Perfiles clínicos en las adicciones comportamentales y trayectorias de curso terapéutico

[spa] ANTECEDENTES Y PLANTEAMIENTO GENERAL DEL PROBLEMA: Las adicciones comportamentales constituyen patologías emergentes cuyas prevalencias están experimentando un crecimiento importante durante las últimas décadas, lo cual ha despertado un notable interés científico y clínico. Se trata de trastornos adictivos sin sustancia, pero que cursan con una acentuada falta de control de una determinada conducta y presentan sustratos neurobiológicos, clínicos y de respuesta al tratamiento similares a las adicciones con sustancia. Los sujetos que presentan estas patologías no pueden cesar en la realización de la conducta adictiva, a pesar de las consecuencias negativas que estas actividades les causan en su entorno personal, familiar y social. El trastorno de juego es el que ha recibido más atención en el ámbito de la investigación científica, pero bajo la denominación de adicción conductual se incluyen otras condiciones como la compra compulsiva, la adicción al sexo, la adicción a los videojuegos o las adicciones a las nuevas tecnologías, a pesar de no estar reconocidas la mayoría de ellas en los manuales diagnósticos al uso, a excepción del trastorno por videojuegos (¿gaming disorder¿) y el trastorno por comportamiento sexual compulsivo, en la recientemente publicada CIE-11 (a pesar de que este último no se ha incluido bajo el epígrafe de trastornos debidos a comportamientos adictivos. Los sujetos que presentan estos problemas acostumbran también a presentar otras condiciones psicopatológicas comórbidas, como abuso de sustancias, depresión, ansiedad, o otros múltiples síntomas psicológicos. Los trastornos adictivos vinculados a actividades humanas pueden comenzar como hábitos de conducta aparentemente inofensivos (como las compras), o que se realizan con una finalidad meramente lúdica (como el juego), pero que con el tiempo pueden convertirse en comportamientos adictivos con una interferencia grave en la vida cotidiana de las personas afectadas y de su entorno cercano. El elemento central de las adiciones comportamentales no es por tanto el tipo de conducta que se realiza, sino la forma en que dicha actividad se realiza y la falta de control por parte de los sujetos, que persisten en dichos comportamientos al margen de la disfuncionalidad que les causan. La prevalencia de las adicciones comportamentales es relativamente alta, y los informes actuales apuntan que los datos de frecuencia están al alza. La sociedad en que vivimos, dinámica y con un fuerte impacto de las nuevas tecnologías, generan un medio favorecedor del inicio y progreso de estos problemas (los medios digitales y las redes sociales facilitan el acceso a múltiples plataformas que pueden potenciar las conductas adictivas). Atendiendo a los indicadores de la Organización Mundial de la Salud, la frecuencia de personas que pueden llegar a presentar problemas de este naturaleza podría alcanzar el 25%, aunque los datos obtenidos en estudios epidemiológicos son muy diferentes dependiendo de las áreas geográficas, la procedencia de las muestras (clínicas o comunitarias, o con diferentes niveles de riesgo), los instrumentos de evaluación que se emplean o incluso las definiciones conceptuales que se utilizan. Esta tesis se plantea como un proyecto empírico para el estudio de los mecanismos implicados en las adicciones comportamentales, tanto en el perfil clínico de los pacientes que solicitan atención por este tipo de trastornos como en los resultados terapéuticos que se obtienen con la terapia cognitivo conductual. El proyecto de tesis se presenta como compendio de cuatro trabajos empíricos publicados en revistas indexadas en el Journal Citation Reports. OBJETIVOS: El objetivo general de la tesis es obtener evidencia empírica de los factores que contribuyen al perfil clínico de pacientes que solicitan tratamiento, debido a los problemas que les generan diferentes formas de adicción comportamental. Uno de los estudios que forman la tesis aborda el rol del sexo, la edad de inicio y la duración de las conductas adictivas, y los rasgos de personalidad en el perfil clínico del trastorno de juego, la adicción a videojuegos, la compra compulsiva y la adicción al sexo. Otro de los estudios valora si los niveles de impulsividad (en diferentes dominios) y los sesgos cognitivos presentes en la conducta de juego estan asociados a la edad de los pacientes