Regulación emocional e impulsividad en las adicciones comportamentales: implicaciones y eficacia de la gamificación como estrategia terapéutica

[spa] INTRODUCCIÓN: La regulación emocional (RE) puede definirse como la capacidad y habilidad para experimentar y modular nuestras propias emociones (positivas o negativas) y sus respuestas en diferentes contextos. Se trata de un proceso complejo, que implica diferentes estrategias de afrontamiento. Las dificultades para regular las emociones se considera un factor clínico transdiagnóstico por ser un elemento común en numerosos trastornos psicológicos, estando en la base para el desarrollo, mantenimiento y/o contribuyendo a una mayor gravedad sintomatológica. Otra variable muy relacionada con RE, que también tiene un papel fundamental en diferentes trastornos, es la impulsividad. Se trata de la tendencia a actuar o tomar decisiones de manera precipitada, sin detenerse a meditar sobre las posibles consecuencias adversas. Este constructo puede dividirse en varias dimensiones, como la impulsividad de elección, impulsividad rasgo e impulsividad de respuesta. Existen estudios previos que informan de que la impulsividad y las carencias en RE pueden interactuar de manera significativa para predecir comportamientos adictivos. Las adicciones comportamentales hacen referencia a un conjunto de trastornos que se caracterizan por un patrón de conductas repetitivas que escapan al control del sujeto, y resultan perjudiciales para el mismo u otros. Entre ellas estarían la adicción al juego y la adicción al sexo. Actualmente el Trastorno de Juego (TJ) se considera la única adicción conductual con suficiente respaldo científico para ser incluida como trastorno mental en el Manual Diagnóstico y Estadístico de Trastornos Mentales (DSM-5). En cuanto a la adicción al sexo o hipersexualidad, puede ser considerada como adicción comportamental o como un Trastorno de Control de los Impulsos (TCI), dándose una falta de consenso general en su conceptualización y diagnóstico. El TJ se define como un comportamiento problemático, persistente y recurrente a pesar de las consecuencias negativas en diferentes contextos de la vida del individuo, y de los intentos fallidos de abandonar dicho comportamiento, lo que conduce a un deterioro o angustia clínicamente significativa. Tanto los déficits en RE como la alta impulsividad son característicos en este tipo de trastornos, existiendo evidencia científica que asocia estas variables con la severidad del mismo. De hecho, numerosos estudios apuntan a que la conducta de juego es utilizada por estos pacientes para aliviar el malestar que experimentan (regular sus emociones), además de informar del uso habitual de estrategias de RE desadaptativas, como la supresión emocional. Adicionalmente, investigaciones previas relacionan las carencias en RE con índices clínicos como las ideas de suicidio. En TJ se encuentra que la prevalencia de ideación de suicidio es tan alta como el 49,2% en estos pacientes, siendo la mortalidad por este motivo 15 veces mayor que en población general. Otro índice clínico que se asocia con ideación de suicidio y con severidad del trastorno es el estado psicopatológico o sintomatología clínica, no encontrando estudios específicamente en TJ que describan qué papel juegan los déficits en RE y la alta impulsividad en estos factores. Por otro lado, la hipersexualidad se caracteriza por un patrón persistente de incapacidad para controlar fantasías, urgencias y comportamientos sexuales, generando consecuencias negativas en la vida del individuo o en la de otros, así como un malestar clínicamente significativo. Del mismo modo, los estudios apuntan a que estos pacientes utilizan las conductas sexuales inapropiadas o excesivas para regular emociones desagradables. Dada la evidencia existente sobre la relevancia de la RE tanto para el bienestar psicológico como para diferentes psicopatologías, cada vez es más frecuente que los tratamientos psicológicos incluyan intervenciones para disminuir estos déficits, y que se desarrollen intervenciones específicas para ello. Así, en las últimas décadas se han diseñado aplicaciones y dispositivos que utilizan el entrenamiento basado en Serious Games (SGs) para mejorar la RE. Además, numerosos estudios muestran que los SGs resultan eficaces para mejorar la adherencia al tratamiento en pacientes con diferentes trastornos, reportando ser particularmente efectivos para aumentar la motivación. En esta línea, los pacientes con TJ podrían beneficiarse en este aspecto, puesto que entre el 30% y el 50% de estos pacientes abandonan la terapia cognitivo-conductual (TCC) antes de finalizarla. Los SGs podrían ser herramientas útiles tanto para mejorar la RE como para disminuir la sintomatología asociada al trastorno y las tasas de abandono y recaídas en adicciones comportamentales. OBJETIVOS E HIPÓTESIS: Primer objetivo (Estudios 1 y 2): Explorar la influencia de la RE y la impulsividad sobre otras variables o índices clínicos frecuentes en el TJ, como son las ideas de suicidio, la sintomatología o estado psicopatológico y la pobre adherencia al tratamiento (recaídas y abandono de la TCC). Se espera que tanto las dificultades en RE como la elevada impulsividad influyan en estas variables y en la severidad del TJ. Segundo objetivo (Estudios 3, 4 y 5): Evaluar la eficacia de una intervención con un nuevo SG (e-Estesia) en pacientes con adicciones comportamentales (TJ e hipersexualidad). Se espera que tal intervención reduzca los déficits en RE, mejore el estado psicopatológico y disminuya tanto las recaídas como el abandono en la TCC en estos pacientes

