Pathological Gambling Secondary to Brain Trauma Alex Blaszczynski, Ph.D. ~ Judy Hyde, M.Clin.Psych 1 Joseph Sandanam, MBBS, DPRM (Aust), FACRM 2 Westmead Hospital, Australia
A 23 year old b r a i n injured male developed a pathological gambling disorder in response to social isolation which resulted from frontal lobe disinihibitory behaviors. T h e case illustrates the difficulties encountered in m a n a g e m e n t and treatment where an impulse control disorder is superimposed on, and compounded by, organic-based frontal lobe impulsivity.
INTRODUCTION
DM, a 23 year old brain injured pathological gambler was initially assessed at the Clinical Psychology Outpatient Clinic of a large university teaching hospital. The Clinic sub-specializes in the behavioral treatment of pathological gambling. He was referred by the treating rehabilitation physician of the hospital for significant loss of control over gambling behavior and associated premeditated and impulsive stealing. Pathological gambling
Correspondence to: A. Blaszczynski, Senior Clinical Psychologist. Department of Clinical Psychology, Westmead Hospital, Westmead, NSW 2145, Australia. 1Department of Clinical Psychology, Westmead Hospital, Westmead, NSW 2145, Australia. 2Deputy Director, Department of Rehabilitation Medicine, Westmead Hospital, Westmead, NSW 2145, Australia.
Journal of Gambling Studies Vol. 7(1), Spring 1991 Q 1991 Human Sciences Press
65
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JOURNAL OF GAMBLING STUDIES
emerged subsequent to a motor vehicle accident in which significant head injuries were sustained. Gambling evolved in response to resultant social isolation and boredom. This case illustrates the complexity involved in the management of an individual with both organic and behavioral impulse control disorders.
CASE H I S T O R Y
Demographics D M was a 23 year old single Australian-born male of Italian extract. Prior to the accident in 1983, he was attending a local high school but was currently unemployed and on sickness benefits with compensation litigation pending. He continues to live in the parental home.
Presenting Problem O n presentation DM's mother expressed concern over recent increased gambling activity supported by indiscriminate theft of money and the pawning of family jewelry. This placed him at significant risk of legal repercussions. The gambling behavior was further compounding his social isolation and causing disruption to the continuity of his brain damage rehabilitation program. The extent of his Frontal based organic impairment, lack of insight, cognitive and memory deficits and impulsivity exacerbated difficulties in family management.
Family History DM's parents emigrated from Italy two years prior to his birth, to take up partnership in an established family business. His father, aged 56 years, was a hard working and ambitious man suffering a mild coronary artery disease and diabetes mellitus. His mother, 53 years of age, was a physically healthy part-time seamstress who described herself as highly stressed and anxious.
ALEX BLASZCZYNSKI,JUDY HYDE, AND JOSEPH SANDANAM
67
While a distant relationship between D M and his father was described, his relationship with his mother impressed as overprotective and enmeshed. This was exacerbated beyond premorbid levels by his increased dependency needs resulting from his trauma. DM's nineteen year old younger sister also lived in the parental home and was undertaking studies at a secretarial college. Their relationship was strained by rivalry issues and the supportive and parentified role which she was required to embrace in conflict with her own separation and individuation processes. There was no family history of psychiatric illness, alcoholism or pathological gambling. His father participated in regular culturallybased social card gambling involving minimal stakes. This was not identified by family members as problematic.
Personal History According to DM's mother, D M was a full-term birth with no preor post-natal complications. Developmental milestones were normal and there was no history of any significant physical illness, emotional disturbance, head injuries or seizures during childhood years. Schooling was commenced at 5 years of age and prematurely terminated at the time of his motor vehicle accident when aged 16 years. Although academically he performed in the low average range, he was described as a friendly, gregarious and popular child who actively participated in team sports. As captain of the under 19's district football team, his ambitions were realistically directed towards a professional first-grade football career. He was physically fit and did not consume excessive amounts of alcohol or use illicit drugs. At age 16 years, D M was involved, as a passenger with six other youths, in a motor vehicle accident in which the driver apparently lost control while traveling on a freeway at a speed in excess of 150 kph. The vehicle struck an embankment and overturned. One female passenger was killed and the others, apart from himself, received minor injuries. D M was found to be unconscious with right dilated pupil, multiple fractures to the parietal bone, and faciomaxillary areas, third nerve palsy and facial/periorbital bruising. A C A T scan revealed a right fronto-parietal extra dural haemotoma. A craniotomy with drainage and insertion of a Richmond bolt was performed.
