Age of Onset in Pathological Gambling: Clinical, Therapeutic and Personality Correlates

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1 J Gambl Stud (2010) 26: DOI /s ORIGINAL PAPER Age of Onset in Pathological Gambling: Clinical, Therapeutic and Personality Correlates Susana Jiménez-Murcia Eva M. Álvarez-Moya Randy Stinchfield Fernando Fernández-Aranda Roser Granero Neus Aymamí Mónica Gómez-Peña Nuria Jaurrieta Francesca Bove José M. Menchón Published online: 10 January 2010 Ó Springer Science+Business Media, LLC 2010 Abstract We aimed to explore the association between age of onset of gambling problems and current psychopathological and clinical status, personality profile and therapeutic outcome in a sample of pathological gamblers. A total of 904 consecutive pathological gambling patients were administered several instruments about gambling behavior, psychopathology and personality. They received a 4-month cognitive-behavioral group treatment. Information of dropouts and relapses during treatment was registered. Older age of onset of gambling problems was associated with higher general psychopathology (SCL- 90-R Paranoid Ideation, Psychoticism, Depression; P \ 0.015). Younger age of onset was S. Jiménez-Murcia (&) F. Fernández-Aranda N. Aymamí M. Gómez-Peña N. Jaurrieta F. Bove J. M. Menchón Department of Psychiatry, Pathological Gambling Unit, Bellvitge University Hospital, C/Feixa Llarga, s/n L Hospitalet de Llobregat, Barcelona, Spain sjimenez@bellvitgehospital.cat F. Fernández-Aranda ffernandez@bellvitgehospital.cat N. Aymamí naymami@bellvitgehospital.cat M. Gómez-Peña monicagomez@bellvitgehsopital.cat N. Jaurrieta njaurrieta@bellvitgehospital.cat F. Bove phedra@inwind.it J. M. Menchón jmenchon@bellvitgehospital.cat S. Jiménez-Murcia E. M. Álvarez-Moya F. Fernández-Aranda CIBER Fisiopatologia Obesidad y Nutricion (CIBEROBN), Instituto Salud Carlos III, Barcelona, Spain E. M. Álvarez-Moya ealvarez@bellvitgehospital.cat

2 236 J Gambl Stud (2010) 26: related to greater severity of pathological gambling (P \ 0.015), higher novelty seeking, and lower self-directedness (P \ 0.015). No statistically significant association was found between age of onset and relapse and dropouts during treatment. Age of onset of gambling problems seems to influence the clinical presentation of pathological gambling but not treatment outcome. Keywords Pathological gambling Age of onset Personality Psychopathology Cognitive-behavioral therapy Introduction Recent studies have suggested the idea that pathological gambling (PG) is a heterogeneous condition, probably composed of distinct subgroups (Blaszczynski and Nower 2002; Cunningham-Williams and Hong 2007; Iancu et al. 2008; Ledgerwood and Petry 2006; Meyer 1991). The identification of homogeneous subgroups of PG patients seems to be important from an etiological and therapeutic point of view. The age of onset in pathological gambling varies significantly across affected people. Whereas some cases begin gambling along childhood, others start gambling along adolescence and adulthood (Kessler et al. 2008). Early onset of gambling behavior is clearly associated with the later development of PG (Bondolfi et al. 2000; Lynch et al. 2004; Johansson et al. 2008; Turchi and Derevensky 2009) and their later clinical symptomatology (Burge et al. 2004). In other related disorders, namely substance abuse, and specifically alcohol use disorders, the relevance of age of onset for clustering type of cases, regarding diagnosis, prognosis and therapy response has been demonstrated (Leggio et al. 2009; Babor et al.1992a, b). One of the most well accepted model, the Cloninger typologies (Cloninger et al. 1981), based on the personality of alcohol dependent patients, distinguished two forms of the disorder related to the age of onset (type I and II). Although, similarities among PG and substance abuse disorders have extensively been documented, there is a lack of research exploring the relevance of age of onset in PG. Several studies have described age of onset in PG, however, the relation among gambling symptomatology, psychopathology, and age of onset has rarely been investigated (Kessler et al. 2008). The few studies that analyzed this issue in depth (Grant et al. 2009; Cunningham-Williams and Hong 2007; Lynch et al. 2004; Shin et al. 2009) have found mixed results. Whereas some studies found that earlier age of onset PG showed major socialfamily problems (Burge et al. 2004), higher impulsivity and novelty seeking (Shin et al. 2009), and higher comorbidity, such as: anxiety (Grant et al. 2009), substances use disorders R. Stinchfield Department of Psychiatry, University of Minnesota Medical School, Minneapolis, MN, USA stinc001@umn.edu R. Granero Laboratori d Estadística Aplicada, Departament de Psicobiologia i Metodologia, Universitat Autònoma de Barcelona, Barcelona, Spain Roser.Granero@uab.cat J. M. Menchón CIBER Salud Mental (CIBERSAM), Instituto Salud Carlos III, Barcelona, Spain