Delay Discounting in Gambling Disorder: Implications in Treatment Outcome

Impulsive choice, measured by delay discounting (DD) tasks, has been shown in patients with gambling disorders (GD). However, the impact of DD and treatment outcome has been scarcely explored in GD patients. The aims of this study were: (1) to examine the baseline association between DD and clinical variables in GD patients depending on their age and gambling preferences (strategic vs. non-strategic); and (2) to estimate the predictive role of DD on poorer outcomes of cognitive-behavioral therapy (CBT) when considering also the effect of other clinical variables. 133 treatment-seeking male GD patients were evaluated at baseline with a DD task and measures of GD severity, personality traits and psychopathology. Treatment outcome was measured in terms of dropout from CBT and relapses. Results showed baseline associations between DD and GD severity (correlation coefficient R = 0.408 among strategic gamblers and R = 0.279 among mixed gamblers) and between DD and positive/negative urgency (R = 0.330 for the youngest patients, R = 0.244 for middle age, and around R = 0.35 for gamblers who reported preferences for strategic games). Other personality traits such as high harm avoidance and low cooperativeness were also related to DD at baseline (R = 0.606 among strategic gamblers). Regarding treatment outcome, a steeper discount rate predicted a higher risk of relapses in strategic gamblers (odds ratio OR = 3.01) and middle-age ones (OR = 1.59), and a higher risk of dropout in younger gamblers (OR = 1.89), non-strategic gamblers (OR = 1.70) and mixed gamblers (R = 4.74). GD severity mediated the associations between age, DD, personality traits and poor CBT outcome. In conclusion, impulsive choice affects treatment response in individuals with GD and may interfere with it to a significant extent. Considering DD in GD, patients seeking treatment could help control its impact on treatment adherence and relapses

e-Estesia: A Serious Game for Reducing Arousal, Improving Emotional Regulation and Increasing Wellbeing in Individuals with Gambling Disorder

Gambling disorder (GD) is associated with deficits in emotion regulation and impulsivity-related personality traits. In recent years there has been an increase in the use of serious games (SG) to address these factors with positive results. The aim of this study was to analyze the efficacy of the intervention with a new SG (e-Estesia), as an adjunct to a CBT intervention for GD. The sample comprised two groups (experimental group (n = 40) and control group (n = 64)) of patients with GD diagnosis. Both groups received 16 weekly CBT sessions and, concurrently, only the experimental group received 15 additional sessions with e-Estesia. Pre-post treatment with e-Estesia administered in both groups were: DSM-5 Criteria, South Oaks Gambling Screen, Symptom Checklist-Revised and measure of relapses, dropout and compliance of treatment. As regards the experimental group were also administered: Difficulties in Emotion Regulation Scale, Emotion Regulation Questionnaire, and Impulsive Behavior Scale. No statistically significant differences in the general psychopathological state, emotion regulation or impulsivity were found when comparing the groups. However, patients enrolled in the e-Estesia intervention had significantly less relapses and better indicators of treatment compliance than the control group. Considering these results, the use of complementary tools such as SG are useful for addressing GD

A Bicyclic 1-Deoxygalactonojirimycin Derivative as a Novel Pharmacological Chaperone for GM1 Gangliosidosis