68
JOURNAL OF GAMBLING STUDIES
Consciousness was not regained for two weeks. A retrograde amnesia of one hour, and anterograde amnesia of four months was reported. On discharge he was noted to have reduced mobility due to poor balance, third nerve palsy with visual impairment, and suffering diabetes insipidus, hypothyroidism, and hypogonadism which were attributed to the head injury. Neuropsychological testing revealed cognitive deficits consistent with frontal lobe dysfunction. Verbal new learning abilities and short term memory functions were impaired but visual memory remained intact. His intelligence quotient five months post trauma was determined to be in the range of I Q = 79-89 (as compared to an estimated premorbid level of I Q = 108) and a memory quotient of M Q = 77. He attempted to resume schooling, but after two days realized he was unable to cope with academic studies. Subsequently, he attended various vocational and rehabilitation re-training programs. On being unable to successfully complete any such program, he was placed on invalid pension status. He has remained unemployed since the trauma.
Gambling History O n full physical recovery, approximately five years post-trauma, D M re-commenced socializing with friends and attending weekly discotheque dances held at his former soccer club. In the state of New South Wales, Australia, poker-machines (equivalent to slot-machines) are legally permitted in certain registered social and sporting clubs. However, D M rapidly found himself isolated from his peers and unable to effectively relate to females who avoided him because of his cognitive slowness and mildly inappropriate, intrusive and disinhibited behavior. In reaction he began playing poker-machines, soon escalating over a period of six months from weekly to almost daily play. Although he consumed alcohol while gambling the amount was minimal and did not constitute a problem for him. There was no relationship between amount consumed and gambling. Amounts of $Ausl5-50.00 were staked each gambling session of an average two to four hours duration. His winnings, including large jackpots, were immediately re-invested and he invariably left the club empty-handed. Given his unemployed status, his source of gambling funds were restricted to pocket-money received from his mother. As his
ALEX BLASZCZYNSKI, JUDY HYDE, AND JOSEPH SANDANAM
69
frequency of play increased, he began redistributing his lunch money and excess change from transport costs toward his gambling. Within twelve months, he found himself frequently preoccupied with gambling and his urge remaining unsatiated at the end of each session. O n one occasion he impulsively seized an opportunity of stealing $50.00 from a friend. He then established a pattern of stealing small amounts of money, between $Aus15--20.00, from his parents on a relatively regular basis. He stole from shops on an indeterminate number of occasions and jewelry belonging to family and friends at least four times. This, and his own gold chain and watch, were pawned to obtain funds to supplement his gambling. Attention was drawn to his offenses when he was apprehended by club officials while stealing SAusl20.00 from the handbag of a club patron. He did not exhibit apparent concern, remorse or even relief when charges were not laid because of his condition. Despite his family's attempts to increase his level of awareness of the consequences of his actions, he exhibited a gross lack of insight into the effects of his continued gambling and offending on himself and family. Although immediately apologetic, contrite and promising to comply with requests to cease both gambling and stealing, his resolve quickly subsided and his aberrant behavior resumed. He reacted with indifference to family or social criticism and appeared unperturbed by the possibility of legal action. Periods of remissions were absent. He ceased to gamble only when temporarily deprived of funds. Family interventions proved ineffective in limiting his behavior. Although he attended a rehabilitation center for brain injured adults, the center lacked resources and expertise to address the issue of his gambling. He was initially assessed at a general hospital offering outpatient treatment for pathological gamblers. Given the need for intensive therapy because of the nature of DM's cognitive impairment, it was considered that hospital admission was required. He was therefore referred to a private psychiatric hospital facility with a specialist inpatient behavior therapy treatment unit for pathological gambling and impulse control disorders. He was admitted for an individual two week imaginal desensitization and impulse control treatment program. But on the admission day he soon made unsolicited and inappropriate sexual advances toward
70
JOURNAL OF GAMBLING STUDIES
four female patients. In one case he physically caressed and kissed the breasts of one schizophrenic woman causing such distress that she discharged herself that afternoon (returning only after D M was discharged). Within half an hour of his being reprimanded and cautioned, D M was apprehended searching through the belongings of another female patient, while yet another reported the theft of $20.00. Nursing staff reported that they were unable to contain his behavior and that other patients were now expressing grave concern over their well being. He was then immediately discharged for transgressing hospital rules. A lack of alternative opportunities resulted in the need for D M to commence an outpatient program with the cooperation of family members acting as co-therapists. He has to date, not completed this program.