3 J Gambl Stud (2010) 26: (Burge et al. 2004) and affective disorders (Argo and Black 2004; Petry et al. 2005), others found no differences regarding age of onset and gambling severity (Grant et al. 2009). Regarding therapy for PG, cognitive-behavioral therapy (CBT) has been the most extensively studied and has demonstrated effectiveness for both short- and long-term results (Ladouceur 2005; Ladouceur et al. 2003; Oakley-Browne et al. 2000; Pallesen et al. 2005), even when compared with control groups (Blaszczynski 2005; Nathan 2005). Systematic reviews of the literature about efficacy of treatments, including controlled and uncontrolled studies, report abstinence rates between 50 and 75% at 6 months after treatment, 50% at 1 year and 30% at 2-year follow-up (Jiménez-Murcia et al. 2007; Gooding and Tarrier 2009; Stinchfield and Winters 2001). However, high dropout rates have also been described during treatment (over 30%) (Milton et al. 2002). In spite of this amount of research on therapy in PG, the relationship between age of onset of PG and treatment outcome has rarely been analyzed in the literature. Aims of the Study To our knowledge, to date this is the largest sample of PG that analyzes age of onset on treatment seekers. The main purpose of the present study was 2-fold: (1) to explore whether early age of onset of problem gambling was associated with specific psychopathological correlates and personality traits, and (2) to analyze the effect of age of onset of problem gambling on the prognosis of PG (severity and response to treatment). Our hypotheses were that earlier age of onset of problem gambling would be related to poorer current psychopathological state (including greater severity of the disorder) and poorer treatment response (more dropouts and more relapses). Secondly, we hypothesized that the more disordered the personality profile was, especially higher novelty seeking and lower self-directedness, the earlier the age of onset of problem gambling would be. Methods Subjects From an initial sample of 1158 PG seeking treatment for pathological gambling in a Pathological Gambling Unit located in a general hospital, the following individuals were excluded: (a) n = 58 patients with a psychotic episode characterized by positive symptoms; (b) n = 51 patients who had current suicidal behaviors; (c) n = 24 patients who did not fulfill full DSM-IV (APA 1994) criteria for pathological gambling; (d) n = 121 patients who had missing information regarding the main variable of this study (age of onset) or dropped-out before the assessment was finished. Patients in condition a and b were referred to our Department of Psychiatry in order to treat and stabilize their emotional and psychopathological problems before starting psychological treatment. All patients were diagnosed according to DSM-IV (APA 1994) criteria for pathological gambling. The entry into the study was from April 2003 to November The Ethics Committee of our hospital approved this study and informed consent was obtained from all participants. The final sample comprised 904 pathological gamblers. Table 1 summarizes main clinical and sociodemographic characteristics of the sample. Mean age of onset was 33.3 years (SD = 11.9; range = 12 66). Mean current age was 39.4 years (SD = 12.5,

4 238 J Gambl Stud (2010) 26: Table 1 Description of the sample (n = 904) SD standard deviation n % Sociodemographics Gender Male Female Education Elementary Secondary University Employment status Unemployed Employed Marital status Single Married Widowed Separated Divorced Living together Clinical information Age of onset \ [ Main Slot machines Gambling problem Bingo Casino Lottery Others Smoking Yes No range: 16 76). Most subjects were male (92.4%) and slot machines were the main gambling problem (94.0%). 25.4% subjects were unemployed. 84.2% were tobacco smokers, 23.9% abused alcohol and 11.9% used/abused illegal substances. The mean duration of the gambling problem was 5.9 (SD = 6.1) years. Mean total SOGS score was 10.5 (SD = 3.0) and mean number of DSM-IV criteria for pathological gambling was 7.2 (SD = 1.9).