y a la gravedad del trastorno de juego. El siguiente estudio es un análisis de clasificación que explora la existencia de clústeres, en pacientes que cumplen criterios clínicos para adicción a videojuegos. El último artículo identifica trayectorias evolutivas de la gravedad del trastorno de juego en pacientes jóvenes, desde el momento de entrada al estudio hasta seis meses después de la intervención terapéutica. MÉTODO: Los participantes que se incluyen en los diferentes estudios empíricos de esta tesis son pacientes que han acudido a la Unidad de Juego Patológico y Otras Adicciones Comportamentales del Hospital Universitario de Bellvitge. La elección de los sujetos se ha basado en el cumplimiento de los criterios de inclusión-exclusión de cada estudio. RESULTADOS: En líneas generales, los resultados han evidenciado que el sexo, la edad de inicio y la duración de los problemas adictivos contribuyen de forma diferente en el perfil clínico, de las distintas adicciones comportamentales. La edad además presentó una tendencia cuadrática con los sesgos cognitivos asociados a la conducta de juego (los grupos de edad más extrema presentaron patrones de pensamiento más disfuncionales), y una tendencia lineal negativa con la impulsividad asociada a la búsqueda de sensaciones. En el caso de pacientes con adicción a videojuegos, se identificaron dos clústeres empíricos diferenciados en el nivel de funcionamiento global (en variables de psicopatología y personalidad), y con diferencias también en edad, edad de inicio y duración de las conductas adictivas, sexo, estado civil y situación laboral. Finalmente, el análisis de la evolución de la gravedad del trastorno de juego, desde la línea base hasta 6 meses post-intervención, facilitó la identificación de 3 trayectoras evolutivas, dos caracterizadas por pacientes con buena evolución y una por pacientes con evolución pobre. CONCLUSIÓN: Las adicciones comportamentales están suscitando enorme interés en múltiples ámbitos, que abarcan el área clínica, la investigación científica y la sociedad en general. En la actualidad numerosas publicaciones (libros, artículos y diversos formatos de divulgación general) aportan datos sobre la génesis y la progresión de estos trastornos. Pero las dificultades (y controversias) existentes en la definición conceptual de estas adicciones (la propia taxonomía DSM-5 incluye en la sección de condiciones emergentes alguna de estas conductas excesivas, problemáticas y, potencialmente, adictivas), la falta de conocimiento sobre cómo interactúan los múltiples factores que inciden en su inicio y evolución, así como la escasez de datos clínicos sobre los mecanismos explicativos de los resultados de la terapia, dan fe de la necesidad de nuevos estudios que aporten evidencia empírica sobre los mecanismos explicativos de estas complejas condiciones clínicas. Esta tesis doctoral presenta resultados específicos sobre cómo variables fundamentales como el sexo, la edad cronológica, la edad de inicio y la duración influyen en el perfil clínico en pacientes que cumplen criterios clínicos para diferentes adicciones comportamentales. La tesis también aporta evidencia sobre la heterogeneidad del fenotipo asociado a una de las adicciones que mayor interés social y sanitario está generando durante los últimos años (la adicción a los videojuegos), en gran medida por el impacto que supone en sujetos que son considerados de alta vulnerabilidad debido a su corta edad (adolescencia e inicios de la edad adulta). Se aportan también resultados sobre los diferentes perfiles (trayectorias) que se identifican tras la aplicación de la terapia cognitivo-conductual en pacientes jóvenes, con trastorno de juego, durante los seis primeros meses tras la intervención, y de las variables explicativas de los diferentes cursos. Los resultados obtenidos en esta tesis poseen implicación en el ámbito de los factores de riesgo y terapéutico. Identificar patrones de asociación que son específicos de cada subtipo de adicción comportamental facilitará la elaboración de instrumentos de cribado y de diagnóstico que resulten más precisos, y que permitan evaluar tanto la gravedad de los trastornos como sus correlatos más directos. Identificar los diferentes fenotipos que conforman cada una de estas adicciones también resulta sumamente útil para el desarrollo de planes preventivos y de tratamientos específicos que se focalicen en las variables centrales de cada perfil

