A Carte Scoperte Ancona 11 ottobre 2012 Dott. Adriano Baldoni Il gioco patologico, nuove evidenze e nuove prospettive organizzative per i Dipartimenti Dipendenze Patologiche: Il Progetto Games Over

Ogni famiglia italiana spende in media 2500 euro annui per il gioco. La maggior parte famiglie povere (56%), il 66% disoccupati. 1-3% della popolazione sviluppa problemi di gioco; dati confermati da altri studi europei (Francia, 2008; Germania, 2009), con prevalenza maggiore in studi Americani e Australiani (fino al 4-5%). La diffusione esplosiva negli ultimi anni del gioco patologico

misleading concept of substance abuse ignorance about drug use disorders prejudice, stigma, discrimination moral consequence of a guilty choice survey results which show that 63% of Americans view alcoholism as a "moral weakness Substance dependence is as much a disorder of the brain as any other psychiatric illness Lo stigma (ONU Gerra – office on drugs and Crimes)

Uso Associato di Droghe Relative risks of associated addictions in pathological gamblers (from Petry, 2005) Associated addictionORIC 95% Smoking6.7[ ] Alcohol6.0[3.8–9.7] Drugs4.4[2.9–6.6]

Comorbilità psichiatrica Relative risk of concomitant psychiatric disorders in pathological gamblers (from Petry, 2005) Concomitant disordersORIC 95% Personality disorders8.3 [5.6–12.3] Mood disorders4.4[2.9–6.6] Anxiety disorders3.9[2.6–5.9]

Neurobiologia del Gioco patologico: ERP e gioco (J.Hewig et al. 2010) Following a bust on the previous trial,the probability of hitting decreased for control participants (.45)but increased for gamblers (.57) p.015. Gamblers behavior could be attributed to insensitivity to losses (busts) or hypersensitivity to rewards (no-busts)? Positive potential following no-busts was significant at p.05.

Neurobiologia del Gioco patologico: FMRI (H.C. Breiter, et al. 2001) Significant NAc signal change is illustrated for the voxel-by-voxel correlational analysis performed post-hoc. Gray-tone averaged structural MRI images for the 12 subjects underlie pseudocolor p value maps for correlation of the difference signal against the simulated g function. Note that left NAc activation is observed for this post- hoc comparison solely for the good to intermediate spinner comparision Target a priori regions included the nucleus accumbens (NAc), the sublenticular extended amygdala of the basal forebrain (SLEA), the amygdala, the hypothalamus, the ventral tegmentum of the midbrain (VT), and the orbital cortex (GOb).

Neurobiologia del Gioco patologico: FMRI (S.F. Miedl, et al. 2009) Activation pattern and percent signal change (±1 SEM) derived from the high-risk vs. low-risk contrast in PG vs. OG (Pb0.001 uncorrected) in the pulvinar nucleus of the thalamus (Tha), inferior frontal gyrus (IFG), and superior temporal gyrus (STG) during a quasi-realistic blackjack scenario. The medial pulvinar nucleus of the thalamus isreciprocally interconnected with the cingulate gyrus and other limbic structures (Morgane et al., 2005) and is consid ered to play a crucial role in learning and memory (Mitchell et al., 2008), emotional experience and expression, drive and motivation (Schmahmann, 2003).

Neurobiologia del Gioco patologico: Il paradosso D2-aloperidolo (M.Zack & C.Poulos, 2005) Mean (SEM) self-reported desire to gamble before and after a 15-minute slot machine game in pathological gamblers (n = 20) and controls (n = 18) under haloperidol (3- mg, oral) and placebo. Haloperidol increased the rewarding, priming, and physiological activating effects of gambling in pathological gamblers. (PET) studies by Volkow et al. (2002), found an inverse correlation between D2 receptor availability and subjective rewarding effects of the psychostimulant methylphenidate in healthy volunteers.