5 J Gambl Stud (2010) 26: Assessment The following tests were administered: South Oaks Gambling Screen (SOGS) (Lesieur and Blume 1987) (Spanish validation by Echeburúa et al. 1994): 20-item diagnostic questionnaire that discriminates among probable pathological gamblers, problematic gamblers and non-problematic gamblers. The Spanish validation of this questionnaire shows high reliability and validity. Test retest reliability is 0.98 (P \ 0.001) and internal consistency 0.94 (Cronbach s alpha). Convergent validity with respect to DSM-III-R criteria for pathological gambling (APA 1987) was estimated 0.92 (P \ 0.001). Furthermore, several studies have reported the use and utility of this test as an index of gambling severity (Alessi and Petry 2003; Stinchfield 2002; Strong et al. 2004). Diagnostic questionnaire for pathological gambling according to DSM-IV criteria (Stinchfield 2003) (validated and adapted to the Spanish population by Jimenez-Murcia et al. (2009): this is a 19-item questionnaire with a Yes/No response format that reflects the DSM-IV diagnostic criteria for pathological gambling. These 19 items are scored to yield ten diagnostic criteria with a score range from 0 to 10. Scores equal to or over 5 indicate the presence of PG. In its original version, reliability was estimated by using a measure of internal consistency (Cronbach s alpha), which yielded the following values: a = 0.81 for the general population and a = 0.77 for a gambling treatment group. Convergent validity in comparison to the SOGS questionnaire was estimated as r = 0.77 (P \ 0.01) for the general population and r = 0.75 (P \ 0.01) for a gambling treatment group.(stinchfield 2003) We administered this test orally at first interview in order to establish a current PG diagnosis and the age of onset of problem gambling. Temperament and Character Inventory-Revised Version (TCI-R) (Cloninger 1999): this is a 240-item, five-point Likert scale, reliable and valid questionnaire that measures, as in the original TCI version (Cloninger et al. 1994), seven dimensions of personality: four temperament (Harm Avoidance, Novelty Seeking, Reward Dependence and Persistence) and three character dimensions (Self-Directedness, Cooperativeness and Self-Transcendence). The performance of the Spanish population on both the original questionnaire (Gutiérrez et al. 2001) and the revised version has been documented. Reliability of the different personality dimensions in the Spanish adaptation ranged between 0.77 and 0.84 (Gutiérrez-Zotes et al. 2004). Symptom Checklist-90 items-revised (SCL-90-R) (Derogatis 1994) (Spanish adaptation by González de Ribera (González de Rivera 2001): the SCL-90-R is a widely used 90-item scale assessing self-reported psychological distress and psychopathology. The test is usually scored on nine primary symptom dimensions (comprising a total of 83 items): somatization, obsessive compulsive, interpersonal sensitivity, depression, anxiety, hostility, phobic anxiety, paranoid ideation and psychoticism. The Global Severity Index (GSI), which is the participant s mean score (using all the 90 items), is a widely used global index of distress. The Spanish validation of this scale yielded a good reliability of the scales (internal consistency) ranging from 0.81 to Test retest reliability ranged from 0.78 to Other Socio-Demographic and Clinical Variables Additional demographic, clinical, and social/family variables related to gambling were measured using a semi-structured face-to-face clinical interview, described elsewhere (Jiménez-Murcia et al. 2007). Also additional psychopathological measures, namely lifetime alcohol and drug abuse/dependence, following DSM-IV criteria, were analyzed by means of the above mentioned semi-structured interview.

