Focus on Anger in the Treatment of Gambling Problems

Lorne Korman, Ph.D., C.Psych.

Director of ResearchBC Provincial Youth Concurrent Disorders Program

Jane Collins

BC Provincial Youth Concurrent Disorders Program

What is Anger?

• Anger is a primary, basic emotion, with characteristic appraisal and action tendency1

• Anger is the blueprint for aggression, violence2

• Anger and violence frequently co-occur3

• Violence can also occur in the absence of anger

1 Fridja, 1986; Ekman, 1984; Ekman & Friesen, 1975, Izard 19772 Averill, 19933 Kassinove & Sukhodolsky, 1995

Self-Reported Anger and Aggression Self-Reported Anger and Aggression among Substance-Using Clients among Substance-Using Clients 18-month Period at ARF and CAMH

• 4995 new patients seeking addictions tx

• 40% reported anger problems at intake

• 19% reported acts of physical aggression related to substance use

• 9.7% reported acts of physical aggression in the last 90 days

From Collins, Skinner, & Toneatto, 2005

Canadian Forensic Data: Violence and S.U. % of Alcohol and Drug Intoxication at Time of Perpetration of Index Violent Crime

Alcohol Intox.

Alc & Drug

Drugs Only

Neither

Homicide 33.9 21.3 7.0 37.8

Attempt Murder

30.3 23.6 8.5 37.6

Assault 39.4 23.8 8.8 28.0

Source: Pernanen et al., 2002. Canadian Centre on Substance Abuse

The Co-occurrence of Substance Use and Violent Crime

• Summary of 26 studies in 11 countries found on average, 61.5% of offenders drank at time of committing violent crime1

• Recent Swedish study found a 13.2-fold increase in the risk of criminal violence within 24 hours of alcohol consumption2

1 Murdoch, Pihl, & Ross, 1990

2 Haggard-Grann, Hallqvist, Langstrom, & Moller, 2006

Substance Use and Intimate Partner Violence

• Very high rates of co-occurrence of substance abuse among perpetrators of IPV, particularly among male perpetrators1

• The relationship between substance use and IPV has been established both in cross-sectional and longitudinal studies2

1 c.f. Quigley & Leonard, 2000

2 Heyman, O’Leary, & Jouriles, 1995;

Leonard & Senchak, 1996; Quigley & Leonard, 2000

Substance Use and Intimate Partner Violence:Recidivism

• IPV recidivism higher among relapsed alcoholics than among remitted alcoholics1

• Following batterer intervention programs, individuals more likely to re-assault if they have substance use problems2

1 Stuart et al., 2003; Maiden, 1997

2 DeMaris & Jackson, 1987; Gondolf, 1997; Jones & Gondolf, 2001

Anger and Addictions

• High rates of co-occurrence of:

– substance use and anger

– substance use (especially alcohol) and violent crime

– substance use and domestic violence

• What about the co-occurrence of pathological gambling and anger/violence?

Anger Problems among Substance-Using Problem Gamblers

• higher proportion of problem gamblers (61%) report anger management problems than non-problem gamblers (40%) 1

• severity of gambling problems associated with greater hostility in treatment-seeking substance users 2

1 Collins, Skinner, & Toneatto, 2005 2 McCormick, 1993

Intimate Partner Violence and Problem Gambling

• Research relatively sparse

• Survey of 144 spouses of compulsive gamblers: 43% reported their spouses had physically or verbally abused them1

1. Lorenz and Shuttlesworth, 1983

Intimate Partner Violence and Problem Gambling (continued)

• In interviews with pathological gamblers, 23% reported having hit or thrown things at their partners at least once 1

• Survey of 300 women attending E.R. in Nebraska: those with spouses who had gambling problems more likely to be victims of IPV 2

1 Bland, Newman, Orn, & Stebelski, 19932 Muellerman, DenOtter, Wadman, Tran, & Anderson, 2002

Treating Comorbid Anger and Addictions

• Much known about the high prevalence of concurrent anger, aggression and substance use (e.g., domestic violence & alcohol)

• Many anger treatments screen out clients with active addictions

• Lack of empirically tested integrated treatments for comorbid anger and addictions

Treat Concurrent Anger & AddictionsTreat Concurrent Anger & AddictionsProblems Concurrently?Problems Concurrently?