Neurobiologia del Gioco patologico: I sistemi Neurotrasmettitoriali (F. D. Zeeb et al., 2009) Both d-amphetamine and the 5-HT1A receptor agonist, 8-OH-DPAT, impaired task performance. (rats) In contrast, the dopamine D2 receptor antagonist, eticlopride, improved performance, whereas the D1 receptor antagonist, SCH23390, had no effect. These data suggest that both serotonergic and dopaminergic agents can impair and improve gambling performance

Neurobiologia del Gioco patologico: Genetic and Environmental Influences on Disordered Gambling in Men and Women ( W.S. Slutske, et al., 2010) The estimate of the proportion of variation in liability forDGdue to genetic influences was 49.2% (95% confidence interval, ). There was no evidence for shared environmental influences contributing to variation in DG liability. There was no evidence for quantitative or qualitative sex differences in the causes of variation in DG liability.

Neurobiologia del Gioco patologico: Similarities and differences between pathological gambling and substance use disorders (R.F. Leeman & M.N. Potenza, 2012) Frontal cortical regions Response impulsivity tasks: PG/problem gamblers demonstrate less activity than do controls.SUD/substance users also demonstrate lessactivity than controls. Compulsivity tasks: PG/problem gamblers demonstrate, less activity than do controls. Lesion studies suggest vmPFC and dlPFC are important for task performance. Risk/reward tasks: PG/problem gamblers demonstrate less activity than do controls. In PD, less activity among those with ICDs, greater activity in those without ICDs. Most findings also suggest less activity in SUD groups than in controls. Striatum Baseline: Limited results have been variable regarding D2-like receptor availability in PG. Limited evidence suggests dorsal hyperactivity. Reduced D2-like recept availability in SUD/substance users. Dorsal hyperactivity in SUD also. Impulsivity and compulsivity tasks: Limited findings suggest no differencesbetween PG and controls.Limited findings suggest no differences between substance users and controls. Anterior cingulate cortex (ACC) Findings that loss chasing is associated with elevated activity in healthy adults suggest a role in gambling.Associated with risky decision-making in SUDs. Insula Activated by healthy adults and occasional gamblers during gambling tasks and by healthy adults inresponse to near misses during gambling tasks.Activated in response to reward by substance users. White matter integrity PG reduced FA values in the corpus callosum. Poor white matter integrity observed diffuselyboth in heavy substance users and in SUDs

Neurobiologia del Gioco patologico: Pathological Gambling: Biological and Clinical Considerations ( J. L. Topf et al., 2009) Pathological gambling (PG) is categorized as an impulse control disorder (ICD). Phenomenological, neurobiological and pharmacological data suggest similarities in the pathophysiologies of substance use disorders (SUDs) and PG. Both behavioral and pharmacological approaches, including those that have been empirically validated for SUDs, have shown promise in the treatment of PG. When compared to findings from neurobiological studies of SUDs, multiple similarities exist.

Neurobiologia del Gioco patologico: Pathological Gambling: Biological and Clinical Considerations ( J. L. Topf et al., 2009) Petry and colleagues (2006) compared the efficacy of GA versus CBT in a sample of 231 individuals with PG who were randomly assigned to one of three conditions... both CBT and CBT workbook conditions were associated with significantly greater improvements during treatment, and these improvements were partially maintained at one- year follow-up. GA attendance adherence, CBT sessions completed and CBT workbook sessions completed were associated with gambling abstinence. These datasuggest that combined CBT and GA attendance is effective in treating PG.

Le fasi dell'abitudine nel Gioco Patologico (Custer, 1982) 1) Fase Vincente: gioco occasionale, gioca soprattutto per divertirsi e passare il tempo. (tipicamente maschile, dura 3-5 aa) ; 2) Fase Perdente: spende sempre più tempo e più soldi nel gioco, inizia linseguimento della perdita (dura > 5 aa); 3) Fase della Disperazione: ha perso completamente il controllo sul gioco, truffe, perdite, aggressioni, prestiti ; 4) Fase Cruciale: Le sofferenze famigliari, esternamente presuntuoso, internamente conflittuale e angosciato (suicidi, crisi,drammi); (Fasi di Guarigione) 5) Fase Critica: smette, lavora, chiede aiuto, 6) Fase di Ricostruzione: migliori relazioni, progetti; 7) Fase di Crescita: smette di pensare al gioco, stabilità dei rapporti, futuro.

