattention as a critical phenomenon in addiction psychopa-thology Robinson and Berridge, 1993). Koob 2000 definedcraving as the desire or the memory of the pleasant expe-rience superimposed on a negative affective state. Hence,conceptually, craving combines elements of desire/motiva-tion and emotions.Temperament, the inheritable side of personality, hasalso been defined as individual differences in motivatedbehavior and emotional response (Livesley, 2001). Fewstudies have explored the impact of personality dimensionson craving. One cue-reactivity study in alcoholics reporteda positive relationship between level of reactivity and neu-roticism and introversion (McCusker and Brown, 1991). Also, neuroticism and impulsivity have been correlated with craving in nicotine- and opiate-dependent subjects(Powell et al., 1990; Powell et al., 1992; Reuter and Netter,2001). Pathologic gamblers (PG) appear to be a heteroge-neous group. Nonetheless, there is a convergence regardingimpulsivity and neuroticism as personality traits acting asrisk factors for pathologic gambling (Raylu and Oei, 2002). Although impulsive and risk-taking behavior are undeni-able features of PG (Martins et al., 2004), there is consid-erable controversy involving the sensation-seeking trait.Few studies have reported higher sensation-seeking for PG  From the Department of Psychiatry, Gambling Outpatient Unit, Faculty of  Medicine, University of Sa˜o Paulo (HT, MLZ), Sa˜o Paulo, Brazil; the Department of Psychiatry, Addiction Centre, Faculty of Medicine, University of Calgary (NeG), Calgary, Canada; and the Department of Psychology,University of Calgary (DCH), Calgary, Canada. Received for publication May 31, 2004; accepted May 3, 2005.Supported in part by the National Council on Research and Development, Brazil (CNPq) (HT, MLZ), and Alberta Gaming Research Institute, Alberta,Canada (AGRI) (HT, DCH, NeG). Presented at “Rethinking Addiction: How Gambling and Other Behavioral Disorders Are Changing the Concept and Treatment of Alcohol and Sub- stance Use Disorders,” Las Vegas, Nevada, December 2002. Dr. Hermano Tavares, Gambling Outpatient Unit, Faculty of Medicine,University of Sa˜o Paulo, R. Purpurina 155 cj. 126/128, Sumarezinho, Sa˜o Paulo-SP 05435-030, Brazil; Fax: 55-11-38143920; E-mail: hermanot@uol.com.br Copyright © 2005 by the Research Society on Alcoholism. DOI: 10.1097/01.alc.0000175071.22872.98 0145-6008/05/2908-1427$03.00/0 A  LCOHOLISM : C LINICAL AND  E XPERIMENTAL   R ESEARCH Vol. 29, No. 8 August 2005  Alcohol Clin Exp Res,  Vol 29, No 8, 2005: pp 1427–1431  1427  as compared with nongamblers, most studies showing nodifferences, and some even lower scores on Zuckerman’sSensations Seeking Scale (Parke et al., 2004). However, theSensations Seeking Scale does not have a one-factor struc-ture, and studies suggest that boredom proneness, a sub-trait of sensation-seeking, and depression may be determi-nants of gambling behavior among PG rather thanexcitement seeking (Blaszczynski et al., 1990; Hammel-stein, 2004).Studies using Cloninger’s temperament model haveshowed a consistent association between one personalitydimension, novelty seeking, and addictive behavior (Clon-inger, 1996). Novelty seeking emerged from independentstudies as a marker of impulsivity across several addictivebehaviors, alcohol, nicotine, binge eating, and gambling(Kim and Grant, 2001; Kleifield et al., 1994; Nixon andParsons, 1990; Pomerleau et al., 1992; Zilberman et al.,2003). Individuals with high novelty seeking may be partic-ularly vulnerable to craving and addiction because of lackof ability to postpone gratification, especially under unfa- vorable emotional states. Accordingly, Petry and Casarella(1999) reported that substance abusers with gambling prob-lems chose smaller and immediate rewards over larger anddelayed rewards when compared with substance abusers without gambling problems on a discount delay paradigm.To date, we found only two studies addressing craving inpathologic gambling. Castellani and Rugle (1995) reportedthat PG scored higher than normal control subjects andcocaine-dependent subjects on personality traits measuresrelated to the inability to resist urges and cravings. Anotherstudy compared PG and frequent but nonpathologic gam-blers. PG reported more frequent craving (Duvarci andVaran, 2000). We found no studies providing direct mea-sures of gambling craving, comparative