• Are there benefits to addressing concurrent anger and addictions in an integrated treatment?

• Theories posit emotion dysregulation as an underlying problem of (separately) gambling, anger, substance use problems1

• Is there utility in targeting emotion dysregulation for people with concurrent anger, gambling, and substance use problems?

1 Dutton, 1995; Greenberg & Paivio, 1997; Khantzian, 1985, 1997; Levinson, Gernstein & Maloff, 1983; Miller, 1980; Moran, 1970

RCT on Integrated Treatment for Comorbid Anger and Addictions

• RCT study compared integrated gambling, anger and substance use treatment to a specialized addictions-only treatment

Research TeamResearch TeamLorne KormanJane CollinsNina Littman-Sharp Shelley McMainWayne Skinner

Project ConsultantProject ConsultantTony Toneatto

With Assistance from:With Assistance from: Therapists of the Problem Gambling Service &

the Anger and Addiction Clinic at CAMH

Research AssistantResearch AssistantVirginia Mercado

Funded by a grant fromThe Ontario Problem Gambling Research Centre

Randomized Control Trial of an Integrated Treatment for Concurrent Anger and Addictions

• Participants: Problem gamblers (CPGI ≥ 8), all with self-identified anger problems, with or without concurrent substance use problem

• RCT, 42 participants stratified by substance dependence disorder

• Assessment periods: Intake (T1), 14 weeks (T2), 12-week follow-up (T3)

Study DesignStudy Design

Treatment ConditionsTreatment Conditions

• Integrated Treatment Targeted both Anger & Addictions

@ an Integrated Anger & Addiction Clinic

• Addictions-Only Treatment-as-Usual (TAU)

Only Targeted Addictions – Gambling & SU

@ Specialized Gambling Clinic

Study Treatments Study Treatments

Integrated Condition:

Max. 12 individual weekly sessions (1 hour)

Diary card of target behaviours

Analyses of reported target behaviours (30-40 min.)

Skills training, as relevant (20-30 min.), and exposure, response prevention, rehearsal

Study Treatments Study Treatments

Addictions-Only TAU

Treatment length varied as needed, 1 hour individual sessions

Focused primarily on problem gambling and substance use using CBT relapse prevention

Study Measures

• Canadian Problem Gambling Index (CPGI)– PGSI (9 items, 9-point lykert scale)

• State-Trait Anger Expression Inventory (STAXI)– 44 items, yielding 2 scales, 6 subscales

• Drug Use History Questionnaire (type, frequency and amount of substances used past 3 months)

• SCID Substance Use/Substance Dependence Sections (T1 only)

Demographics

Integrat.

n=20

TAU

n=22

age 44.5

(sd= 11.9)

50.4

(sd=9.85)

sex 18 Male

2 Female

18 Male

4 Female

income $ 33,579 $ 30,810

Treatment Engagement: % subjects attended at least 1 session

0

10

20

30

40

50

60

70

80

90

100

% s

ubje

cts

TAUIntegrative

# Sessions Attended by Group# Sessions Attended by Group

0

1

2

3

4

5

6

7

8

9

# s

ub

jec

ts

TAU Integrative

0

1 to 4

5 to 8

9 to 12

13 to 16

17 +

Sessions Attended = CovariateSessions Attended = Covariate

• Integrated treatment significantly better at engaging clients than addictions-only TAU

• Because # of sessions attended in Integrative condition was greater, # of treatment sessions attended was used as a covariate in analyses of outcome.