Le fasi dell'abitudine nel Gioco Patologico Fase 1: l'incontro con l'abitudine; Fase 2: l'equilibrio (deriva borderline); Fase 3: La Crisi (o la richiesta di terzi);

Le funzioni psicologiche dell'abitudine nel Gioco Patologico Vantaggi di soddisfazione –piacere /coping; Vantaggi secondari dellabitudine e sue conseguenze sulle relazioni significative; Mantenimento di stabilità, coesione e valore di Sé in condizioni di disagio apparentemente non modificabili; Contrasto e trasgressione dello sviluppo naturale.

Fattori predisponenti al Gioco Patologico (Guerreschi, 1998) genitore alcolista; perdita di un genitore (per decesso, divorzio o abbandono) prima delladolescenza; assenza affettiva dei genitori; incongruenza delle regole date dai genitori o rigidità eccessiva; poca attenzione al risparmio e alla pianificazione del bilancio familiare; esposizione al gioco dazzardo in famiglia.

Gioco Patologico e psicoterapia (Per Carlbring et al., 2010) The aim of this study was to test the effectiveness of motivational interviewing, cognitive behavioral group therapy, and a no-treatment control (wait- list) in the treatment of pathological gambling. This was done in a randomized controlled trial at an outpatient dependency clinic at Karolinska Institute (Stockholm, Sweden). A total of 150 primarily self- recruited patients with current gambling problems were randomized to four individual sessions of motivational interviewing (MI), eight sessions of cognitive behavioral group therapy (CBGT), or a no- treatment wait-list control. Instead, both MI and CBGT produced significant within-group decreases on most outcome measures up to the 12-month follow-up.

Gioco Patologico e Mindfulness ( Chad E. Lakey and W. Keith Campbell, 2007) Two studies were conducted to test and explain the relation of mindfulness to the severity of gambling outcomes among frequent gamblers. In both studies, dispositional mindfulness related to less severe gambling outcomes as measured by a DSM- IV-based screen for pathological gambling, even after controlling for gambling frequency and dispositional self-control. These studies suggest a role for mindfulness in lessening the severity of gambling problems and making adaptive decisions, especially in risk- relevant contexts.

I trattamenti nel Gioco Patologico Psicoterapia individuale: inserita in una struttura progettuale, con controllo del gioco, coinvolgendo la rete; Psicoterapia della famiglia: attenta alle comunicazioni ma anche ai problemi fiduciali specifici; Programma di psico-educazione: funzione preventiva informativa ma anche di abbattimento delle difese all'intake; Gruppi di auto aiuto: gestiti da operatori formati, sostiene l'arresto della patologia; Psichiatra: gestione delle comorbilità, terapia di sintomi bersaglio, gestione delle crisi depressive individuali e familiari; Tutoraggio: gestione dei problemi economici e sostegno alle difficoltà quotidiane; Consulente finanziario; Comunità - Diurni: per ora difficile per assenza di LEA.

I trattamenti nel Gioco Patologico I gruppi, la psicoterapia e la supervisione: La supervisione nel trattamento del gap aiuta a mantenere lattenzione sulla storia personale dei pazienti e a mantenere la coesione dei terapisti Il sintomo non è più lelemento centrale del trattamento ma lo diventa ilprocesso (mentale, di costruzione della identità del paziente e del contesto terapeutico/ relazionale).

Gli attuali risultati neurobiologici e psicoterapici indicano l'approccio integrato alla persona ed alla rete, come essenziali al trattamento, in grado di intervenire specialisticamente e in modo differenziato in gruppi eterogenei di utenti con diverse linee di sviluppo e compromissione bio-psico-sociale. Una valutazione dellimpatto è sempre necessaria considerata laumento della prevalenza ai servizi e la particolarità-diversità del servizio, per cui nasce la necessità di Altri Spazi fisici e di Mentalizzazione, da cui il nostro progetto Games Over. Conclusioni: I Dipartimenti e il Gioco Patologico