data to other ad-dictions, or the specific impact of personality on gamblingcraving.In this study, we compare the cravings of PG with crav-ings of alcohol-dependent subjects (ADS). As secondarygoals, we want to examine the association between craving,negative emotional state, and temperament factors among ADS and PG separately and compare their temperamentprofile. We hypothesize that if addictive behaviors sharethe same roots, then both gambling and alcohol craving willcorrelate with negative emotions and with the same tem-perament factor, novelty seeking. MATERIALS AND METHODS Sample Subjects were recruited among patients seeking outpatient treatment atcommunity agencies and a hospital-based treatment center in Calgary,Canada, between April 2001 and November 2002. Additional advertise-ment was placed on local newspapers targeting ADS and PG interested intreatment for quitting their addiction. Psychiatric assessment and treat-ment advice were offered. Volunteers were initially screened by phone andasked to abstain from any mood-altering substance and from gambling.Volunteers who reported current problems with both alcohol and gam-bling, a current drug addiction (excluding nicotine), a history of deliriumtremens or severe abstinence symptoms, or more than 21 days of absti-nence were excluded. Forty-nine PG and 103 ADS were personally as-sessed by a psychiatrist. A structured interview modeled after the SCID-I(First et al., 1997) of DSM-i.v. criteria for pathologic gambling, alcohol,and drug dependence was used (APA, 1994). Three PG reported currentalcohol abuse but did not meet criteria for dependence; six had a pasthistory of alcohol dependence but were abstinent for more than one year.Seventeen ADS reported current drug abuse but did not meet criteria fordependence; 39 had a past history of drug dependence but were abstinentfor more than one year. Two ADS were excluded because of currentcomorbidity with drug addiction. The final sample had 150 subjects, 49 PGand 101 ADS, all fulfilling DSM-i.v. criteria.The study protocol was approved by the Conjoint Medical EthicsReview Committee, University of Calgary, and work with human subjectsreported here complies with the guiding policies and principles for exper-imental procedures of the World Medical Association Declaration of Helsinki (2002).  Measures Two scales were developed after the Weiss Craving Scale (WCS),designed by Weiss et al. (1995): one to evaluate the intensity of craving foralcohol in ADS and another to evaluate the intensity of craving forgambling in PG. The five-item scales assess craving in the 24-hour periodbefore the interview, with questions about strength and frequency of urges, response to craving cues, and likelihood of relapsing if facing theenvironment where the addictive behavior usually takes place. Examples:“Please rate how strong your desire for alcohol was during the past 24hours”; “Please rate how often you had the urge to drink during the past24 hours.” Questions in the gambling scale replaced “desire for alcohol”and “urge to drink” for “desire for gambling” and “urge to gamble.”Possible responses range from zero (no) to nine (extremely). The sum of scores from each item provides a final score ranging from zero to 45.The Penn Alcohol Craving Scale (PACS) evaluates the overall severityof craving for alcohol in the week before the assessment. It is a five-itemmeasure that assesses frequency and time spent thinking about alcohol,difficulty in resisting relapse opportunities, and strength of craving epi-sodes (example: “How often have you thought about drinking or abouthow good a drink would make you feel during the past seven days?”).Responses range from zero (never, none, not at all) to six (nearly all,strong, all the time) (Flannery et al., 1999). The adaptation for PG wasdone by replacing the words “drink” and “drinking” for “gambling.” Thesum of scores from each item provides a final score ranging from zero to30.The Temperament and Character Inventory is a 240 item self-reportquestionnaire with true-or-false statements developed to assess dimen-sions of two broad domains of personality: temperament and character. Inthis study, we focused on temperament factors; hence, character scores were not computed. According to Cloninger (1987), temperament factorsare mostly heritable, corresponding to independent brain systems forbehavior activation, inhibition, and