6 240 J Gambl Stud (2010) 26: Procedure We used a retrospective design to assess the effect of age of onset of gambling problems on the current psychopathological and clinical status (as measured by the SCL-90-R, SOGS and Stinchfield s diagnostic questionnaire for pathological gambling according to DSM-IV criteria), as well as on the treatment outcome (as measured by dropout and abstinence rates during treatment) in a sample of pathological gamblers. In addition, we analyzed the association between TCI-R factors, as an explanatory variable, and age of onset of gambling problems, as a dependent variable. A semi-structured interview, which focused on different aspects of gambling behavior, was administered to the subjects at first visit. We checked for age of onset of gambling behavior (social/recreational gambling), type of game first engaged in, age of onset of gambling problems, current type of problematic gambling and current presence of other types of gambling. According to the treatment program model of our unit, which has already been manualized and published (Jiménez-Murcia et al. 2006, 2007), we follow a specific semistructured interview and functional analysis of PG, where patients relatives are invited to provide their view of the client s level of gambling involvement. This allows us to corroborate some of the findings of patient s statements. During the first interview, we also identified retrospectively the age at which the patient had first met five or more DSM-IV criteria for pathological gambling (APA 1994). The remaining psychometric assessments mentioned above were administered to all subjects in a second session. Both interviews were conducted in a timeframe of one week. We distinguished the age of onset of gambling behavior (social/recreational/nonpathological gambling) from the age of onset of gambling problems (described above, and considered as Index Age). The latter variable is being the focus of the present report. Most subjects (85.7%) received a cognitive-behavioral group treatment consisting of sixteen 90-min sessions once-weekly (over 4 months). Subjects with a period of full abstinence of problem gambling over 3 months (14.3%) attended a less intensive group treatment (eight sessions fortnightly, over 4 months). Both types of treatment were based on the same techniques (stimulus control, family intervention, skills training, cognitive restructuring, psychoeducation, etc.). In 7 out of 16 sessions, patients relatives also took part of the group therapy. The role of relatives was to control for the patient s money (only during treatment and always with the agreement of the patient) and giving them reinforcement for their achievements. A describe handbook of our treatment program has been published in Spain (Jiménez-Murcia et al. 2006) and its efficacy has previously been reported (Jiménez-Murcia et al. 2005, 2007). Treatment outcome was measured by the percentage of dropouts and relapses during treatment. Relapses were defined as any episode of gambling (commercial and noncommercial, involving a money bet) during the 4-month treatment. Statistical Analyses Statistical analyses were carried out with the SPSS 15 for Windows. We obtained different multiple linear regression models in order to measure the effect of age of onset (measured in years, with the status of independent variable) on the current psychopathological status of subjects, as measured by the SCL-90-R. We carried out one regression model for each SCL-90-R subscale (twelve in total). These models were adjusted for

7 J Gambl Stud (2010) 26: gender, duration of gambling problems, and severity of the disorder (according to the SOGS total score). Due to the explanatory objective of these analyses, Enter procedure was specified to simultaneously adjust the set of independent variables and co-variates and, in that way, to obtain the specific contribution of the predictor on the correspondent criterion (Kleinbaum et al. 2007). Multiple linear regression models also assessed the effect of age of onset on current severity of pathological gambling (as measured by the SOGS questionnaire) and current number of diagnostic criteria for PG endorsed (as measured by Stinchfield s questionnaire). The analyses were adjusted for gender and duration of the gambling problem. Next, with the aim to obtain a predictive model for the variable age of onset of pathological gambling (criterion) based on the patients personality traits measures, multiple linear regressions selected the best predictors between the set of TCI-R scores. In this analysis age of onset was defined as the dependent variable given that personality could be considered as a stable construct (Cloninger 1999) and consequently precedent to the onset of the disorder. Due the predictive modeling objective of the regression, Forward Backward procedures were employed. Sex, current age and type of gambling problem were entered as co-variates. Finally, we obtained two multiple logistic regression models (Enter procedure) in order to measure the specific contribution of age of onset (as an independent variable) on treatment outcomes (risk of dropouts and relapses). Both models were adjusted for sex, duration and severity of gambling. In this study, covariates included in each regression were those variables that were of no interest in the research but that literature suggests that could have an effect on each dependent variable (criterion). Depending on the specific criterion, covariates can vary. The control for variation in these concrete covariates allows the analysis of the dependent variable of interest made more accurate, and prevent biases. In addition, due the multiple comparisons in the study, Bonferroni s correction was used in each regression analysis. Results Correlation Between Age of Onset of Gambling Disorder and Psychopathological, Clinical, Personality Indices and Therapy Response Table 2 shows the results of correlational analyses (Pearson Product Moment Correlation) between age of onset and the variables analyzed (TCI-R factors, SCL-90-R subscales, SOGS questionnaire, and DSM-IV criteria). Age of onset showed a negative moderate correlation with total SOGS, number of DSM-IV criteria and TCI-R Novelty Seeking, and a positive correlation with Self-Transcendence. At a lesser degree, it correlated positively with TCI-R Cooperativeness. Additionally, t-tests showed no statistically significant associations between age of onset and relapses (P = 0.268) or dropouts (P = 0.093) during treatment. Effect of Age of Onset on Psychopathological Status In relation to the multiple linear regression models analyzing the effect of age of onset on the psychopathological status of the sample (as measured by the SCL-90-R), three models

