Problem Gambling and Reward Inflexibility

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“A gambling disorder (GD) is characterized by a lack of self-regulation. Patients suffering from this disorder are not able to inhibit their urge to gamble, and are unable to shift their behavior. Because of the similarities between GD and substance use disorders it is now generally seen as a non-substance related addictive disorder. Further, there is clear connection between GD and obsessive compulsive disorder. A core feature of these both disorders is the inability to stop repetitive detrimental behavior.”

One specific process related to the lack of self-regulation suggested to underlie GD is cognitive (behavioral?) inflexibility associated with reward learning. More specifically, we refer to a tendency to hold on to behavior that has been profitable before, but no longer leads to gain. In patients with GD, this reward-based cognitive inflexibility presumably can be observed as some kind of continuous gambling even in the face of increasing losses.

Reward-based cognitive inflexibility, i.e., reversal learning, has been associated with the orbitofrontal cortex, the ventral prefrontal cortex, the ventrolateral prefrontal cortex and is facilitated by dopaminergic activity in the ventral regions of the striatum. The concept of reward-based cognitive inflexibility is also closely related to the concept of reward sensitivity and the concept of impaired decision making under conflicting contingencies…GD-patients have non-reward-based cognitive inflexibility and suffer from perseveration.

GD was associated with cognitive inflexibility with reward, but not with inflexibility without reward. Importantly, they found a relationship between cognitive inflexibility with and without reward in GD.

t GD-patients have higher levels of cognitive inflexibility without reward, that GD-patients are more cognitive inflexible with reward and that cognitive inflexibility with and without reward are not related. Further, the relationships between self-reported symptoms related to cognitive inflexibility (i.e., obsessive compulsive disorder symptoms), psychological distress, and cognitive inflexibility with and without reward were studied. This was done in order to find out if cognitive inflexibility was related to OCD-symptoms and psychological distress and to possibly obtain insight in which form of cognitive inflexibility is more related to and more relevant for the phenotypical manifestations of GD. Lastly, we studied the association between the cognitive inflexibility with and without reward in both GD and controls.

Further, they displayed more reward-based cognitive inflexibility. No evidence was found that GD was related to non-reward-based cognitive inflexibility, i.e., perseveration. In the GD-group, reward-based and non-reward-based cognitive inflexibility were not related. Reward-based cognitive inflexibility was significantly related to level of psychological distress; more inflexible GD-patients reporting more symptoms. A near-significant correlation was found between reward-based cognitive inflexibility and OCD-symptoms. Non-reward-based cognitive inflexibility was not related to level of psychological distress or OCD-symptoms.

In the control group, no relationship was found between the two forms of cognitive inflexibility, and between cognitive inflexibility and symptoms. In the total group, however, significant relationships were found between reward-based cognitive inflexibility on one side and psychological distress and OCD-symptoms on the other. Non-reward-based cognitive inflexibility was not related to level of psychological distress or OCD-symptoms. Once again, reward-based and non-reward-based cognitive inflexibility were not related.

The findings in the present study suggest that:

reward-based cognitive inflexibility characterizes GD-patients in contrast to non-reward-based cognitive inflexibility
GD-patients, in other words, do not seem to have problems with general flexibility in strategy and behavior, but do have difficulties with altering a response that is rewarded before, but no longer is (i.e., a dysfunctional focus on rewards).
This is line with findings of several studies that suggest that GD is intertwined with reward-based cognitive inflexibility
reward-based and non-reward-based cognitive inflexibility are not related in GD.

Therefore, it seems that the reward-based cognitive inflexibility observed in GD is not the result of a more general, non-reward-based tendency to perseverate…non-reward-based cognitive inflexibility in itself is not a characteristic of GD but plays a role in reward-based cognitive inflexibility, when the rules about winning and losing are explicit.

The present study gives preliminary evidence for the idea that reward-based cognitive inflexibility is a more central feature of GD than non-reward-based cognitive inflexibility. This conception is further supported by the finding that in the GD-group reward-based inflexibility was related to level of psychological distress and nearly significantly related to level of OCD-symptoms; in the total group reward-based cognitive inflexibility was related to psychological distress and OCD-symptoms. In other words, subjects who were inflexible when rewards were at stake, were more obsessive and compulsive and reported lower levels of psychological well-being. Cognitive inflexibility without reward was not related to OCD-symptoms and psychological distress. This is another indication that GD might be more a problem of reward-based inflexibility than of a general tendency to perseverate. This stresses the importance of possible dysfunctioning of the orbitofrontal cortex, the ventrolateral prefrontal cortex, and the ventral regions of the striatum in GD-patients

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