maintenance. Four factors were mea-sured: 1) novelty seeking: a tendency toward frequent exploratory behav-ior and intense excitement in response to novel stimuli, scoring zero to 40;2) harm avoidance: a tendency to respond intensely to aversive stimuli andto learn to avoid punishment, scoring from zero to 35; 3) reward depen-dence: a tendency to maintain behaviors previously rewarded, usuallymanifested as sentimentality and social attachment, scoring from zero to24; and 4) persistence: a tendency to persevere despite fatigue or frustra-tion, scoring zero to eight.Negative emotional states were assessed by the Beck Depression In- ventory (BDI) (Beck et al., 1988a), a self-administered, 21-item measure, with responses ranging from zero (least) to three (most) that assessesdepressive symptoms in the past seven days. Likewise, anxiety was assessedby the Beck Anxiety Inventory (BAI) (Beck et al., 1988b), a self-administered, 21-item measure, with responses ranging from zero (not at 1428  TAVARES ET AL.  all) to three (severely) that assesses anxiety symptoms in the past sevendays.Total days of abstinence at the time of assessment was computed asanother potential moderator of craving.  Procedures Selected subjects were monitored regularly by phone regarding days of abstinence and symptoms of physical withdrawal from alcohol. A face-to-face interview was booked when the subject completed at least five days of abstinence and physical symptoms of withdrawal had ceased. This timeframe of five to 21 days of abstinence was devised to optimize themeasurement of craving while minimizing the impact of physical with-drawal over alcohol craving. At the assessment, ADS answered a semi-structured interview aiming at demographic data and diagnosis confirma-tion, the self-report questionnaires, and the alcohol version of the cravingscales. PG went through the same assessment and questionnaires butanswering to the gambling version of the craving scales instead. Statistical Analysis Two sets of data analysis were conducted. In the first set, a preliminaryexploratory univariate comparison contrasted PG and ADS for possibledifferences in demographics and potential moderators of craving (i.e., theBDI score, the BAI score, and total days of abstinence), other than temper-ament factors.    2 tests with continuity correction for 2  2 tables and  t  tests were used, respectively, for categorical and continuous data. Analyses of covariance were then conducted to compare PG and ADS in regard tocraving intensity and temperament factors, having age as covariate.In the second set of analyses, correlations between craving and poten-tial moderators and temperament factors were investigated separately forPG and ADS in a preliminary exploratory univariate analysis. Pearson’scorrelation coefficients were obtained. Variables with a correlation coef-ficient significant at 0.10 or lower entered a stepwise linear regression. TheSPSS software package (1997) was used for statistical analysis. RESULTS No significant differences were found between PG and ADS for demographics and craving moderators, except forage ( t [148]  2.4,  p  0.017). Table 1 describes the demo-graphic profiles of ADS and PG. Mean of positive DSM-IVcriteria (out of 10) for PG was 8.2 (SD  1.3; 82%). Meanof positive DSM-IV criteria (out of seven) for alcoholdependence was 5.8 (SD  1.3; 83%). The mean scores onthe BDI and BAI were, respectively, 21.5 (SD  11.0) and16.5 (SD  12.5), which indicate moderate levels of depres-sion and anxiety; mean number of days of abstinence atassessment time was 11.8 (SD    4.9). No statistically sig-nificant differences were found between ADS and PG re-garding these variables.Pearson’s correlation showed that the scores on WCSand PACS were highly correlated (  r   0.82;  p  0.001,  n  150). The srcinal value range on the PACS was adjusted tothe WCS range by multiplying the PACS values by 1.5(standardized PACS score). A combined craving score wasobtained by the sum of the standardized PACS score andthe WCS score. Analyses of covariance were performed,controlling for age. PG and ADS differed significantly re-garding the craving score (  F  [1,147]  16.6,  p  0.001). PGhad a mean score of 48.9 (SD  23.7), and the ADS mean was 35.1 (SD    21.8). Significant differences were alsodetected for two personality factors, with PG scoring higherthan ADS on novelty seeking (respectively, M  