Hello, good evening, everyone. My name is Kishan. I'm a second-year psychiatry resident at Rutgers NJMS. Along with me today, we have Dr. Lavounis, among many things, the chair of psychiatry at Rutgers NJMS. We'll have our resident panelists tonight. We have Carl Steyer, Mohamed Abil, and Nick Shaker, as well as our fourth-year medical student, David Lazar. With that being said, we can jump into our video. Hello, and welcome to the workshop, Quit While You're Ahead, Recognizing Gambling Disorder in Uncut Gems. In today's workshop, we're going to take you through gambling disorder as depicted in the film, Uncut Gems. We're going to start off with a presentation from Dr. Diego Garces on what is gambling disorder, the history of gambling disorder as seen in DSM IV and then DSM V. Then we're going to go into the evolution of gambling disorder on how it was culturally done versus all the modalities of gambling seen today. Then we're going to go into gambling personified in Uncut Gems, basically a synopsis of the movie highlighting and epitomizing all the diagnostic criteria of gambling disorder seen in our film. Then we transition to the predispositions, the comorbidities, and the future of gambling disorder. And finally, we end with the treatment modalities that are used for gambling disorder. Good evening, everyone. I am Dr. Diego Garces Gross, and I have no disclosures to mention. The educational objectives of this talk are to show the DSM classification and the history of gambling disorder, to learn about the diagnostic criteria of gambling disorder and the prevalence of gambling disorder. So what is gambling disorder? It was first introduced in the DSM V, and it was included in the section of substance-related and addictive disorders. It replaced the previous diagnosis of pathological gambling that was in DSM IV, which was classified in the section of impulse control disorders, not elsewhere classified. When talking about the DSM criteria evolution, we can see that the DSM IV and the DSM V have very similar criteria. In their similarity, they also have some differences. One thing that we can see that was added in the DSM V is the gambling behavior has to lead to a clinically significant impairment or distress. And they also added that the criteria have to be present in a 12-month period. We will describe the rest of criteria in the next slides. The DSM IV required to have five or more criteria, whereas the DSM V now requires just four or more. And then you can see the second criteria in the first section is that the gambling behavior is not better accounted for by a manic episode. And this has remained almost unchanged in the DSM V, where it says the gambling behavior is not better explained by a manic episode. Now let's move on to the criteria. We can see that the DSM IV has 10 possible criteria. And to diagnose a person, you need at least five of these. One of these, number eight, was dropped when starting the DSM V, because it was recognized that a person does not need to commit illegal actions or be involved in illegal behaviors to have a problem of gambling disorder. Some of these have just moved in place, for example, this number two in DSM IV is now the number one in DSM V. Number four in DSM IV moved to number two in DSM V. Some of these criteria have remained unchanged. We can see that number three is exactly the same. Number six is exactly the same. And in number seven, there is a small change in the text, but remains almost the same. Number nine and eight, after the dropping of criteria number eight, have become criteria eight and nine, respectively. Some of the specifiers added in the DSM V are timing, remission, and severity. When talking about timing, we can see that gambling disorder can be episodic or persistent. Episodic meaning that the person meets the criteria at different points in time, but they also have periods of time in which they do not meet the criteria. Persistent meaning that the person experiences continuous symptoms meeting the criteria for a prolonged time. When we talk about remission, we can talk about early remission and sustained remission. Early remission being that the person who was previously diagnosed has not met the criteria for at least three months and less than 12 months. To consider gambler in sustained remission, we would have to see that the person has not met criteria for at least 12 months. And then we have the severity in which gambling disorder is considered mild if four or five criteria are met, moderate with six or seven, and severe with eight or nine criteria. This is a report from SAMHSA in 2016, which reports on four main points. Number one is the decrease in the number of criteria required to diagnose a person from five to four. Then the addition of that 12-month window, the addition of clinically significant distress in criterion A, and then removal of criterion eight, which is related to illegal behaviors. This SAMHSA report also presented a prevalence study done in a call center in which people called when they were concerned for gambling disorder or gambling behaviors. And what they reported is that in random sampling of the people who called this call center, when using DSM-IV criteria, they found a prevalence of 16.2%. And when using DSM-V criteria, they found a prevalence of 18.1%, which shows a 9% increase in diagnosis of gambling disorder when using five versus four criteria. In a prevalence study done by Reynard and team that was conducted in a substance use disorder group, they had 6,613 participants in a substance use disorder study. They did a questionnaire, and 1,507 of the respondents said, responded that they ever gambled