Common and differential risk factors behind suicidal behavior in patients with impulsivity-related disorders: the case of bulimic spectrum eating disorders and gambling disorder

Background and aims: Mental disorders with high levels of impulsivity such as bulimic spectrum eating disorders (BSED) and gambling disorder (GD) are associated with high risk of suicidal behavior. The aim of the present study was to identify the common and differential vulnerability factors behind suicide attempts in a sample of patients with BSED compared to patients with GD. Methods: A total of 6,077 adults who sought treatment and met criteria either for BSED (n 5 2,391) or GD (n 5 3,686) were assessed at a specialized hospital unit. Personality traits, psychopathological symptomatology, lifetime history of suicide attempts and socio-demographic variables were evaluated. Results: The prevalence of suicide attempts was higher for BSED patients (26.2%) compared to GD patients (7.1%) being anorexia nervosa (Binge/Purge type) and bulimia nervosa the most affected subtypes. In the predictive model, the transdiagnostic vulnerability factors with the highest contribution to the risk of suicidal behavior both in BSED and GD were unemployment, early age of onset of the disorder, worse psychopathological state, and self-transcendence personality trait. However, specific risk factors for suicidal acts were identified in each disorder: longer duration of the disorder, lower education levels and reward dependence were exclusively associated with BSED while female gender, older age, and higher harm avoidance were associated with GD. Discussion: Patients with GD and BSED share certain vulnerability factors although certain factors are exclusive to each disorder. Conclusions: Interventions need to pay special attention to both common and specific vulnerability factors to mitigate the risk of suicidal acts in these disorders

Suicidal behavior in patients with gambling disorder and their response to psychological treatment: The roles of gender and gambling preference

Suicidal ideation and attempts are prevalent among patients with gambling disorder (GD). However, patients with GD and a history of lifetime suicidal events are not a homogeneous group. The main objective of this study was to compare sociodemographic, clinical, personality, and psychopathological features among different profiles of adults with GD with and without a history of suicidal behavior, taking into account two relevant variables: gender and gambling preference. The second aim was to examine how the different profiles of patients with a history of suicidal events responded to cognitive-behavioral therapy (CBT). A total of 1112 treatment-seeking adults who met the criteria for GD were assessed at a hospital specialized unit for the treatment of behavioral addictions. The participants completed self-reported questionnaires to explore GD, personality traits, and psychopathological symptomatology. The lifetime histories of suicidal ideation and attempts, and gambling preferences, were assessed during semi-structured face-to-face clinical interviews. Of the total sample, 229 patients (26.6%) reported suicidal ideation and 74 patients (6.7%), suicide attempts. The likelihood of presenting suicidal ideation was higher for women than men, but no differences were observed based on gambling preference. Regarding suicide attempts, the odds were higher among women with non-strategic forms of gambling. Suicidal ideation and attempts were associated with higher GD severity, a worse psychopathological state and higher self-transcendence levels. In terms of treatment outcomes, neither gambling preference nor past suicidal behavior had an influence on dropouts and relapses. Nevertheless, female gender and a lack of family support constitute two good predictors of a worse treatment outcome

The influence of chronological age on cognitive biases and impulsivity levels in male patients with gambling disorder

Background and aims: due to the contribution of age to the etiology of gambling disorder (GD), there is a need to assess the moderator effect of the aging process with other features that are highly related with the clinical profile. The objective of this study is to examine the role of the chronological age into the relationships between cognitive biases, impulsivity levels and gambling preference with the GD profile during adulthood. Methods: sample included n = 209 patients aged 18-77 years-old recruited from a Pathological Gambling Outpatients Unit. Orthogonal contrasts explored polynomial patterns in data, and path analysis implemented through structural equation modeling assessed the underlying mechanisms between the study variables. Results: compared to middle-age patients, younger and older age groups reported more impairing irrational beliefs (P = 0.005 for interpretative control and P = 0.043 for interpretative bias). A linear trend showed that as people get older sensation seeking (P = 0.006) and inability to stop gambling (P = 0.018) increase. Path analysis showed a direct effect between the cognitive bias and measures of gambling severity (standardized effects [SE] between 0.12 and 0.17) and a direct effect between impulsivity levels and cumulated debts due to gambling (SE = 0.22). Conclusion: screening tools and intervention plans should consider the aging process. Specific programs should be developed for younger and older age groups, since these are highly vulnerable to the consequences of gambling activities and impairment levels of impulsivity and cognitive biases