CONCLUSIONS
This case describes the development of pathological gambling behavior in response to impaired psychosocial functioning resulting from extensive frontal lobe brain damage. In this case study, pathological gambling became established as a maladaptive coping strategy to deal with social isolation produced by organic inappropriate and disinhibitory behaviors. Pathological gambling is defined as a disorder of impulse control (A.P.A., 1987), although Allcock and Grace (1988) question the validity of the view that gamblers load highly on traits of impulsivity, while others (Blaszczynski, Buhrich & McConaghy, 1985; Jacobs, 1988) conceptualize pathological gambling as an addictive disorder. Irrespective of which theoretical model is accepted, treatment objectives are specifically aimed at the reinstitution of control over excessive impulsive and/or addictive behaviors. Impulsivity is reflected by behaviors that are carried out without forethought and with scant regard for consequences. In the context of gambling, impulsivity is closely associated with apetitive drive that may result in dysfunctional consequences. Attempts to regain control over behavior are severely restricted when such behaviors are compounded by the presence of additional organically based impulsivity, specifically from frontal lobe damage. Frontal lobe damage impairs
ALEX BLASZCZYNSKI, JUDY HYDE, AND JOSEPH SANDANAM
71
higher order intellectual functions including insight, social judgment, inhibitory control over behavior, initiative and motivation. Where frontal lobe organicity exists with the additional presence of m e m o r y dysfunction, the usual cognitive and/or behavioral treatment strategies are generally precluded or prove ineffective. Techniques such as imaginal desensitization (McConaghy, Armstrong, Blaszczynski & Allcock, 1983) are difficult to implement where ease of distractability and intrusive thoughts interfere with goal directed thinking. Multi-modal approaches where hospitalization is necessary may be difficult unless constant supervision is available or where socially disinhibitory or potentially illegal behaviors may be contained. Given these restraints, recourse to aversive therapy procedures or the use of family members as co-therapists in a home-based, highly structured learning regime may be useful alternatives. The pathological gambler with co-existing frontal lobe damage and inappropriate behavior poses a significant management problem. The prevalence of such cases do not warrant the establishment of specialist units while existing rehabilitation facilities lack adequate treatment resources to deal with gambling. Aversive therapy and time consuming individual support utilizing family support appears the only avenue of help at the moment.
REFERENCES Allcock, C.C. & Grace, D.M. (t988). Pathological gamblers are neither impulsive nor sensation seekers. Australian and New Zealand,journal of Psychiatry, 22, 307-311. American Psychiatric Association. (1987). Diagnostic and Statistical Manual--Revised. (Third edition). Washington, DC Blaszczynski, A., Buhrich, N. & McConaghy, N. (1985). Pathological gamblers, heroin addicts and controls compared on the EPQ'addiction Scale.' British Journal of Addictions, 80, 315-319. Jacobs, D. (1988). Evidence for a common dissociative-like reaction among addicts. `journal of Gambling Behavior, 4, 27-37. McConaghy, N., Armstrong, M.S., Blaszczynski, A. & Allcock, A. (1983). Controlled comparison of aversive therapy and imaginal desensitization in compulsive gambling. British,journal of Psychiatry, 142, 366-372.