• Therefore observed treatment effects on all major outcome variables were not dependent on the number of treatment sessions attended

• Also, patterns of change same for participants in TAU who had 4 or more sessions

Gambling: PGSI

0

10

20

T1 T2 T3

aver

age

PG

SI s

core

TAUIntegrative

% Meeting Criteria for Problem Gambling (PGSI≥8)

01020304050

60708090

100

T1 T2 T3

% s

ubje

cts

TAUIntegrative

Gambling: % monthly income spent gambling

01020304050

60708090

100

T1 T2 T3

mea

n %

inc

ome

gam

bled

TAUIntegrative

STAXI Trait Anger

0

10

20

30

40

50

60

70

T1 T2 T3

aver

age

T s

core

TAUIntegrative

STAXI Anger Expression

0

10

20

30

40

50

60

70

T1 T2 T3

aver

age

T s

core

TAUIntegrative

Clinical Significance of Changes:

STAXI Anger Expression

01020304050

60708090

100

T1 T2 T3

aver

age

perc

enti

le

TAUIntegrative

(expressed in percentiles, based on a standardized normal population)

Problem Anger Threshold

Substance Use (at intake)Substance Use (at intake)

Integrt.n=20

TAUn=22

Dependence 8 8

Abuse 2 1

Use not meeting disorder criteria

3 3

No use in past 90 days 7 10

Substance Use: Days Used

0

15

30

45

T1 T2 T3

aver

age

# da

ys u

sed

in p

ast

90

TAUIntegrative

DiscussionDiscussion

• An integrated approach treating concurrent anger & gambling appears to improve both addictions & anger outcomes

• The presence of anger may make gambling treatment less effective if anger not addressed.

• Addictions clinicians need to assess & treat concurrent anger & other addictions problems.

• Anger treatments need also to screen & target addictions.

DiscussionDiscussion

• Addressing concurrent anger may provide a big bang for the buck in gambling treatment

• Findings underscore importance of using engagement strategies with clients with concurrent anger and gambling problems

• Integration & flexibility important- i.e., the ability to target multiple relevant problems concurrently.

Response to the Study (I)

• Sample size (20/22 per group)

• TAU was not a manualized treatment

• Follow-up was relatively short (3 months)

Integrated Anger and Addiction Treatment Study: RCT # 2 – Just starting

• N = 80 youth (40 per condition)

• TAU is a manualized CBT with adherence monitoring

• One-year follow-up

Korman, Toneatto, Collins, & Cripps, in progress

Funded by a grant from the Ontario Gambling Research Centre

Response to the Study (II)

Findings may be less important because angry problem gamblers are a small “niche” population.

So, are angry problem gamblers in fact a small “niche” population of problem gamblers?

Are Angry Problem Gamblers a Small, “Niche” Population of Problem Gamblers?

Study examined the prevalence of problem anger, substance use and intimate partner violence among problem gamblers.

n=248 problem gamblers (43 females, 205 males)

Korman, Collins, Littman-Sharp, Dutton, Cripps & Skinner, 2007

Funded by a grant from the Ontario Problem Gambling Research Centre

Angry Problem Gamblers not a “Niche” Population: They may be the Majority

In a recently completed prevalence study of 248 problem gamblers in Canada, 64.5% found to have clinically significant anger problems on the STAXI-II

Source: Korman, Collins, Littman-Sharp, Dutton, Cripps & Skinner, 2007

Funded by a grant from the Ontario Problem Gambling Research Centre

Problem Gamblers

What about the prevalence of

Intimate Partner Violence?