Exploring the Association between Gambling-Related Offenses, Substance Use, Psychiatric Comorbidities, and Treatment Outcome

Several studies have explored the association between gambling disorder (GD) and gambling-related crimes. However, it is still unclear how the commission of these offenses influences treatment outcomes. In this longitudinal study we sought: (1) to explore sociodemographic and clinical differences (e.g., psychiatric comorbidities) between individuals with GD who had committed gambling-related illegal acts (differentiating into those who had had legal consequences (n = 31) and those who had not (n = 55)), and patients with GD who had not committed crimes (n = 85); and (2) to compare the treatment outcome of these three groups, considering dropouts and relapses. Several sociodemographic and clinical variables were assessed, including the presence of substance use, and comorbid mental disorders. Patients received 16 sessions of cognitive-behavioral therapy. Patients who reported an absence of gambling-related illegal behavior were older, and showed the lowest GD severity, the most functional psychopathological state, the lowest impulsivity levels, and a more adaptive personality profile. Patients who had committed offenses with legal consequences presented the highest risk of dropout and relapses, higher number of psychological symptoms, higher likelihood of any other mental disorders, and greater prevalence of tobacco and illegal drugs use. Our findings uphold that patients who have committed gambling-related offenses show a more complex clinical profile that may interfere with their adherence to treatment

The prevalence and features of schizophrenia among individuals with gambling disorder

Background-objectives: Few studies have analyzed the comorbid presence of gambling disorder (GD) with schizophrenia, its sociodemographic correlates and clinical implications. This study estimated the prevalence of the dual diagnosis (GD with schizophrenia) and the differences in the profiles of patients with and without the dual condition. Method: The sample included n = 3,754 patients consecutively accepted for treatment for GD. Sociodemographics, gambling-related variables, psychopathological state and personality traits were assessed and compared between the groups. Results: The prevalence of schizophrenia within patients who met clinical criteria for GD was 4.4% (95% confidence interval: 3.8%-5.1%). Variables related to the dual presence of GD with schizophrenia were single marital status, lower education level, inactive working status, socioeconomic disadvantage, younger age, earlier onset of gambling problems, worse global psychopathological state and more dysfunctional personality profile (higher level in harm avoidance and lower level in cooperativeness, reward dependence, persistence and selfdirectedness). Conclusion: The presence of schizophrenia among patients with GD was around 4 times higher than the prevalence rate estimated in the reference general population. The differences in the profiles of GD patients with and without schizophrenia suggest that individuals with the dual diagnosis condition require unique assessment considerations and tailored treatment interventions specifically designed for the clinical and functioning higher risk

Gambling phenotypes in online sports betting

Background and objectives: The Internet provides easy access to multiple types of gambling and has led to changes in betting habits. A severe rise in problematic gambling has been predicted among all sectors of the population, and studies are required to assess the emerging phenotypes related to the new structures of gambling activities. This study aimed to explore the existence of latent classes associated with gambling habits among treatment-seeking gamblers due to Online Sports Betting (OSB). Method: Initial sample included n = 4,516 patients consecutively admitted for treatment in a hospital unit specialized in behavioral addictions. Two-step clustering analysis was used within the subsample of n = 323 patients who reported problems related with OSB, within a set of indicators including sociodemographics, psychopathological distress, personality, and severity of the gambling activity. Results: The prevalence of OSB as a main type of gambling problem in the study was 7.2% (95% confidence interval: 6.4 to 7.9%). Two latent clusters were identified, with differences in sociodemographics and clinical status. Cluster 1 (n = 247, 76.5%) grouped patients that were more affected due to the OSB behaviors, and it was characterized by non-married patients, lower socioeconomic position index, higher comorbidity with other substance related addictions, younger age, and early onset of the gambling activity, as well as higher debts due to the OSB, higher psychopathological distress, and a more dysfunctional personality profile. Cluster 2 (n = 76, 23.5%) grouped patients that were less affected by OSB, mostly married (or living with a stable partner), with higher social position levels, older age and older onset of the gambling activity, as well as a more functional psychopathological and personality profile. Conclusion: The increasing understanding of latent classes underlying OSB phenotypes is essential in guiding the development of reliable screening tools to identify individuals highly vulnerable to addictive behaviors among Internet gamblers, as well as in planning prevention and treatment initiatives focused on the precise profiles of these patients