8 242 J Gambl Stud (2010) 26: Table 2 Pearson s bivariate correlations between age of onset of gambling disorder and psychopathological, clinical and personality measures r P SCL-90-R Somatization Obsessive compulsive Interpersonal sensitivity Depression Anxiety Hostility Phobic anxiety Paranoid ideation Psychoticism GSI PST PSDI SOGS \ DSM-IV criteria \ TCI-R Novelty seeking \ Harm avoidance Reward dependence Persistence Self-directedness Cooperativeness \ Self-transcendence \ Table 3 Multiple linear regression measuring the effect of age of onset of problem gambling on SCL-90-R scores Results adjusted by sex, age and type of gambling problem. P-values include Bonferroni s correction SCL-90-R B p 95% CI for B Somatization Obsessive compulsive Interpersonal sensitivity Depressive Anxiety Hostility Phobic anxiety Paranoid Ideation Psychoticism GSI PSDI PST were statistically significant. As shown in Table 3, once adjusted for gender, severity and duration of gambling problems, older age of onset predicted higher current scores on Depressive, Paranoid Ideation and Psychoticism subscales.

9 J Gambl Stud (2010) 26: Table 4 Predictive linear regression of TCI-R scores on the age of onset of problem Final model a B P 95% CI for B (Constant) Novelty seeking to Self-directedness Current age \ a Dependent variable: Age of onset. Results adjusted for sex, current age and type of gambling problem. P-values include Bonferroni s correction Effect of Age of Onset on Personality Traits In relation to the effect of personality traits in age of onset, once adjusted for gender and age, the final model selected by backward methods revealed that high Novelty Seeking (P = 0.014) and low Self-Directedness (P = 0.002) were associated with younger age of onset of gambling problems (see Table 4). The model was statistically significant (F = 770.5; df = 4; P \ 0.001). Effect of Age of Onset on Severity of PG The results of multiple linear regression models (adjusted for sex and duration of gambling), assessing the effect of age of onset of problem gambling on the severity of the disorder, revealed that an earlier age of onset predicted greater current severity of pathological gambling, both as measured by the SOGS questionnaire (b =-0.045; 95%CI: to ; P = 0.002), and by the number of DSM-IV criteria fulfilled (b = ; 95%CI: to ; P = 0.013). Effect of Age of Onset on Treatment Outcome General rates for treatment outcome during treatment were 24.0% of relapses and 36.3% dropouts. As shown in Table 5, once adjusted for gender, duration and severity of the gambling problem, younger age of onset was significantly associated with dropouts during treatment (OR = 0.976; 95%CI: ; P = 0.050), so the risk for dropouts during treatment multiplied for with every year of later onset. However, the global model did not result statistically significant (v 2 = 7.89; df = 4; P = 0.096). No statistically significant association was observed between age of onset and risk of relapse during treatment. Table 5 Logistic regression models measuring the effect of age of onset on the risk of dropouts and relapses during treatment Dependent variable B P OR 95% CI for OR Dropouts (n = 262) Relapses (n = 217) Predictor: Age of onset. Results adjusted for sex, current age and type of gambling problem. P-values include Bonferroni s correction