at least $10 monthly. Of those people, 563 met criteria for both DSM-IV and DSM-V diagnosis. And 678 of the people in that group met criteria for only DSM-V diagnosis. And that, again, tells us that decreasing the threshold to diagnose gambling disorder from five to four criteria increases the sensitivity in diagnosing. And talking of prevalence, Collado and Griffiths, in a systematic review, report that the worldwide prevalence goes from 0.12% to 5.8%. And a study done by Velte and group in 2013 showed that historically, prevalence in the United States has been from 0.9% to 1.9% since the 70s. And the average rate is 1% of prevalence of gambling disorder. This last data was obtained in a national survey done in 2013 using the DSM-V criteria. And that's all what I have to say for now. Thank you for listening, and we'll be here for your questions. Thank you. Hello, my name is Dr. Carl Steyer, and today I'll be presenting the evolution of internet gambling. Here's my contact info. Here are my disclosures. Objectives. Today we'll review the history of online casinos, sports betting, and loot crates as they relate to gambling addiction and disorder. Now a brief history. In 1990s, internet gambling became a feasible option. Entrepreneurs began to realize the potential for internet gambling. However, there were some barriers and limitations present, such as legality, software, and encryption difficulties. In 1994, microgaming develops the first fully operational internet gambling software platform. In 1994, we have the Free Trade and Processing Act, which allowed licenses to be granted for the operation of online casinos. 1995, Cryptologic develops encryption for online monetary transactions, thus addressing some of our barriers and limitations discussed earlier. 1996, the first online casino with a money wager is claimed by InterCasino and the Gaming Club. InterCasino is based in Antigua and was primarily controlled by Cryptologic. 1997, we have Starnet Systems begins to grant licenses to casino operators with customizable software packages, which in return, they wanted a percentage of the earnings. By 1998, we have Planet Poker, the first online poker room, and Cash Splash, the first online slot machine released by microgaming. And here is how the websites appeared in 1996, 1997 on the right. Per growth, at the end of 1997, we have effectively 15 websites for online gaming. By 98, 200. By 99, or the end of 99, 650. And by 2002, 1800. In 2000, internet gambling brought forth an estimated $2.2 billion in worldwide revenues. In the early 2000s, televised poker was cultivating a larger viewership, and party poker and poker stars began to advertise. Texas Hold'em poker became a common household name. Party poker launched in 2001 soon became the largest online room until 2006. In 2009, it's estimated that gross gaming revenue is $21.7 billion worldwide and $6.3 billion in the US. And an industry report published by Grandview Research Incorporated in April 2020 announced that the online gambling market size was valued at effectively $54 billion and expected to be $127.3 billion by 2027. And there's some factors for growth that are being fleshed out. Some of them are COVID-19, the fact that land-based casinos were locked down, there was cancellation of major sports events, etc. Virtual reality, augmented reality, with things like Facebook being rebranded as meta, we see more delivery of this content. Security, blockchain-based gaming platforms, reducing the effects from bad actors and so far of manipulating the game, and concerns for theft. So now we have sports betting, also known as in-play betting or live-action betting or in-run betting or in-running betting. It first appeared at the end of the 90s, but at that time you would have to call a bookkeeper while the game was in progress and there was a cumbersome task to place a bet. But this in-play betting, it increased the number of markets accessible to wager on a sports event. There's now other activities you could bet on, like for a soccer game, it's not only who's going to win the game, how much will they win it by, how many yellow cards will a player get, what will be the halftime score, what will be the name of the goal scorer, things like that. And according to data from Bet365, a UK-based gambling company, they suggest that approximately 80% of all sports revenue in 2015 came from in-play bets alone. And here you can see on the right, this is a new wagering kiosk in a casino in Connecticut, fairly recent, September 30th of this year. So sports betting, we have these structural characteristics and they can, these are a design of a gambling product that can affect the way gamblers play, defined as characteristics that facilitate the acquisition or development and or maintenance of gambling behavior, irrespective of the person's or individual's psychological, physiological, or socioeconomic status. And listed here are some common structural and situational characteristics from Griffiths, 1999, stake size, event frequency, amount of money lost or earned, a period of time, price structures, probability of winning, et cetera. So in-play sports betting has changed the structural mechanics of the game. There's a larger number of bets to be placed. There's high-speed continuous betting requiring fast decision-making with minimal time for really decision-making or reflection. And this can enhance the illusion of control, one of our cognitive biases that we see. We see that Tversky and Kahneman kind of ferreted out gambler's fallacy to suggest that this is more of a representativeness heuristic versus a psychological heuristic. So people will often believe