Women and gambling disorder: Assessing dropouts and relapses in cognitive behavioral group therapy

Background: Gender-specific literature focused on gambling disorder (GD) is scarce, and women with GD have been understudied. Therefore, the aim of this study was to estimate the short-term effectiveness in women with GD (n = 214) of a group standardized cognitive-behavioral therapy (CBT) and to identify the most relevant predictors of the primary therapy outcomes (dropout and relapse). Methods: The manualized CBT consisted of 16 weekly outpatient group sessions. Women were provided with resources to obtain a better understanding of the GD, to improve self-control and to manage risk situations. Results: The dropout risk was higher for women with lower GD severity and higher psychopathological distress. Among other factors, lower education levels were a significant predictor of the relapse risk and and the frequency of relapses was higher for divorced women with a preference for non-strategic gambling and with substances consumption. Conclusions: Our findings evidence women-specific predictors of the primary therapy outcomes. The results highlight the need to design psychological interventions that address dropout and relapse risk factors in women

Subtyping treatment-seeking gaming disorder patients

Background and aims: Gaming Disorder (GD) is characterized by a pattern of persistent and uncontrolled gaming behavior that causes a marked impairment in important areas of functioning. The evolution of the worldwide incidence of this disorder warrants further studies focused on examining the existence of different subtypes within clinical samples, in order to tailor treatment. This study explored the existence of different profiles of patients seeking treatment for GD through a data-driven approach. Methods: The sample included n = 107 patients receiving treatment for GD (92% men and 8% women) ranging between 14 and 60 years old (mean age = 24.1, SD = 10). A two-step clustering analysis approach explored the existence of different underlying GD profiles based on a broad set of indicators, including sociodemographic features, clinical course of the condition (e.g., onset or evolution), psychopathological symptoms, and personality traits. Results: Two GD profiles emerged. The first cluster grouped together patients who presented with a lower psychological impact (n = 72, 66.1%), whereas the second cluster comprised patients with a higher psychological impact (n = 35, 32.7%). Cluster comparisons revealed that those patients presenting the higher impact were older, with a later onset of pathological gaming patterns, and more pronounced psychopathological symptoms and dysfunctional personality profiles. Conclusions: GD severity is influenced by specific demographic, clinical, and psychopathological factors. The identification of two separate profiles provides empirical evidence that contributes to the conceptualization of this disorder, as well as to the development of reliable and valid screening tools and effective intervention plans focused on the precise characteristics of the treatment-seeking patients

The contribution of sex, personality traits, age of onset and disorder duration to behavioral addictions

Background and aims: Increases in the prevalence of behavioral addictions worldwide have led to a growth in the etiological research of the specific contribution of risk/protective factors to these disorders. The objective of this study was to assess the relative role of patients' sex, age of disorder onset and disorder duration on the clinical profile of behavioral addictions. Methods: Our sample included treatment-seeking patients diagnosed with gambling disorder (GD, n = 3,174), internet gambling disorder (IGD, n = 45), compulsive buying (CB, n = 113), and sex addiction (SA, n = 34). Results: The pattern of associations between the independent variables and the outcomes were strongly related to the behavioral addiction subtype: (a) for GD-men early onset of the disorder was related to GD severity, while for GD-women early onset was linked to novelty seeking; (b) for IGD-men, late onset correlated with addiction severity, worse psychopathological state, and high harm avoidance and self-transcendence levels; (c) for CB-women, early onset was related to higher reward-dependence scores and lower self-transcendence levels, and longer duration predicted higher cumulate debts; for CB-men, early onset and long duration correlated with high scores in harm-avoidance, self-directedness, self-transcendence, and cooperativeness; and (d) for SA-men, late onset and longer duration correlated with high disorder severity. Discussion and Conclusions: These findings are relevant for developing prevention and treatment programs specific to different behavioral addictions