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Executive Functioning in Pathological Gamblers and Healthy Controls

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Executive Functioning in Pathological Gamblers and Healthy Controls 1 Executive Functioning in Pathological Gamblers and Healthy Controls Study Final Report Submitted to Ontario Problem Gambling Research Centre Principal Investigator: David M. Ledgerwood, Ph.D.(1) Co-Investigators/Collaborators: Leslie H. Lundahl, Ph.D.(1) G. Ron Frisch, Ph.D.(2) Nick Rupcich (3) 1. Department of Psychiatry and Behavioral Neurosciences, Wayne State University School of Medicine, 2761 E. Jefferson Ave., Detroit, MI, USA, 48207. 2. Department of Psychology, University of Windsor, 401 Sunset, Windsor, Ontario, N9B 3P4. 3. Problem Gambling Services, Windsor Regional Hospital, 2109 Ottawa St., Windsor, Ontario, N8Y 1R8. 2 Table of Contents Page Number List of Tables 3 List of Figures 4 Acknowledgements 5 Abstract 6 Executive Summary 7 Introduction 9 Methods 12 Participants 12 Inclusion/Exclusion 12 Pathological Gamblers 12 Controls 12 Measures 13 Demographics, Gambling, Inclusion and Exclusion Measures 13 Impulsivity Measures 13 General Intelligence 13 Executive Function 14 Ethics Approval 15 Procedure 15 Sample Justification 16 Data Analysis 16 Results 18 Demographic and Gambling Variables 18 Executive Function 18 Decision Making 18 Response Inhibition 18 Memory 19 Impulsivity 19 Discussion 20 Executive Function 20 Decision Making 21 Impulsivity 22 Changes to the Original Proposal 22 Limitations & Strengths 22 Implications and Conclusions 23 References 25 Tables 28 Figures 34 3 List of Tables Table 1. Demographic and gambling variables. Table 2. Raw means and standard deviations on executive function measures. Table 3. Correlations between executive function variables and intelligence. Table 4. Raw means and standard deviations for Wechsler Memory Scale scores. Table 5. Correlations between Delay Discounting Area Under the Curve (AUC), Barrett Impulsiveness Scale (BIS), executive function measures and full scale intelligence. 4 List of Figures Figure 1. Flow of participants through the study. Figure 2. Mean Iowa gambling task: (a) raw scores; and (b) T scores, for pathological gamblers (closed square) and controls (open diamonds). Figure 3. Median GoStop scores for pathological gamblers (PGs) and controls at 50, 150, 250 and 350 msec time-points Figure 4. Delay discounting subjective dollar amounts and delay periods for pathological gamblers (PGs) and controls. 5 Acknowledgements We would like to thank the staff of the Windsor Regional Hospital Problem Gambling Services for their support and assistance in completing this project. We would also like to thank our graduate students and research staff members at Wayne State University for their assistance, particularly Emily Orr, Aleks Milosevic, Kristen Hodges, Ken Bates, Debra Kish, Joi Moore, Lisa Sulkowski and Dr. Caren Steinmiller. Additional thanks go to Dr. Donald Dougherty, who provided the GoStop task. We thank the Ontario Problem Gambling Research Centre for providing funding for this project through the Level III funding mechanism. Finally, we thank all of those who served as participants in this study. 6 Abstract Pathological gambling (PG) is categorized as an impulse control disorder in DSM-IV, and research has consistently demonstrated that gambling problems are associated with higher levels of trait impulsivity. However, very little research has focused on identifying the underlying neuropsychological factors associated with impulsivity in pathological gamblers (PGs). In other clinical and non-clinical populations, research findings point to a relationship between trait impulsivity and executive functions (EF), which involve cognitive processes implicated in the formation of goal-directed behaviours and learning. The current lack of research on gamblers greatly limits our understanding of the role of EF deficits in the development and maintenance of PG. In this study, we examined the potential role of EF dysfunction in PG. Specifically, we compared PGs with non-problem gambling controls on several EF and impulsivity tasks. In total, 45 PGs and 45 controls were recruited and tested. PGs and controls were well matched on gender and age, and EF analyses were controlled for full-scale intelligence. EF tasks included measures of response inhibition, working memory, cognitive flexibility and perseveration, and planning. PGs differed from controls only on measures of planning, when the analysis was controlled for intelligence. PGs also experienced significantly more difficulty with decision-making as measured by the Iowa Gambling Task and scored significantly higher on two measures of impulsivity. EF and impulsivity were not correlated with each other. These findings provide evidence that, while PGs may exhibit substantial impulsivity relative to