10 244 J Gambl Stud (2010) 26: Discussion The present study aimed to explore the relationship between age of onset of gambling problems and current psychopathological state, personality profile, severity of the disorder and treatment outcome. In agreement with the literature, most pathological gamblers in our sample were male, employed, (Shaffer et al. 1999; Wood and Griffiths 1998) and their main gambling problem was slot machines. They had a mean problem duration of 6 years, which is also consistent with other reports (Breen and Zimmerman 2002; Tavares et al. 2001). Older age at onset was associated with a higher level of current depressive, paranoid and psychoticism symptoms. This finding coincides with other reports such as that by Livingston (Livingston 1974), who established two subtypes of pathological gamblers: those with earlier age of onset and greater impulsivity, and those with later age of onset and greater social isolation. Lesieur and Rugle also described a group of pathological gamblers (escape seekers), who were characterized by older age of onset of gambling behavior and greater psychopathology, specifically anxiety and depression (Lesieur and Rugle 2000). In contrast, other authors have observed more severe medical and psychiatric problems in early-onset PG in comparison to late-onset PG (Burge et al. 2004; Lynch et al. 2004). This discrepancy may be caused by differences in recruitment and source of the sample, i.e., in the present study, we recruited patients who were consecutively admitted for treatment in a specialized Unit for PG; however, previous reports used other recruitment methods (e.g., advertisements, approaching waiting areas of medical clinics or senior citizen centers). Kessler and colleagues conducted a retrospective analysis of PG and concluded that the onset of the disorder is usually predated by other disorders that also predict the persistence of PG (Kessler et al. 2008). Patients with younger age of onset also showed higher level of novelty seeking and low self-directedness. Interestingly, this association remained statistically significant even after adjusting for chronological (current) age. This means that subjects who began to have gambling problems at earlier ages were more impulsive, sensation seekers, tempered, curious, easily bored, emotionally variable and unpredictable. These personality traits have been associated with immaturity, lack of acceptance of responsibility for one s own choices, poor identification of individually valued goals and purposes, and low development of skills and confidence in solving problems (Cloninger et al. 1993). Other studies have addressed the relationship between age of onset of pathological gambling and TCI-R profiles (Shin et al. 2009). Similarly, they conclude that early onset patients show high novelty-seeking and harm avoidance temperament style. Age of onset of gambling problems was related to severity of the disorder (as measured by the total SOGS score and DSM-IV diagnostic criteria questionnaire). This finding is supported by other studies reporting an association between early age of onset and greater severity of gambling behavior (as measured by frequency of gambling and bet size) (Lynch et al. 2004). In this regard, one study observed a close relationship between impulsivity and severity of gambling behavior in adolescents. This finding suggests that impulsiveness may act as a strong vulnerability and susceptibility factor for gambling problems (Fernández- Aranda et al. 2006; Vitaro et al. 1997). Finally, age of onset was not related to treatment outcome. We only observed a trend to statistical significance in relation to dropouts such that earlier age of onset tended to be associated with higher risk of dropouts during treatment. In this regard, some authors consider that one of the most important variables involved in adherence to treatment is motivation to change (Hodgins 2005; Toneatto and Millar 2004). The rate of dropouts and

11 J Gambl Stud (2010) 26: relapses during treatment that we observed in the present sample may be related to this fact, although seeking treatment may itself involve a certain willingness to change. However, we must take into account that those individuals who present for treatment may represent the most severely affected subgroup of individuals with PG symptoms, according to Sartor and colleagues (Sartor et al. 2007). Given that we used a treatment-seeking sample, our findings might not be generalizable to non-treatment seeking individuals with PG. Other related studies, in substance abuse disorders field, and specifically in alcohol, have similarly demonstrated the relevance and specificity of the variable age of onset for clustering type of cases, regarding diagnosis, prognosis and therapy response (Leggio et al. 2009). Actually, the Cloninger typologies (Cloninger et al. 1981), based on the personality of alcohol dependent patients, distinguished two forms of the disorder related to the age of onset of the disorder (type I and II), that have distinct genetic and environmental factors. Whereas, type I persons were characterized by a late-onset (after the age of 25 years), better response to treatment and by the influence of social factors, the type II were more characterized by earlier onset, poorer response to treatment and stronger genetic influence. Accordingly, our results showed in the later group more dysfunctional personality traits (namely higher novelty seeking) and more severity of the disorder. The specific discrepancies observed in our study, concerning therapy response and age of onset type, should be interpreted with caution as our results are limited to short-term outcome. Further studies should continue investigating the association of age of onset and middle and long-term therapy response. Summarizing, all these results confirm partially our first hypothesis, as we observed an association between early age of onset of gambling problems and greater severity of the disorder, but not with response to treatment. Our second hypothesis is also supported, as we found that higher novelty seeking was associated with earlier age of onset of problem gambling. We believe that this personality trait may act as a risk factor for the development of gambling problems at earlier ages. Longitudinal studies in the general population would be of great utility in this regard. Limitations Limitations of the present study were fourfold. On the one hand, we used a retrospective design to determine the age of onset of gambling problems, and therefore these results might be confounded by memory biases of the subjects. Corroboration by relatives was used to minimize this possible bias. Secondly, our sample consisted of pathological gamblers seeking treatment in a specialized Unit, who may show a different personality pattern in relation to those who do not seek professional help for this disorder. Thirdly, we have not used additional scales for exploring other psychiatric diagnoses in depth (e.g. affective and anxiety disorders, substance abuse disorders, etc.), or other semi-structured interviews for measuring those comorbid Axis I disorders (e.g. SCID-I). Finally, we used dimensional instruments such as the TCI-R in order to measure disordered personality traits, but we did not assess specifically axis-ii personality disorders. Then, our results must be interpreted with caution. Conclusions The association between age of onset of gambling problems and personality and clinical factors has scarcely been explored. Even so, our results are consistent with the literature,