23.6 [SD  5.9], M  21.8 [SD  6.6],  F  [1,147]  6.8,  p  0.010) andlower on harm avoidance (respectively, M    17.0 [SD   8.0], M  20.8 [SD  8.3],  F  [1,147]  6.9,  p  0.010). Forcomparison, US normative data (Cloninger et al., 1993) fornovelty seeking and harm avoidance are, respectively, 19.2(SD  6.0) and 12.6 (SD  6.8).Pearson’s correlation analyses (  n    101) found signifi-cant correlations between ADS craving scores and the BAIscore (  r     0.37,  p    0.001), the BDI score (  r     0.35,  p   0.001), total days of abstinence (  r   0.28,  p  0.005), age (  r    0.25,  p    0.012), persistence (  r     0.38,  p    0.001),novelty seeking (  r   0.32,  p  0.001), and harm avoidance(  r     0.28,  p    0.005). These variables entered a linearstepwise multiple regression and the final model is de-scribed in Table 2. The regression model was highly signif-icant (  R 2  .34,  F  [4,96]  12.1,  p  0.001).Pearson’s correlation analyses found significant correla-tions between PG craving scores (  n    49) and the BDIscore (  r     0.34,  p    0.018), total days of abstinence (  r    0.40,  p    0.005), and reward dependence (  r     0.40,  p   0.005). These variables entered a linear stepwise multipleregression; they all held in the final model, which is de-scribed in Table 3. The regression model was highly signif-icant (  R  2  0.40,  F  [3,45]  9.81,  p  0.001). Table 1.  Profiles of Alcohol Dependent Subjects (ADS) and PathologicalGamblers (PG) ADS (   n  101) PG (   n  49) Test  p GenderMale 40 (40%) 22 (45%)    2 [1]  0.194 nsFemale 61 (60%) 27 (55%) Age (y)Mean (SD) 40.7 (11.4) 45.4 (11.3) t[148]  2.4 0.017Marital statusMarried 34 (34%) 24 (49%)    2 [1]  2.65 nsSingle, divorced, orwidowed67 (66%) 25 (51%)Formal education (y)Mean (SD) 13.0 (2.45) 13.2 (2.27) t[148]  0.368 nsCultural groupEnglish Canadian 85 (84%) 37 (76%)    2 [1]  1.11 nsOther 16 (16%) 12 (24%)Employment statusWorking 42 (42%) 28 (57%)    2 [1]  2.61 nsNot working 59 (58%) 21 (43%)Days of abstinenceMean (SD) 12.1 (4.71) 11.3 (5.31) t[148]  0.904 ns Table 2.  Linear Regression for Craving Among Alcohol Dependent Subjects(   n  101) Variables  CoefficientStandardErrorStandardized   Coefficient  t p BAI a score 0.568 0.145 0.334 3.91   0.001Days of abstinence   1.081 0.398   0.234   2.72 0.008Persistence   2.334 0.903   .229   2.58 0.011Novelty seeking 0.609 0.291 0.184 2.10 0.039Constant 36.36 10.3 – 3.53 0.001 a Beck Anxiety InventoryCOMPARISON OF CRAVING BETWEEN GAMBLERS AND ALCOHOLICS  1429  CONCLUSIONS This investigation provides the first objective and quan-titative assessment of gambling craving under partially con-trolled circumstances. In accordance with the addictionmodel of gambling, PG experienced intense craving, evenhigher than ADS, suggesting that craving might be a dis-turbing experience for PG undergoing treatment and apotential cause for relapse. In previous research focusingon the relapse process, we found that giving into urges wasdescribed as the main reason for 11% of 244 gamblingrelapse episodes (Hodgins and el-Guebaly, 2004).The higher scores in novelty seeking differentiating PGfrom ADS concur with Castellani and Rugle (1995), whoreported that PG scored significantly higher on impulsivityand inability to resist craving. It is well known that noveltyseeking is inversely related to age (Cloninger et al., 1993).It should be noted, however, that the age difference be-tween ADS and PG cannot be responsible for observeddifferences in novelty seeking, since PG were older than ADS. ADS higher scores on harm avoidance suggest agreater vulnerability to anxiety (Ball et al., 2002) compared with PG. Accordingly, anxiety remained in the final regres-sion model as the strongest predictor of alcohol craving. As predicted, negative affect and days of abstinencesignificantly correlated with both alcohol and gamblingcraving. However, alcohol craving correlated with depres-sion and anxiety but more strongly with anxiety, whereasgambling craving correlated only with depression. The neg-ative correlation between craving and days of abstinencereinforces the clinical perception that craving episodes de-crease with abstinence, which can be used as an encourag-ing argument for patients initiating and continuing treat-ment.The results regarding temperament factors partly con-firmed our initial hypothesis and were partly surprising.Personality did affect