A 23 year old b r a i n injured male developed a pathological gambling disorder in response to social isolation which resulted from frontal lobe disinihibitory behaviors. T h e case illustrates the difficulties encountered in m a n a g e m e n t and treatment where an impulse control disorder is superimposed on, and compounded by, organic-based frontal lobe impulsivity.
INTRODUCTION
DM, a 23 year old brain injured pathological gambler was initially assessed at the Clinical Psychology Outpatient Clinic of a large university teaching hospital. The Clinic sub-specializes in the behavioral treatment of pathological gambling. He was referred by the treating rehabilitation physician of the hospital for significant loss of control over gambling behavior and associated premeditated and impulsive stealing. Pathological gambling
Correspondence to: A. Blaszczynski, Senior Clinical Psychologist. Department of Clinical Psychology, Westmead Hospital, Westmead, NSW 2145, Australia. 1Department of Clinical Psychology, Westmead Hospital, Westmead, NSW 2145, Australia. 2Deputy Director, Department of Rehabilitation Medicine, Westmead Hospital, Westmead, NSW 2145, Australia.
Journal of Gambling Studies Vol. 7(1), Spring 1991 Q 1991 Human Sciences Press
65
66
JOURNAL OF GAMBLING STUDIES
emerged subsequent to a motor vehicle accident in which significant head injuries were sustained. Gambling evolved in response to resultant social isolation and boredom. This case illustrates the complexity involved in the management of an individual with both organic and behavioral impulse control disorders.
CASE H I S T O R Y
Demographics D M was a 23 year old single Australian-born male of Italian extract. Prior to the accident in 1983, he was attending a local high school but was currently unemployed and on sickness benefits with compensation litigation pending. He continues to live in the parental home.
Presenting Problem O n presentation DM's mother expressed concern over recent increased gambling activity supported by indiscriminate theft of money and the pawning of family jewelry. This placed him at significant risk of legal repercussions. The gambling behavior was further compounding his social isolation and causing disruption to the continuity of his brain damage rehabilitation program. The extent of his Frontal based organic impairment, lack of insight, cognitive and memory deficits and impulsivity exacerbated difficulties in family management.
Family History DM's parents emigrated from Italy two years prior to his birth, to take up partnership in an established family business. His father, aged 56 years, was a hard working and ambitious man suffering a mild coronary artery disease and diabetes mellitus. His mother, 53 years of age, was a physically healthy part-time seamstress who described herself as highly stressed and anxious.
ALEX BLASZCZYNSKI,JUDY HYDE, AND JOSEPH SANDANAM
67
While a distant relationship between D M and his father was described, his relationship with his mother impressed as overprotective and enmeshed. This was exacerbated beyond premorbid levels by his increased dependency needs resulting from his trauma. DM's nineteen year old younger sister also lived in the parental home and was undertaking studies at a secretarial college. Their relationship was strained by rivalry issues and the supportive and parentified role which she was required to embrace in conflict with her own separation and individuation processes. There was no family history of psychiatric illness, alcoholism or pathological gambling. His father participated in regular culturallybased social card gambling involving minimal stakes. This was not identified by family members as problematic.
Personal History According to DM's mother, D M was a full-term birth with no preor post-natal complications. Developmental milestones were normal and there was no history of any significant physical illness, emotional disturbance, head injuries or seizures during childhood years. Schooling was commenced at 5 years of age and prematurely terminated at the time of his motor vehicle accident when aged 16 years. Although academically he performed in the low average range, he was described as a friendly, gregarious and popular child who actively participated in team sports. As captain of the under 19's district football team, his ambitions were realistically directed towards a professional first-grade football career. He was physically fit and did not consume excessive amounts of alcohol or use illicit drugs. At age 16 years, D M was involved, as a passenger with six other youths, in a motor vehicle accident in which the driver apparently lost control while traveling on a freeway at a speed in excess of 150 kph. The vehicle struck an embankment and overturned. One female passenger was killed and the others, apart from himself, received minor injuries. D M was found to be unconscious with right dilated pupil, multiple fractures to the parietal bone, and faciomaxillary areas, third nerve palsy and facial/periorbital bruising. A C A T scan revealed a right fronto-parietal extra dural haemotoma. A craniotomy with drainage and insertion of a Richmond bolt was performed.
