The treatment of gambling disorder: A comprehensive (socio-psychological-neurobiological) explanation and therapy model?

Abstract

Summary In this theoretical work, we present the clinical picture of pathological gambling, an etiological explanatory model and resulting therapeutic implications. Social, psychological and physiological factors are included. The "addiction model" also distinguishes between factors relevant to the onset and continuation of disturbed gambling behavior. Multifactorial causes must be postulated in the "entry phase" of the behavior. During the actual "addiction phase", the self-perpetuating disturbed gambling behavior is characterized by a strong mental dependence and a nearly autonomously triggered addiction behavior (loss of control) associated with structural changes in the deeper brain areas of the „reward system“. There is an "irresistible urge" to continue gambling, upheld not least by a dominance of gambling behavior in the reward system and the accompanying dysfunction of this area of the brain. At the beginning of therapy, the focus lies on the addictive behavior itself. The symptoms that developed last are the ones that are first incorporated into the therapy consideration, whereby the therapeutic goals are to be set in a certain order: (a) Motivation, withdrawal symptoms after the patient stopped gambling, (b) insight into the disease (do not deny further) and its acceptance, (c) consolidation of the abstinence through a treatment of the causes of disease development. Dependence means not having sufficient alternatives. The reconstruction of the reward system and the development of a wide range of varied alternatives are an important prerequisite for avoiding relapse and achieving a balanced and satisfied way of life. Eliminating the dominance of gambling in the reward system and strongly anchoring the desired potently rewardable alternatives in behavior is associated with significant psychological and physiological resistance. The adrenaline rush of gambling is not easily compensated and cannot be replaced with lukewarm water or realistic thinking. Problems of implementing desired behavioral changes have not yet been sufficiently taken into account and there is a lack of necessary research. Are there any obligatory treatment factors?