that chance is cumulative. As a result of this, we see that people engaged in gambler and gambling within sports betting, they have a higher illusion of control. In gamblers, they often dictate the speed of play, the volume of betting, and the amount of money wagered. And this may enhance the perception that they are in control or have a greater low side of control than they perceive or they assess. So cell phones have made this ever-present now. We have these advertisements for Caesar Sportsbook and BetMGM. They reduce safety concerns. It's easier to do transactions through PayPal, Apple Pay. There's better customer support. You're not dealing with Antigua or the Bahamas with a game of three-card Monte, finding a person you don't know, greater depiction of realism, more authentic experience. So finishing off with loot boxes and loot crates. Now, is it gambling? Is it not? That's a greater debate. But loot box and loot crates, they refer to virtual items, which can be redeemed for these various tangibles related to the game, such as avatar skins, equipment, etc. First appeared in the massively multiplayer online role-playing games of the 2000s, such as World of Warcraft. And loot boxes, they work on this variable rate reinforcement of players working for reward by making a series of responses with an unpredictable delivery of rewards. And from Dr. Lou Clark, Director of the Center of Gambling Research at the University of British Columbia, we know that the dopamine system, which is targeted by drugs and abuse, is also interested in unpredictable rewards. So as we look at parts of the brain, like the ventral tegmental area, the nucleus accumbens, and the dopaminergic circuits there, it seems like this is a very similar reward response, or overlapping reward response. So here's an example of loot boxes. This is from Blizzard's hit game Overwatch, released in 2016. This is a picture of what the loot crate looks like. These are the prices of them. And you're going to get four items. You may get skins. You may get the way your character looks, little ways they could cheer or yell, weapons, gear, etc. And it's estimated they made a billion dollars in their fourth year of the release, purely from costumes and loot box purchases. And this is just to give you an idea of how common it is to discuss this now that this is a pervasive issue, that loot crates and loot boxes are akin or comparable to gambling insofar as their addictive qualities, which is for another day, another time. And thank you for your attention and your time. All right. So today we'll be talking about gambling as it is personified in uncut gems. So my name is David Lazar. I'm a fourth year medical student at the New Jersey Medical School. And here's my contact information. I have no relevant disclosures. And our educational objectives for today is to recognize the signs of a gambling disorder and to summarize the criteria of gambling disorder as it is depicted in uncut gems. So to give you a little bit of a background of the movie, I'll talk about some of the main characters and what role they play. So we start off with Howard Ratner, as you see here on the right side, played by Adam Sandler. He's a jewelry store owner in the New York City Diamond District. And as we see in the very first part of the movie, he has a large amount of gambling debt. And he becomes our prototype for a gambling disorder. Arno, as you see in the bottom right, he is a loan shark. And he is Howard's brother-in-law. And we find out that he is the man that Howard owes most of his money to. And then we also see Kevin Garnett, who is a big vehicle to display Howard's gambling tendencies and chaotic lifestyle. Here we have Dina on the left. She is Howard's wife and soon to be ex-wife. Due to Howard's gambling, they haven't been getting along too well and has had a lot of issues in his personal life because of that. In the middle, we see Julia, who is Howard's now girlfriend, as well as one of Howard's employees. On the right, we see Damani, who is Howard's liaison to the stars. He's the man that's supposed to be bringing in well-known clients to Howard's shop. And on the bottom, we see Gary, who is Howard's bookie, and Phil, who is one of Arno's associates. And as we'll see later on, he has a big role to play in the plot of this movie. So to start off the movie, the movie shows Adam Sandler walking down the street, talking on the phone, and he is being questioned by Arno about his gambling debt and why isn't he paying back. So we find out that he owes Arno about $100,000, and we can assume that it was for gambling purposes. And while he's walking down, he is walking to Gary to go place another bet instead of paying back his debt. So the money he's going to Gary with was money he obtained by pawning a necklace that he got from Julia that she obtained from The Weeknd. He eventually places that bet, and we soon find Howard in his jewelry store where he meets Kevin Garnett. While Kevin Garnett is at the store, one of Howard's obsessions, this Ethiopian opal, comes in and he gets Kevin Garnett very enamored with this piece. Kevin ends up thinking that it has magical properties and really wants to have this opal. But Howard refuses to sell it to him and instead lends it to him only, but gets Garnett's championship ring as collateral. So here we see Howard getting that ring and immediately pawning it. And as soon as he pawns it, he goes back to Gary and places a massive bet. So altogether, the bet is now at $40,000, and he's betting on a dominant performance by Kevin Garnett because of the opal. So after he places that bet, we see Gary call it the dumbest bet I've ever