6255

59.7

0

10

20

30

40

50

60

70

80

Any IPV* Perpetrator Victim

%

Intimate Partner Violence in the Past Year: CTS2 Data

* either perpetrator or victim of physical assault, injury, and/or sexual coercion

N = 248

39.9

12.1

0

10

20

30

40

50

60

70

80

PG Sample General Male Pop'n*

%

"Minor" Physical Assault among Problem Gamblers: Perpetration

CTS2 Minor Physical Assault: e.g. push, grab, shove

* ( male pop. norms from Kwong, Bartholomew, & Dutton, 1999)N = 248

17.3

2.20

10

20

30

40

50

60

70

80

PG Sample General Male Pop'n*

%

“Severe" Physical Assault among Problem Gamblers Perpetration

* ( male pop. norms from Kwong, Bartholomew, & Dutton, 1999)

CTS2 Severe Physical Assault: e.g. punch, kick, use weapon

N = 248

46.8

12.1

0

10

20

30

40

50

60

70

80

PG Sample General Male Pop'n*

%

"Minor" Physical Assault among Problem Gamblers Victimization

CTS2 Minor Physical Assault: e.g. push, grab, shove

* ( male pop. norms from Kwong, Bartholomew, & Dutton, 1999)

N = 248

27.4

4.8

0

10

20

30

40

50

60

70

80

PG Sample General Male Pop'n*

%

“Severe" Physical Assault among Problem Gamblers Victimization

* ( male pop. norms from Kwong, Bartholomew, & Dutton, 1999)

CTS2 Severe Physical Assault: e.g. punch, kick, use weapon

N = 248

Prescription Opioids

2%

Other3%

Alcohol58%

Cocaine23%

Cannabis9%

Heroin5%

Alcohol

Cocaine

Cannabis

Heroin

Prescription Opioids

Other

Lifetime Substance Use Disorder in Problem Gamblers (N=185/248)

What Accounts for High Rates of Anger and IPV among Problem Gamblers?

• Psychiatric Comorbidity?

• And/or Impulsivity?

• And/or general emotion dysregulation?

Axis II Comorbidity?

• High rates of Axis II comorbidity among pathological gamblers 1

• Blaszczynski and Steel (1998): 92% of 82 treatment-seeking problem gamblers met criteria for at least one personality disorder

– Cluster B most prevalent: 57.3% pathological gamblers met criteria for borderline, histrionic, and/or narcissistic PD

– Note two of these PDs feature emotion dysregulation

1 Black & Moyer, 1998; Blaszczynski and Steel, 1998; Fernandez-Montalvo & Echeburua, 2004; Lesieur & Blume, 1990

The Role of Emotion Regulation

Are there functional relationships between anger and gambling?

Functional Relationships between Anger and Gambling

• Violence and Anger History Interview (VAHI; Korman & Collins, 2005)

• Structured interview of violent and angry episodes. Episodes divided into:

1) serious consequences to the participant

2) serious consequences to others

From Brunelle, Korman, Collins, & Cripps, 2005

Emotion Regulation:Anger and Gambling

• 45.2% (28/62) gambled after an anger episode with serious consequences to self

• 30.60% (19/62) gambled after an anger episode with serious consequences to other

Serious Consequence to Self : Change in Anger Intensity After Gambling

18%

21%61%

Decrease

Increase

No change

Serious Consequence to Other: Change in Anger Intensity After Gambling

32%

68%

Decrease

No change

Emotion Regulation: Anger and Alcohol

36.1% (22/62) drank alcohol after an anger episode with serious consequences to self

• 24.2% (15/62) drank alcohol after an anger episode with serious consequences to other

23%

36%41%

Decrease

Increase

No change

Serious Consequence to Self: Change in Anger Intensity After Alcohol

Serious Consequence to Other: Change in Anger Intensity After Alcohol

47%

20%

33%

Decrease

Increase

No change

Summary

• There appears to be benefit in addressing concurrent anger and addiction problems in an integrated treatment

• Much higher prevalence of anger problems and intimate partner violence among problem gamblers…. Why?

Final Thoughts

• Some preliminary evidence of functional relationships between anger and gambling, among some problem gamblers with comorbid anger

• The relationship between anger, intimate partner violence and gambling merits further study

– What role(s), if any, does gambling have in IPV?

– How do Anger Problems Overlap with Impulsivity, Emotion Dysregulation, and Psychiatric Co-Morbidity in PG?

THANK YOU

lkorman@cw.bc.ca