Lysosomal β-galactosidase (β-Gal) deficiency causes a group of disorders that include neuronopathic GM1 gangliosidosis and non-neuronopathic Morquio B disease. We have previously proposed the use of small molecule ligands of β-Gal as pharmacological chaperones (PCs) for the treatment of GM1 gangliosidosis brain pathology. Although it is still under development, PC therapy has yielded promising preclinical results in several lysosomal diseases. In this study, we evaluated the effect of bicyclic 1-deoxygalactonojirimycin (DGJ) derivative of the sp2-iminosugar type, namely 5N,6S-(N′-butyliminomethylidene)-6-thio-1- deoxygalactonojirimycin (6S-NBI-DGJ), as a novel PC for human mutant β-Gal. In vitro, 6S-NBI-DGJ had the ability to inhibit the activity of human β-Gal in a competitive manner and was able to protect this enzyme from heat-induced degradation. Computational analysis supported that the rigid glycone bicyclic core of 6S-NBI-DGJ binds to the active site of the enzyme, with the aglycone N′-butyl substituent, in a precise E-orientation, located at a hydrophobic region nearby. Chaperone potential profiling indicated significant increases of enzyme activity in 24 of 88 β-Gal mutants, including four common mutations. Finally, oral administration of 6S-NBI-DGJ ameliorated the brain pathology of GM1 gangliosidosis model mice. These results suggest that 6S-NBI-DGJ is a novel PC that may be effective on a broad range of β-Gal mutants.Ministerio de Ciencia e Innovación de España. SAF2010-15670 y CTQ2010-15848Junta de Andalucía. P08-FQM-0371

Probing the Inhibitor versus Chaperone Properties of sp2-Iminosugars towards Human β-Glucocerebrosidase: A Picomolar Chaperone for Gaucher Disease

A series of sp2-iminosugar glycomimetics differing in the reducing or nonreducing character, the configurational pattern (d-gluco or l-ido), the architecture of the glycone skeleton, and the nature of the nonglycone substituent has been synthesized and assayed for their inhibition properties towards commercial glycosidases. On the basis of their affinity and selectivity towards GH1 β-glucosidases, reducing and nonreducing bicyclic derivatives having a hydroxylation profile of structural complementarity with d-glucose and incorporating an N′-octyl-isourea or -isothiourea segment were selected for further evaluation of their inhibitory/chaperoning potential against human glucocerebrosidase (GCase). The 1-deoxynojirimycin (DNJ)-related nonreducing conjugates behaved as stronger GCase inhibitors than the reducing counterparts and exhibited potent chaperoning capabilities in Gaucher fibroblasts hosting the neuronopathic G188S/G183W mutation, the isothiourea derivative being indeed one of the most efficient chaperone candidates reported up to date (70% activity enhancement at 20 pM). At their optimal concentration, the four selected compounds promoted mutant GCase activity enhancements over 3-fold; yet, the inhibitor/chaperoning balance became unfavorable at much lower concentration for nonreducing as compared to reducing derivatives.España Ministerio de Economía y Competitividad (contract numbers CTQ2015-64425-C2-1-R and SAF2016-76083-R)Junta de Andalucía contract number FQM2012-146

Probing the Inhibitor versus Chaperone Properties of sp2-Iminosugars towards Human -Glucocerebrosidase: A Picomolar Chaperone for Gaucher Disease

A series of sp2-iminosugar glycomimetics differing in the reducing or nonreducing character, the configurational pattern (d-gluco or l-ido), the architecture of the glycone skeleton, and the nature of the nonglycone substituent has been synthesized and assayed for their inhibition properties towards commercial glycosidases. On the basis of their affinity and selectivity towards GH1 β-glucosidases, reducing and nonreducing bicyclic derivatives having a hydroxylation profile of structural complementarity with d-glucose and incorporating an N′-octyl-isourea or -isothiourea segment were selected for further evaluation of their inhibitory/chaperoning potential against human glucocerebrosidase (GCase). The 1-deoxynojirimycin (DNJ)-related nonreducing conjugates behaved as stronger GCase inhibitors than the reducing counterparts and exhibited potent chaperoning capabilities in Gaucher fibroblasts hosting the neuronopathic G188S/G183W mutation, the isothiourea derivative being indeed one of the most efficient chaperone candidates reported up to date (70% activity enhancement at 20 pM). At their optimal concentration, the four selected compounds promoted mutant GCase activity enhancements over 3-fold; yet, the inhibitor/chaperoning balance became unfavorable at much lower concentration for nonreducing as compared to reducing derivatives.Ministerio de Economía y Competitividad CTQ2015-64425-C2-1-R , SAF2016-76083-RJunta de Andalucía FQM2012-1467Japan Society for the Promotion of Science JSPS KAKENHI 17K1005

Cognitive Behavioral Therapy Plus a Serious Game as a Complementary Tool for a Patient With Parkinson Disease and Impulse Control Disorder: Case Report