68
JOURNAL OF GAMBLING STUDIES
Consciousness was not regained for two weeks. A retrograde amnesia of one hour, and anterograde amnesia of four months was reported. On discharge he was noted to have reduced mobility due to poor balance, third nerve palsy with visual impairment, and suffering diabetes insipidus, hypothyroidism, and hypogonadism which were attributed to the head injury. Neuropsychological testing revealed cognitive deficits consistent with frontal lobe dysfunction. Verbal new learning abilities and short term memory functions were impaired but visual memory remained intact. His intelligence quotient five months post trauma was determined to be in the range of I Q = 79-89 (as compared to an estimated premorbid level of I Q = 108) and a memory quotient of M Q = 77. He attempted to resume schooling, but after two days realized he was unable to cope with academic studies. Subsequently, he attended various vocational and rehabilitation re-training programs. On being unable to successfully complete any such program, he was placed on invalid pension status. He has remained unemployed since the trauma.
Gambling History O n full physical recovery, approximately five years post-trauma, D M re-commenced socializing with friends and attending weekly discotheque dances held at his former soccer club. In the state of New South Wales, Australia, poker-machines (equivalent to slot-machines) are legally permitted in certain registered social and sporting clubs. However, D M rapidly found himself isolated from his peers and unable to effectively relate to females who avoided him because of his cognitive slowness and mildly inappropriate, intrusive and disinhibited behavior. In reaction he began playing poker-machines, soon escalating over a period of six months from weekly to almost daily play. Although he consumed alcohol while gambling the amount was minimal and did not constitute a problem for him. There was no relationship between amount consumed and gambling. Amounts of $Ausl5-50.00 were staked each gambling session of an average two to four hours duration. His winnings, including large jackpots, were immediately re-invested and he invariably left the club empty-handed. Given his unemployed status, his source of gambling funds were restricted to pocket-money received from his mother. As his
ALEX BLASZCZYNSKI, JUDY HYDE, AND JOSEPH SANDANAM
69
frequency of play increased, he began redistributing his lunch money and excess change from transport costs toward his gambling. Within twelve months, he found himself frequently preoccupied with gambling and his urge remaining unsatiated at the end of each session. O n one occasion he impulsively seized an opportunity of stealing $50.00 from a friend. He then established a pattern of stealing small amounts of money, between $Aus15--20.00, from his parents on a relatively regular basis. He stole from shops on an indeterminate number of occasions and jewelry belonging to family and friends at least four times. This, and his own gold chain and watch, were pawned to obtain funds to supplement his gambling. Attention was drawn to his offenses when he was apprehended by club officials while stealing SAusl20.00 from the handbag of a club patron. He did not exhibit apparent concern, remorse or even relief when charges were not laid because of his condition. Despite his family's attempts to increase his level of awareness of the consequences of his actions, he exhibited a gross lack of insight into the effects of his continued gambling and offending on himself and family. Although immediately apologetic, contrite and promising to comply with requests to cease both gambling and stealing, his resolve quickly subsided and his aberrant behavior resumed. He reacted with indifference to family or social criticism and appeared unperturbed by the possibility of legal action. Periods of remissions were absent. He ceased to gamble only when temporarily deprived of funds. Family interventions proved ineffective in limiting his behavior. Although he attended a rehabilitation center for brain injured adults, the center lacked resources and expertise to address the issue of his gambling. He was initially assessed at a general hospital offering outpatient treatment for pathological gamblers. Given the need for intensive therapy because of the nature of DM's cognitive impairment, it was considered that hospital admission was required. He was therefore referred to a private psychiatric hospital facility with a specialist inpatient behavior therapy treatment unit for pathological gambling and impulse control disorders. He was admitted for an individual two week imaginal desensitization and impulse control treatment program. But on the admission day he soon made unsolicited and inappropriate sexual advances toward
70
JOURNAL OF GAMBLING STUDIES
four female patients. In one case he physically caressed and kissed the breasts of one schizophrenic woman causing such distress that she discharged herself that afternoon (returning only after D M was discharged). Within half an hour of his being reprimanded and cautioned, D M was apprehended searching through the belongings of another female patient, while yet another reported the theft of $20.00. Nursing staff reported that they were unable to contain his behavior and that other patients were now expressing grave concern over their well being. He was then immediately discharged for transgressing hospital rules. A lack of alternative opportunities resulted in the need for D M to commence an outpatient program with the cooperation of family members acting as co-therapists. He has to date, not completed this program.