craving expression but in different ways for alcohol and gambling. As predicted, novelty seek-ing was associated with alcohol craving but not gamblingcraving, despite the fact that novelty seeking was a promi-nent trait of the PG personality. The temperament scoresof our ADS are remarkably similar to those obtained byBasiaux et al. (2001). In their study, ADS scored signifi-cantly higher than normal control subjects in novelty seek-ing. In our study, PG scored even higher than ADS. Thisfinding is puzzling because, with novelty seeking being sucha prominent trait of the PG temperament and having pre-sented such high levels of craving, one could suppose they would be related, just as we did on the study hypotheses.On the other hand, it concurs with previous findings thatreport drug-addicted patients as more impulsive than thenorm and PG as even more impulsive than drug-addictedpatients (Castellani and Rugle, 1995; Petry and Casarella,1999). It is possible that impulsiveness, as measured bynovelty seeking, is an important factor for initiation of gambling behavior (Vitaro et al., 2001), but apparentlyother factors are at play for the maintenance of gamblingand craving.Reward dependence has been reported as a predictor of positive emotionality (Zelenski and Larsen, 1999). Its neg-ative relationship to gambling craving suggests that individ-uals who have a lesser propensity to experience joy orhappiness are the ones who miss gambling the most whenabstaining. In our analysis of relapse episodes, 13% weredescribed as related to unstructured time or boredom(Hodgins and el-Guebaly, 2004). Watson and colleagues(1988) have related increased negative affects to both anx-iety and depression, whereas decreased positive affects were related only to depression. Taken together, our datasuggest that ADS turn to alcohol as a way to deal with theirproclivity to negative emotions, in particular, anxiety.Meanwhile, PG seem to turn to gambling as a way to cope with depressive feelings and lack of positive experiences inlife.We relied on the self-report of abstinence of our partic-ipants and, although they were encouraged to provide hon-est reports, no collateral or biochemical confirmation wasobtained. We also did not control for environmental crav-ing cues. The results of these exploratory analyses requireconfirmation with other samples. The requirement for min-imal alcohol withdrawal symptoms may have skewed theselection of volunteer ADS toward less severe cases. None-theless, the similar percentages of DSM-i.v. criteria fulfilledby ADS and PG suggest comparable levels of addictionseverity. Finally, the clinical nature of our sample hindersgeneralization for subjects outside treatment settings. A study conducted with naturalistic samples of ADS and PG would be warranted to confirm the findings of this prelim-inary study.Nevertheless, the differences found in craving intensityand correlates for ADS and PG underscore the need fordifferent strategies for their clinical management. For in-stance, ADS undergoing craving would require emphasison relaxation and techniques aiming to decrease negativeemotions, whereas PG would potentially benefit from in-terventions targeting early relief of depression symptomsand replacement of the activity and joy once prompted bygambling. By comparing a model of behavioral addiction(gambling) with a substance addiction (alcohol), this studyhighlights the importance of psychological factors such aspersonality and emotional imbalance in shaping cravingand addiction. Table 3.  Linear Regression for Craving Among Pathological Gamblers (   n  49) Variables  coefficientStandarderrorStandardized   coefficient  t p Reward dependence   1.899 0.572   0.385   3.32 0.002Days of abstinence   1.723 0.519   0.386   3.32 0.002BDI a score 0.586 0.256 0.267 2.29 0.027Constant 82.55 12.8 – 6.45   0.001 a Beck Depression Inventory 1430  TAVARES ET AL.   ACKNOWLEDGMENTS The authors thank the staff of the Addiction Centre, FoothillsHospital, Alberta Alcohol and Drug Abuse Commission, and Aventa Treatment Centre for Women (Calgary, Alberta). REFERENCES  American Psychiatric Association (1994) Diagnostic and Statistical Man-ual of Mental Disorders (DSM-IV). 4th edition. Washington, DC.Ball S, Smolin J, Shekhar A (2002) A psychobiological approach topersonality: examination within anxious outpatients. 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