Background: Impulse control disorders (ICDs) are commonly developed among patients who take dopamine agonist drugs as a treatment for Parkinson disease (PD). Gambling disorder and hypersexuality are more frequent in male patients with PD, with a prevalence over 4% in dopamine agonists users. Although impulsive-compulsive behaviors are related to antiparkinsonian medication, and even though ICD symptomatology, such as hypersexuality, often subsides when the dopaminergic dose is reduced, sometimes ICD persists in spite of drug adjustment. Consequently, a multidisciplinary approach should be considered to address these comorbidities and to explore new forms of complementary interventions, such as serious games or therapies adapted to PD. Objective: The aim of this study is to present the case of a patient with ICD (ie, hypersexuality) triggered by dopaminergic medication for PD. A combined intervention was carried out using cognitive behavioral therapy (CBT) for ICD adapted to PD, plus an intervention using a serious game-e-Estesia-whose objective is to improve emotion regulation and impulsivity. The aim of the combination of these interventions was to reduce the harm of the disease. Methods: After 20 CBT sessions, the patient received the e-Estesia intervention over 15 sessions. Repeated measures, before and after the combined intervention, were administered to assess emotion regulation, general psychopathology, and emotional distress and impulsivity. Results: After the intervention with CBT techniques and e-Estesia, the patient presented fewer difficulties to regulate emotion, less emotional distress, and lower levels of impulsivity in comparison to before the treatment. Moreover, the frequency and severity of the relapses also decreased. Conclusions: The combined intervention-CBT and a serious game-showed positive results in terms of treatment outcomes

Suicidal ideation and history of suicide attempts in treatment-seeking patients with gambling disorder: The role of emotion dysregulation and high trait impulsivity

Background and aims: Gambling disorder (GD) presents high rates of suicidality. The combined influences of emotion dysregulation and trait impulsivity are crucially important (albeit understudied) for developing strategies to treat GD and prevent suicide attempts. The aim of this study is to investigate the association between trait impulsivity, emotion dysregulation, and the dispositional use of emotion regulation (ER) strategies with suicidal ideation and psychopathological symptom severity in GD. Methods: The sample composed of 249 patients with GD (166 with suicidal ideation) who underwent face-to-face clinical interviews and completed questionnaires to assess psychopathological symptoms, impulsive traits, and ER. Results: Patients with GD who presented suicidal ideation were older and had a later age of GD onset and higher GD severity. Analyses of variance showed higher comorbid symptoms, emotion dysregulation, and trait impulsivity in patients with suicidal ideation. Still, no significant differences were found in the use of ER strategies. SEM analysis revealed that a worse psychopathological state directly predicted suicidal ideation and that both emotion dysregulation and GD severity indirectly increased the risk of suicidal ideation through this state. High trait impulsivity predicted GD severity. Finally, a history of suicide attempts was directly predicted by suicidal ideation. Conclusions: Patients with GD are at risk of presenting suicidal behaviors. The results of this study revealed the importance of comorbid psychopathology in the occurrence of suicidal ideation and the indirect effect of trait impulsivity and emotion dysregulation on suicidality. Thus, suicidal rates in GD could possibly be reduced by specifically targeting these domains during treatment

Cyberbullying and Gambling Disorder: Associations with Emotion Regulation and Coping Strategies

The presence of unsuitable coping and emotion regulation strategies in young populations with gambling disorder (GD) and in those who have experienced cyberbullying victimization has been suggested. However, this association has not been explored in depth. In this study, our aim was to analyze individual differences in emotion regulation, coping strategies, and substance abuse in a clinical sample of adolescents and young adult patients with GD (n = 31) and in a community sample (n = 250). Furthermore, we aimed to examine the association between cyberbullying and GD. Participants were evaluated using the Cyberbullying Questionnaire-Victimization, the Canadian Adolescent Gambling Inventory, the Coping Strategies Inventory, the Difficulties in Emotion Regulation Scale, the Alcohol Use Disorders Identification Test and the Drug Use Disorders Identification Test. Structural Equation Modeling was used to explore associations between these factors in a community sample and in a clinical group. In both groups, exposure to cyberbullying behaviors was positively associated with higher emotion dysregulation and the use of maladaptative coping styles. Our findings uphold that adolescents and young adults who were victims of cyberbullying show difficulties in emotion regulation and maladaptive coping strategies when trying to solve problems. The specific contribution of sex, age, gambling severity, emotion regulation, and coping strategies on cyberbullying severity is also discussed. Populations at vulnerable ages could potentially benefit from public prevention policies that target these risk factors