heard, which just shows to what kind of bets Howard is making. And as you see on the image on the right, he goes, I disagree. So eventually, the bet does hit. And as we see, that goes on into the next plot point. So then we see Howard at a school play, and there Arnold shows up with his thugs. This gives you an idea of how bad it's getting and how it is impacting his personal life, where his loan sharks are showing up at a school function where his daughter is in a play. So they eventually kidnap Howard at the play and beat him up, shake him down, and eventually stuff him in the truck. In this scene, Howard also finds out that Arnold ended up stopping the bet that he hit yesterday and is very distraught about it. So fast forward a little bit, we see how further Howard schemes to get money to gamble some more. So with regards to the opal that he lent Kevin Garnett, he was wanting to sell it at a very, very high price at auction. But the auctioner priced it at a much lower price than Howard wanted to. So he came up with a scheme to try and increase the price of it. He involved his father in law into this, and the scheme, of course, backfired. And now Howard is in more trouble. And here we see how it eventually breaks down. And he states, I can't figure out everything I do. It's not going right. So this just shows how things are just spiraling for him due to his gambling problems. So he reaches out to Kevin and directly sells the Opal to him for around $160,000. So this leads to our closing scenes. Here, as Kevin Garnett leaves the shop, Arno and his thug Phil come into the store and try to threaten Howard again. So as this is going on, Howard eventually locks them in the doorway, as you see here on the bottom, in the two doorways leading out of the store, and gives the money to Julia to send her on a helicopter to go place another massive bet. And he's once again betting on Kevin Garnett, and he's betting with ever increasing amounts of money with this time, $160,000. So Julia eventually does get the bet in and the bet does hit. Howard is wildly excited about it. And in his excitement, lets Arno and Phil out of their holding cell. And this leads to the last scene of the movie where Phil gets fed up with Arno and Howard and kills them both. And that is the end of the movie. So here we can see the various criteria that Howard meets for gambling disorder. He's gambling with ever increasing amounts of money. As you see, he goes from 20K to 160K. He's always preoccupied with gambling, constantly thinking about gambling, what kind of bets to hit, how he can get money to finance his gambling. He's chasing his losses. As we've seen, he's already in debt and he's trying to win bigger and bigger so he can pay back his debt. His relationships are very jeopardized throughout the movie. As we see that he's an ever absent father to his kids and he is getting a divorce with his wife. And he's always relying on others to provide money. As we see with him having a loan shark and then eventually getting his dad to try and increase the price of the Opal at auction. So these are just some of the criteria that Howard exhibits. And that's that for me. My name is Mohammad Adil. I'm a psychiatry resident, PGY-4 at Rutgers New Jersey Medical School. Thank you everyone for joining in. And I'm going to be presenting on predisposition, comorbidities, and the future of gambling disorders. I have no relevant financial disclosures. And I'm going to begin by talking about what are the various psychiatric comorbidities that are associated with pathological gambling. The most common one is the substance use disorder. And there are some studies that have found that alcohol and substance use problem are at least seven to 11 times higher in individuals with gambling disorder compared to non-gamblers. There's another study that I found that said that alcohol and other substance use are four times more higher in individuals with gambling disorder. There's one study that said that in individuals with gambling disorder, 75% of the patients suffer from substance use problem at least once in their life. So it's very frequent in individuals with gambling disorder. Mood disorders are also very frequent, particularly major depressive disorder. Bipolar disorder, dysthymia, and even suicidality is very prevalent. One study in UK found that rate of suicidality is 15 times higher in individuals with gambling disorder. I'm going to link all these references at the end of my slides. So if anyone wants to look up for more research, they can find that. Anxiety disorders, particularly generalized anxiety is also common in gambling disorder. ADHD, particularly the hyperactive type of ADHD has been found in patients with gambling disorders. Impulse control and OCD are some of the other psychiatric comorbidities that we have seen. OCD is also very prevalent. The rate is around 2.5 to 20%. And it's very similar to gambling addiction because it deals with urges, thoughts, and similar repetitive behavior. But both of them carry very distinctive qualities that differentiate them from one another. Personality disorders is the other form that we see in individuals with gambling problems. Borderline personality has been seen most frequently. And some other personalities include antisocial personality, avoidant histrionic personality disorders. They all are seen as comorbidities in pathological gambling. During the COVID-19, there has been like a huge surge in online applications and online platforms that you can utilize to participate in gambling. And keeping in view of the lockdown and the limited resources that are available during the COVID-19 restrictions, it