healthy controls, their potential EF deficits appear to be specifically related to processes associated with planning and decision-making. Key Words: Gambling, Executive Function, Impulsivity, Pathological Gambler, Decision Making 7 Executive Summary Pathological gamblers (PGs), as a group, are often characterized as being more impulsive than individuals who gamble without problems. Recent studies have begun to explore possible neurocognitive correlates impulsivity in PGs, but these studies are relatively few. One proposed area of study is executive functions (EFs), which are a set of neurocognitive processes that involve learning and the formation of goal-directed behaviours. Specific EFs include: 1) response inhibition (ability to respond to a stop signal after being presented with a ‘go’ signal); 2) working memory (temporary memory used to form complex cognitive and planning tasks); 3) cognitive flexibility and perseveration (ability to change one’s behaviour in the face of shifting rules); 4) planning behaviours based on environmental feedback; and, 5) decision-making to maximize positive consequences and minimize negative ones. We examined these EF processes in the present study. We compared PGs (n = 45) to non- problem gambling control participants (n = 45) on several measures of EF and impulsivity. Our primary research questions were: Do PGs experience deficits in their EF compared with control participants who do not experience any gambling problems? Do PGs experience greater impulsivity than non-problem gambling controls, as has been demonstrated in several past studies? And, will EF deficits correlate with greater impulsivity among PGs and control participants? Participants completed several measures of gambling severity, EF, impulsivity and general cognitive functioning (intelligence and memory). Our main findings were as follows: • We were able to recruit PG and control groups that were similar on several demographic factors, such as age and gender. • Contrary to our predictions, PGs and controls differed significantly on full scale intelligence (IQ), and subsequent EF analyses statistically corrected for IQ. • As predicted, PGs scored higher than controls on all gambling severity measures. • Compared with control participants, PGs demonstrated greater deficits on two measures of planning and one measure of perseveration, but the perseveration differences were no longer significant when we controlled statistically for group differences in IQ. • PGs experienced greater difficulty on a measure of decision making. • No other measures of EF differed between the two groups. • PGs were more impulsive than controls on our two impulsivity measures (self-reported impulsivity and a delay discounting task). • Contrary to our hypothesis, EF was mostly uncorrelated with measures of impulsivity. The one exception was that one planning measure was significantly associated with self- reported impulsivity. These findings have several implications for understanding pathological gambling (PG). First, PG appears to be associated with fairly specific deficits in EF. Planning and decision making measures accounted for the most variability between these two groups, and should be a focus of additional study. PGs were significantly more impulsive than controls, and self-reported impulsivity may be related to planning processes. Thus, new treatment approaches should 8 address potential deficits in planning and decision making, in addition to focusing on impulsivity. 9 Introduction Pathological gambling (PG) is classified as an impulse control disorder in the DSM-IV- TR (American Psychiatric Association, 2000), and impulsivity is considered one of the most prominent features of PG. Characteristics of impulsivity include risk-taking, acting quickly without thinking, and failure to plan for the future. Many studies have shown that self-reported impulsivity is correlated with PG (e.g., Blaszczynski & Steel, 1998; Ledgerwood, Alessi, Phoenix, & Petry, 2009; Petry, 2001; Steel & Blaszczynski, 1998; Vitaro, Ferland, Jacques & Ladouceur, 1998), and some evidence indicates that self-reported impulsivity may be related to treatment failure (Leblond, Ladouceur & Blaszczynski, 2003). Despite the importance and complexity of the relationship between impulsivity and PG, very few studies have addressed the neurocognitive deficits that potentially underlie impulsivity in pathological gamblers (PGs). That is, research has largely not investigated the extent to which identifiable neurocognitive dysfunctions may directly contribute to impulse control issues often seen among PGs. Impulsivity is thought to be associated with underlying functional deficits in particular areas of the brain (e.g., prefrontal cortex) related to executive function (EF) (Hinson, Jameson & Whitney, 2003). EF involves processes implicated in goal-directed behaviours
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