Common and differential brain abnormalities in gambling disorder subtypes based on risk attitude
Introduction
Gambling disorder (GD) is now classified into “Substance-Related and Addictive Disorders” in the Diagnostic and Statistical Manual of Mental Disorders 5th Edition (DSM-5) (American Psychiatric Association, 2013). Thus, GD has been conceptualized as a form of behavioral addiction. Studying brain abnormalities in behavioral addiction including GD enables us to exclude possible confounding effects of exposure to neurotoxic substances, which should provide important insight that can lead to a better understanding of addiction per se (Tsurumi et al., 2014). However, there have been a few studies using brain structural magnetic resonance imaging (MRI) on GD, but the results have been inconsistent. Initial studies using voxel-based morphometry (VBM) reported that there was no significant difference between healthy control (HC) subjects and GD patients in regional gray matter volumes (Joutsa et al., 2011, van Holst et al., 2012). Subsequent studies concerning regional gray matter volumes in GD patients reported reduction in the left hippocampus and right amygdala (Rahman, Xu, & Potenza, 2014), greater gray matter volume in the striatum and prefrontal cortex (Koehler, Hasselmann, Wustenberg, Heinz, & Romanczuk-Seiferth, 2015), and a reduction in the prefrontal cortex (Zois et al., 2016). Thus, alterations of brain structure in GD have not been sufficiently clarified.
Continual gambling in spite of continual loss may be attributed to altered decision-making under risk (Takeuchi et al., 2015). Behavioral economics tools can assess risk attitude in real-life decision-making (Camerer, 2004, Kahneman and Tversky, 1984). In the behavioral economics field, one of the most predominant and successful theories of decision-making under risk is the prospect theory (Kahneman & Tversky, 1979). A core part of this theory is loss aversion, meaning that a loss is subjectively felt to be larger than the same amount of gain, even if they are objectively equivalent. Tasks of behavioral economics have been employed in GD studies (Ligneul et al., 2013, Giorgetta et al., 2014, Takeuchi et al., 2015).
We previously reported that GD patients could be categorized into two extremes in terms of loss aversion, that is, low loss-aversion GD and high loss-aversion GD (Takeuchi et al., 2015). The two groups in GD showed the specific personality traits that were proposed in the pathways model (Blaszczynski & Nower, 2002). Within this model, one group is characterized by high impulsivity and/or sensation-seeking and the other is characterized by emotional vulnerability with premorbid anxiety and/or depression. In line with this, low loss-aversion GD seems to correspond to the former group and high loss-aversion GD to the latter group.
On the basis of this evidence, we considered that the inconsistent results in terms of brain structure in GD might partly stem from the existence of subtypes, although other factors such as the severity of disorders and differences in brain imaging analyses might also account for such inconsistencies. The personality traits of impulsivity and sensation-seeking might be related to the fronto-parietal network, and emotional vulnerability might be related to the network of emotion-related regions. We hypothesized that there were significant differences in regional gray matter volume between low loss-aversion GD and high loss-aversion GD in these regions.
Section snippets
Subjects
Thirty-six male GD patients, who had been referred to a treatment facility, participated in the current study. The treatment facility is a residential type where GD patients receive 12-step-based psychological therapy. Twenty-six of the GD patients were the same as in the previous study (Takeuchi et al., 2015). The GD patients were medication-free and participated after they had completed at least one cycle of 12-step-based intervention (about one month). The GD patients met the criteria for GD
Loss-aversion parameter assessment
The GD patients and HC subjects did not differ in terms of loss-aversion parameter λ (GD patients: median = 2.55; HC subjects: median = 3.18; Mann-Whitney's U test, p = 0.86). The HC group consisted of 19 subjects in the low loss-aversion group, 10 in the middle loss-aversion group, and 7 in the high loss-aversion group. The GD group consisted of 23 patients in the low loss-aversion group, none in the middle loss-aversion group, and 13 in the high loss-aversion group. In order to investigate the
Discussion
To our knowledge, this is the first study to investigate regional gray matter volume differences in two GD groups categorized by the levels of loss aversion, low and high. The two groups in GD had specific characteristics in terms of clinical symptoms and regional gray matter volumes.
We categorized the total subjects into three groups according to loss-aversion levels based on our previous study (Takeuchi et al., 2015). All GD patients were then categorized into groups of extreme loss-aversion
Role of funding sources
This study was supported in part by Grants-in-Aid for Scientific Research A (24243061), and on Innovative Areas (grant number 23118004, 23120009, 16H01504, 16H06572) from the Ministry of Education, Culture, Sports, Science and Technology of Japan; a grant from SENSHIN Medical Research Foundation; and a grant from Takeda Science Foundation. These agencies had no further role in the study design, collection, analysis or interpretation of the data, writing the manuscript, or the decision to submit
Contributors
H. Takeuchi, K. Tsurumi, A. Takemura, T Murao, R. Kawada, T. Murai, and H. Takahashi designed the study. H. Takeuchi, K. Tsurumi, A. Takemura, T Murao R. Kawada, S. Urayama, and T. Aso contributed acquisition of data, H. Takeuchi, G. Sugihara, J. Miyata and H. Takahashi contributed analysis and interpretation of data. H. Takeuchi and H. Takahashi drafted the article, and the other authors revised it critically for important intellectual content. All authors approved for publication.
Conflict of interest
All authors declare that they have no conflicts of interest.
Acknowledgments
We are deeply grateful to Serenity Park Japan (Nara, Japan) for recruiting GD patients to this study, and to Dr. Taku Sato for coordination of Serenity Park Japan (Nara, Japan) with this study.
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