has been quite a recipe of disaster for individuals who are suffering already with severe gambling disorders. I'm gonna talk a bit about what are the various platforms that are getting popularity and being utilized to do bettings and do gambling. Of these platforms, mobile gambling is the most commonly utilized and getting the most popularity. It's available in the form of like online casinos and like video games. And all you need is just like an email and a password and your credit card, and you can indulge in these gambling applications. Broader in-play betting is something that you can bet while the event is happening live. So it can be like a sports event, or it can be like a presidential election, or even like a dog show, and you bet who's gonna win or lose, and you can earn more cash or lose cash. E-sports betting is also getting popularity, and there are so many new applications that are accessible to a full unit. Crypto gambling is very common and popular among the younger crowd, and you bet which currency is gonna go up in value, which cryptocurrency is gonna lose value, and then you make more money or lose money depending on your betting. Lastly, the last one is a virtual reality gambling platform in which you are basically using like a VR set, and you are present inside a virtual casino, and then you are doing the betting there. So really immersive form of experience that you can get. So there are all these new platforms that are available now, and the need of ours is that we need to study and do more research on how this platform functions, how addictive these platforms are, so that we can provide more resources to our patients who are suffering from gambling disorder. So I'm Nikith Shaker. I'm a first-year psychiatry resident at Rutgers New Jersey Medical School, and today I'm gonna be presenting on treatment modalities for gambling disorder, and I have no relevant disclosures. So the learning objectives for today, we're gonna identify various treatment modalities for gambling disorder. We're gonna analyze some pathophysiological explanations for different treatment modalities, and its effects on different components of gambling disorder. And here listed below are some of the treatment modalities for gambling disorder, and while there are no medications that are officially FDA approved for gambling disorder, many medications and treatment options have shown to be beneficial in decreasing gambling behaviors. So to start, opioid antagonists, such as naltrexone, are very helpful in reducing the urges for gambling disorder, and work similarly to the way opioid antagonists work on the dopamine pathway for other substance addiction. So by modulating the effects of the arcuate nucleus opioid neurons on the ventral tegmental area and mesolympic dopamine reward way pathways. And recent studies have shown efficacy in reducing the intensity of urges to gamble, thoughts of gambling, and overall gambling behavior. Selective serotonin reuptake inhibitors, or SSRIs, have been studied as well to help with gambling disorder. And recent studies have shown that SSRIs, such as fluvoxamine and paroxetine, have been beneficial for gambling disorder. And the hypothesis is that if there's an underlying depressive or anxiety disorder that could be contributing to gambling disorder, that the SSRIs can treat the comorbid anxiety and depression in these patients with gambling disorder, and this in and of itself can lower gambling behaviors. Recent studies have also been conducted to test the efficacy of mood stabilizers and their effects on gambling disorder. Studies have shown that lithium, falproic acid, and topiramate have helped reduce behaviors. Hollander et al conducted a double-blind placebo-controlled trial enrolling individuals with gambling disorder and comorbid bipolar disorder, and results showed that lithium limited gambling urges and behavior. Also, a recent double-blind placebo-controlled study showed that topiramate was superior to the placebo in reducing cravings to gamble, money spent on gambling, and impulsive behaviors. Dannon et al conducted a blind rater study that showed bupropion is similar to naltrexone, which we had referenced earlier, and its efficacy in gambling disorder. Modafinil decreased motivation to gamble and risky decision-making and improved inhibitor control in highly impulsive patients, and this might decrease gamblers from chasing losses, which is another issue that a lot of gamblers face, is chasing their losses. And n-acetylcysteine was found to be effective in an open-label double-blind study, and n-acetylcysteine is also off-label for a lot of impulsive behaviors as well. Amantadine has benefited patients with gambling disorder and comorbid Parkinson's disease. And now we'll transition from some of the psychopharmacological treatment options to psychological treatment options. And the main first-line psychological therapy for gambling disorder is cognitive behavioral therapy, or CBT. And the way CBT works with gambling disorder is it targets certain aspects of gambling, such as the patient's own distortions, their cognitive distortions towards gambling behavior, and their decision-making involving gambling, as well as their psychological responses towards gambling. And studies have shown that both in the individual setting as well as in the group setting can benefit patients in relapse prevention of their gambling behaviors. Motivational interviewing has helped patients to change their gambling behaviors, and this works by identifying patients' own perceptions towards their gambling issues to help facilitate a change. And overall, the goal is to increase motivation