CONCLUSIONS
This case describes the development of pathological gambling behavior in response to impaired psychosocial functioning resulting from extensive frontal lobe brain damage. In this case study, pathological gambling became established as a maladaptive coping strategy to deal with social isolation produced by organic inappropriate and disinhibitory behaviors. Pathological gambling is defined as a disorder of impulse control (A.P.A., 1987), although Allcock and Grace (1988) question the validity of the view that gamblers load highly on traits of impulsivity, while others (Blaszczynski, Buhrich & McConaghy, 1985; Jacobs, 1988) conceptualize pathological gambling as an addictive disorder. Irrespective of which theoretical model is accepted, treatment objectives are specifically aimed at the reinstitution of control over excessive impulsive and/or addictive behaviors. Impulsivity is reflected by behaviors that are carried out without forethought and with scant regard for consequences. In the context of gambling, impulsivity is closely associated with apetitive drive that may result in dysfunctional consequences. Attempts to regain control over behavior are severely restricted when such behaviors are compounded by the presence of additional organically based impulsivity, specifically from frontal lobe damage. Frontal lobe damage impairs
ALEX BLASZCZYNSKI, JUDY HYDE, AND JOSEPH SANDANAM
71
higher order intellectual functions including insight, social judgment, inhibitory control over behavior, initiative and motivation. Where frontal lobe organicity exists with the additional presence of m e m o r y dysfunction, the usual cognitive and/or behavioral treatment strategies are generally precluded or prove ineffective. Techniques such as imaginal desensitization (McConaghy, Armstrong, Blaszczynski & Allcock, 1983) are difficult to implement where ease of distractability and intrusive thoughts interfere with goal directed thinking. Multi-modal approaches where hospitalization is necessary may be difficult unless constant supervision is available or where socially disinhibitory or potentially illegal behaviors may be contained. Given these restraints, recourse to aversive therapy procedures or the use of family members as co-therapists in a home-based, highly structured learning regime may be useful alternatives. The pathological gambler with co-existing frontal lobe damage and inappropriate behavior poses a significant management problem. The prevalence of such cases do not warrant the establishment of specialist units while existing rehabilitation facilities lack adequate treatment resources to deal with gambling. Aversive therapy and time consuming individual support utilizing family support appears the only avenue of help at the moment.
REFERENCES Allcock, C.C. & Grace, D.M. (t988). Pathological gamblers are neither impulsive nor sensation seekers. Australian and New Zealand,journal of Psychiatry, 22, 307-311. American Psychiatric Association. (1987). Diagnostic and Statistical Manual--Revised. (Third edition). Washington, DC Blaszczynski, A., Buhrich, N. & McConaghy, N. (1985). Pathological gamblers, heroin addicts and controls compared on the EPQ'addiction Scale.' British Journal of Addictions, 80, 315-319. Jacobs, D. (1988). Evidence for a common dissociative-like reaction among addicts. `journal of Gambling Behavior, 4, 27-37. McConaghy, N., Armstrong, M.S., Blaszczynski, A. & Allcock, A. (1983). Controlled comparison of aversive therapy and imaginal desensitization in compulsive gambling. British,journal of Psychiatry, 142, 366-372.