12 246 J Gambl Stud (2010) 26: although no previous studies had included treatment variables in their analyses. In this regard, the present study suggests that earlier age of onset of gambling problems is associated with specific personality traits (especially Novelty Seeking) and greater severity of the disorder, but not with therapeutic outcome. The lack of studies in this respect makes further research necessary in order to confirm these findings and then to tailor more specific therapeutic interventions for patients with early age of onset. In summary, age of onset is an important characteristic for a better understanding of the PG heterogeneity. Our final comment should be addressed to the relationship between gambling and cultural aspects. Although, is generally accepted that gambling preferences and attitudes towards gambling, are culturally and socially learned, and that they are different among the countries (e.g. type of gambling, sex specific differences, ), their differential effect on the development of PG has rarely been investigated and should be addressed in future research. Acknowledgements This work is part of the PhD dissertation of Neus Aymami at the University Autonoma of Barcelona. Financial support was received from Fondo de Investigación Sanitaria -FIS (PI081573; PI081714) and AGAUR (2009SGR1554). It was also partially supported by the European Commission under the Seventh Framework Programme (FP7-ICT Playmancer project). CIBER Fisiopatología de la Obesidad y Nutrición (CIBERobn) and CIBER Salud Mental (CIBERsam), are initiatives of ISCIII. References Alessi, S. M., & Petry, N. M. (2003). Pathological gambling severity is associated with impulsivity in a delay discounting procedure. Behavioural Processes, 64(3), APA. (1987). Diagnostic and statistical manual of mental disorders (3rd ed. Revised). Washington, DC: American Psychiatric Association. APA. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: American Psychiatric Association. Argo, T. R., & Black, D. W. (2004). Clinical characteristics. In J. E. Grant & M. N. Potenza (Eds.), Pathological gambling: A clinical guide to treatment (pp ). Arlington: APPI. Babor, T. F., Dolinsky, Z. S., Meyer, R. E., Hesselbrock, M., Hofmann, M., & Tennen, H. (1992a). Types of alcoholics: Concurrent and predictive validity of some common classification schemes. British Journal of Addiction, 87, doi: /j tb01921.x. Babor, T. F., Hofmann, M. I., DelBoca, F. K., Hesselbrock, V., Meyer, R. E., Dolinsky, Z. S., et al. (1992b). Types of alcoholics, I. Evidence for an empirically derived typology based on indicator of vulnerability and severity. Archives of General Psychiatry, 49, Blaszczynski, A. (2005). Conceptual and methodological issues in treatment outcome research. Journal of Gambling Studies, 21(1), Blaszczynski, A., & Nower, L. (2002). A pathways model of problem and pathological gambling. Addiction, 97(5), Bondolfi, G., Osiek, C., & Ferrero, F. (2000). Prevalence estimates of pathological gambling in Switzerland. Acta Psychiatrica Scandinavica, 101(6), Breen, R. B., & Zimmerman, M. (2002). Rapid onset of pathological gambling in machine gamblers. Journal of Gambling Studies, 18(1), Burge, A. N., Pietrzak, R. H., Molina, C. A., & Petry, N. M. (2004). Age of gambling initiation and severity of gambling and health problems among older adult problem gamblers. Psychiatric Services, 55, Cloninger, C. R. (1999). The temperament and character inventory revised. St Louis, MO: Center for Psychobiology of Personality, Washington University. Cloninger, C. R., Bohman, M., & Sigvardsson, S. (1981). Inheritance of alcohol abuse. Cross-fostering analysis of adopted men. Archives of General Psychiatry, 38, Cloninger, C. R., Przybeck, T. R., Svrakic, D. M., & Wetzel, R. D. (1994). The temperament and character inventory (TCI): A guide to its development and use. St. Louis, Missouri: Center for Psychobiology of Personality. Cloninger, C. R., Svrakic, D. M., & Przybeck, T. R. (1993). A psychobiological model of temperament and character. Archives of General Psychiatry, 50(12),

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