towards making a change and also committing to a change, so this is a more long-lasting approach as well. And lastly, there are support groups such as Gamblers Anonymous, and this is based on a 12-step model similar to Alcoholics Anonymous and Narcotics Anonymous, where a peer support group is in place to help patients with their gambling disorder feel like they're not alone and work on some of the behaviors to help improve. And here are my references. Thank you, everyone. Before we get to some of the questions I see in the chat, I just wanted to briefly discuss why we wanted to do this workshop today. So when I first watched the film Uncut Gems, I felt very uncomfortable, and that was the exact response that the film was trying to elicit. The depiction of gambling disorder in Uncut Gems, it was pervasive. The protagonist, you just see the downward spiral get worse and worse for our protagonist. So I felt that it was a good and important discussion to have given the exponential rise seen in gambling disorder over the recent years. So generally before we see a change in classification in medical terminology or the passing of new legislation, we generally see a cultural shift that's preceding that. And with gambling disorder, it's just that, right? Politicians don't wake up one day and say, hey, I'm gonna pass some LGBTQ legislation. Similarly, medical associations don't just change the diagnostic criteria right away. There has to be a cultural shift that kind of occurs. So gambling disorder was just that, given the countless new outlets and modalities that are now accessible to everyone to engage in pathological gambling behavior. So some of the studies that we referenced, Diego mentioned the prevalence of gambling disorder is around 1%. A lot of the studies say that that statistic is actually very underreported and it's much higher. It's just oftentimes masked by the superimposed depression or suicidality or substance use disorders that the patients present with. Also gambling disorder, it's interesting in that it kind of helped shaped and cultivate the way we look and define addiction. So we used to think of addiction as requiring a substance to function. And this definition was first challenged by cocaine and subsequently by crack in which you don't see the stereotypical physical withdrawal symptoms, right? So you might crave it, but you don't have the vomiting or the autonomic instability that's associated with things like alcohol and heroin. So this definition was also unfair to patients that take opioids for chronic pain, because while they have a physical dependence on these substances, they don't engage in the compulsive behaviors despite the negative consequences that are typically seen and associated with addiction. So addiction is not simply an exposure to a substance, but it's a rather, it's a pattern of behavior that's inherently addictive. So gambling is a great example of this because it has intermittent reinforcement, right? Where you have a win every now and then, and then it makes you keep wanting to come back for more and more. It certainly shares a lot of qualities with substance use disorders. It has preoccupation where you're constantly thinking about gambling. It has tolerance where you develop an amount you wanna bet with. It has withdrawal properties where if you're not gambling, you'll have a negative mood. There's occupational disturbances where you have poor relationships with your friends, your family. You're not performing well at work because of all the gambling you're doing. And there's misrepresentation, right? Where you're lying about the time and money you're spending while gambling. But the one property that's unique to gambling disorder is chasing losses that was touched upon in the presentation. It's this feeling that a win is imminent, that I lost once, I lost twice. So what are the chances that I'm gonna lose a third time? And it keeps making you wanna bet more and more money when in reality, your previous two failed attempts have no correlation to your impending future attempt. That Carl touched upon as well as the gambler's fallacy is what it's called. So we'll take some of the questions that have come up. The first, I would just like to open the forum up to the panelists, to the audience members, and just talk about some of the experience any of you have had in treating patients with gambling disorder. Given the lack of comprehensive research or case reports, just share your experience under what context it was and some of the treatment modalities you may have used. If anyone would like to join, you can comment in the chat or. If I can just say a few things, Kishan and team, thank you so much for this wonderful presentation. It really is amazing that you put so much excellent information in such a short period of time. I just want to make one comment that in my clinical experience with gambling, we were in a situation in 2021 where we both under appreciate gambling and sometimes over appreciate gambling. We talked about the under appreciation of it, but there's also an angle of where a lot of times, both for a patient and her or his family, it's easier to accept the diagnosis of gambling instead of some more severe psychiatric disorder. What I'm talking about here is a college kid who may very well be suffering from schizophrenia or a major depressive disorder and do some gambling at the same time. And then the family and sometimes the patient latch on the diagnosis of a gambling disorder in an effort to avoid a more severe diagnosis like one of schizophrenia. So that's exactly where we come in as a specialist in this area to shift through all that and make sure that the patient gets the best care that she or he possibly can. Absolutely. And like what was previously mentioned, the prevalence is just getting more and more, right? So it's always something you have to kind of be looking for, asking the right questions. I wanted to just briefly mention some of the cultural changes that have been happening with gambling disorder. I was literally just watching basketball two weeks ago and Carl mentioned it in his point with sports betting nowadays, you can bet on various components of the game, right? It's not just who's winning, who's losing. It's how many points are you gonna score, what's the score at the quarter. So the athletes are also aware of the bets that are being placed on them. And there was an incident two weeks ago when it was the first quarter of a basketball game and there was a bet placed on a player who had to get three rebounds in the first quarter of the game. He had two rebounds and the third rebound that was coming in, he was surrounded by three other players on his team. He was the furthest away from the rebound, but his two teammates let him get that rebound just so he could fulfill that sports bet that was placed on him. And even the way it's shown on TV, there was a recent commercial for sports betting and it showed an office building in a nice winter environment, holiday spirit. Everyone's watching the big basketball game on a projector and the whole office bet on one certain thing. And the second the player makes the basket, the whole office kind of erupts in laughter and excitement. And it kind of masquerades the gambling component of it more as something to build camaraderie and connect with your peers with. So, you know, it's just ever pervasive in our society and the numbers are only gonna get more and more. We'll post it on the chat. I think there was one talking about someone's engagement in stocks and betting on cryptocurrency and that can absolutely qualify as a diagnosis or the diagnosis of gambling disorder can certainly extend to stocks and cryptocurrency. We have another interesting question. Where does the role of a psychiatrist stop and that of a rep, payee, or a financial advisor begin? I have often wondered how to respond when a patient shares that they are engaging in cryptocurrency buying and selling out of desperation. Anyone have any thoughts to that? Yeah, in really big gambling disorder treatment programs, big gambling disorder treatment programs, specialized financial counseling is one of the services that is offered to patients. So financial counseling in general, I'm not sure how helpful it would be, but the specialized one, the one that really targets patients with gambling disorder could be quite helpful. I just find the question here about contingency management we use a lot of contingency management with stimulants, crystal methamphetamine and cocaine. And I never thought that maybe contingency management will unmask a gambling disorder. It's a fascinating angle here. I cannot say that I have seen that, but I wouldn't put it past the clinical reality of an unintended consequence of an excellent treatment for stimulant use disorder. Certainly, and Dr. Weiss mentioned that she has not found medication useful when treating patients for gambling disorder. There's advertising platforms are being directed towards African Americans and the youth. Is that something others have noticed? I have not personally noticed specifically targeting African Americans, but the youth, there's definitely objective evidence in what Carl was mentioning with loot boxes, loot boxes are employed in video games to make the video game more appealing. And it definitely makes the people that play the video games kind of keep coming back and spending more and more time with the video games. So a genuine concern for the rise and gambling disorders influence these loot boxes and the fact that they're starting employing and utilizing these so early on in their lives. Someone else is asking if someone has used TMS for gambling. I'd like to add that there were recent studies done for anticipation processing and craving, which is a huge factor in the severity of an addiction and the risk of relapse. So with gambling disorder specifically, the imaging showed that there was some blunting in the fronto-striatal system, and then there was a subsequent meta-analysis that came out that showed that this blunting in the fronto-striatal system was also seen in cannabis use disorder, opioid use disorder, alcohol use disorder, and stimulant use disorder as well. So there's a lot more similarities in these processes. I would like to go back a little bit on the issue of the medications and we've heard from Adil and others that SSRIs and other antidepressants may be helpful because they may be treating a co-occurring depression or other psychiatric disorder and that is true across the board for pretty much all of addiction psychiatry. We all know that we have a better chance of success if we also treat any kind of co-occurring conditions but from what it seems like there has not been a robust effect of medications one way or another for gambling itself outside the co-occurring disorders and I wonder if anybody has any experience I would say well yes I think that this one has worked for me or for my patients obviously above and beyond what I would expect for the treatment of co-occurring other psychiatric disorders. Maybe Talal can talk about it. I see that put a message on the on the chat room. Sure, my experience has been relatively successful with a combination of Prozac, Naltrexone and CVT and MI so I don't know which one was more effective so you get you get these patients who are struggling and you know the only option is to throw everything at them when you see them you can't do it selective so I don't have a steady population that I can tell you you know like one is better than the other. You're not the first one to have used the kitchen sink approach successfully so we're all kind of you know in the same boat with that one. Another question I was typing and maybe somebody else can maybe I can explain better because I'm speaking. So when we had casinos back in the day two years ago a patient could blacklist themselves from the casino with the help of a physician or a family member they could say well if you see me on the video don't allow me. I guess we have lost that in the online version of casinos. You don't even have that ability when a patient is willing to get help they can't even do that anymore. Excellent point. I had a patient that I was treating with gambling and he was in a support group and one of the criteria to be in that support group was that you will not be carrying credit card and your spouse or your partner will carry that card for you and that was like the criteria list for that support group. So that was helping that patient a lot and he was on naltrexone which I found to be very helpful for that patient. Absolutely. And that's why that's the problem, right? It's so easy with these online outlets to gamble. All you need is a phone, a credit card, confirm your age, and you're ready to go. Definitely makes it harder to monitor. And the worst part is this industry is so lucrative, you know, just loot boxes alone, Carl mentioned, it's a billion dollar industry, right? Online casino, sports betting, millions of dollars of industry. So it's very hard to enact these restrictions when this much money is coming in. It's going to take some time, but it would definitely help and is necessary. It also differs state by state. For example, Michigan has very strict laws. And when you self-exclude, it's a lifelong self-exclusion, and you under no circumstances have the ability to reverse your own self-exclusion from casinos. And they really mean business. So it does have to do with how much the state takes it seriously, too. Thank you. There's a comment, I would argue the gambling industry and social media platforms understand the human reward system as well as or better than the addiction specialists do. That's certainly a valid point. And they have a lot of experts on their own of their own that work behind the scenes in designing these things. Carol's question is a very central one as well, like, when does it become excessive? But I would argue this is not very different than good old substance use disorders. We always struggle with some of the Alcoholics Anonymous mandates, not only for a lifelong abstinence, but let's say the frequency of attendance to AA meetings. Beyond 90 minutes and 90 days, how frequently somebody should stick with AA in order to fulfill those requirements. So it's, you know, to me, it's very similar to malignant melanoma. It's like when you excise a melanoma, the more, the greater you excise, the greater your chance of non-recurrence. But pretty soon you have amputated the person for not necessarily all that good of a reason. So it's how far do you go to just say, you know, that's safer. Let's just point out what Chance has said about the behavioral scientists. Our colleague, James Scherer, has done work on these matters and has certainly studied the hiring of behavioral scientists in both internet gaming and internet gambling. Yeah, let's have one more question. Kishan, you take the last question, choose one and then we'll discuss that one before we close. So is there any connection to online games affects the likelihood of gambling and afterlife. I later life later. I personally have not come across any studies indicating that I think it's hard to to say preemptively only because there hasn't been so much exposure to gambling behaviors for youth in the past. It's more so a more recent advent, where we're seeing these little loot boxes being the prime example, present for the youth that weren't necessarily the case years ago. But you know, I would certainly hypothesize that there is some kind of correlation in that you know there. Some kind of change in your circuitry may affect you later on. Much of the behavioral addictions that technological addictions gambling and so on is informed, of course, from the substance use disorders, because we know so much more about the substance use disorders and the behavioral addictions. And if we want to make an analogy there. The second part of that question may have to do with genetics. So often in alcoholism and in drug abuse, the people who end up having the more serious problems in adulthood. In earlier in life, we end up seeing that the genetics probably played played the most significant role there so who knows maybe further down the line, genetics of gambling will tell us who is really at risk. If she or he starts gambling earlier in life. There was some alteration to the D two receptors seen in patients with gambling disorders so genetics is something certainly something that can contribute to this later on in life. All right, take us home to Sean. Thank you everyone for tonight. I hope you watch the film, enjoy the synopsis and learned a little bit about some learned a little about gambling disorder that hopefully you can take away with an employee in your practice.

gambling disorder

Uncut Gems

diagnostic criteria

online gambling platforms

substance use disorders

medications

cognitive-behavioral therapy

support groups

ethical considerations