Features of formation of pathological urge to gamble depending on alexithymia, in the conditions of stress of COVID-19 pandemic

Abstract

Introduction. The COVID-19 pandemic may exacerbate mental health problems in the general population, including increasing involvement in addictive behavior. Recent observations suggest that the current crisis and its consequences may exacerbate gambling problems. There are a number of English-language studies with a fundamental analysis of the accumulated knowledge on the causes of pathological gambling and stress-related problems, but the analysis of accumulated in recent years data from the domestic scientific literature on this problem has not yet been done. A clear understanding of the relationship between alexithymia and pathological gambling in the stressful pandemic of the COVID-19 pandemic is a prerequisite for further research to develop new approaches to therapy. Need advice and recommendations for the general public and for professionals. Important national or local references to information on treatment and support options, including those that can be performed remotely.

Goal. To determine the current state of analysis of the peculiarities of the formation of pathological cravings for gambling depending on alexithymia, to systematize the data and compare the information presented in the Ukrainian and foreign scientific literature on this issue in recent years.
Materials and methods. A qualitative and quantitative content analysis of scientific Ukrainian and English literature, published until 2019, was conducted, which sets out different views on the peculiarities of the formation of pathological craving for gambling depending on alexithymia. The search was performed using PubMed, Web of Science and Scopus databases. To analyze the views of world researchers on the peculiarities of the formation of pathological gambling addiction depending on alexithymia, it was decided to include only review articles, concept analyzes, meta-analyzes, systematic reviews published in English, presented in the scientific literature. All studies evaluated alexithymia on the TAS scale - Toronto alexithymia scale, while gambling was assessed mainly using the SOGS scale - South Oaks Gambling Screen.
Conclusions. The data found in this review suggest that alexithymia should be considered in the clinical evaluation of gambling. Because alexithymia has been found to respond positively to psychological interventions, and gambling problems can also be effectively reduced through multiple care strategies, assessing alexithymia in these subjects can help plan more effective individualized treatment protocols. Gamers may find it helpful to focus on recognizing and understanding their own emotional states and developing more adaptive ways to manage their feelings.

Background

Risk factors that may trigger gambling include demographic, environmental, personal, and cognitive factors. Most risk factors identified include gender (men are more prone than women [1]), sociocultural background (an environment where gambling is accepted without stigmatization [2]), personality factors (impulsivity, sensation, under-controlled temperament, and antisocial behavior [1]), as well as cognitive distortions in luck and control [2,3].

Not surprisingly, gambling problems are very much associated with emotional disturbances [4]. Among the various personality traits that are believed to underlie emotional dysregulation, the issue of alexithymia has gained widespread popularity in recent decades.

Alexithymia is a multifaceted personality problem that is a deficiency of cognitive processing of emotions. It consists of two factors: lack of awareness of affect (difficulties in identifying and describing feelings) and operational thinking (externally oriented thinking and poor image processes) [5]. And it has been repeatedly shown to be associated with a variety of medical and psychiatric syndromes that are part of a wider range of affective disorders [5].

Alexithymic individuals find it difficult to understand and express their feelings, as well as to reflect experiences, behaviors, and mental states in themselves and others. The idea that alexithymia can be considered as a personal problem of affective dysregulation is based on several areas of research. For example, neurobiological studies have suggested that alexithymia is associated with impaired coordination and integration of interhemispheric communication, dysfunction of the right hemisphere, or dysregulation of the prefrontal cortex and anterior regions (e.g., anterior cortex) [5]. In addition, a high prevalence of alexithymia has been found in various medical and psychiatric disorders of affect regulation, such as eating disorders, drug addiction, somatoform disorders, and panic disorders [5]. There is still evidence that alexithymic deficiency in the processing of feelings can affect mental and physical health through behavioral actions such as ways to regulate affective states (e.g., substance abuse, eating behavior) or psychophysiological emotional discharge (e.g., somatization and panic disorder) [6].

Aim

To determine the current state of analysis of the peculiarities of the formation of pathological gambling addiction depending on alexithymia, to systematize the data and compare the information presented in the Ukrainian and foreign scientific literature on this issue in recent years.

Materials and Methods

A qualitative and quantitative content analysis of scientific Ukrainian and English literature, published until 2019, was conducted, which sets out different views on the peculiarities of the formation of pathological gambling addiction depending on alexithymia. A database of medical, and psychological literature PubMed, Web of Science, and Scopus were used, and the search included all years of publications (until 2019). The keywords gambl * AND alexithym * were used for systematic search. Inclusion criteria: original scientific papers conducted in any population, including any age group, that investigated the relationship between gambling problems and alexithymia. Exclusion criteria: reviews, opinions, comments and editorials, gambling studies published in languages other than English, French, Italian, and Spanish. After completing the search in electronic databases, the titles and abstracts of the identified articles were evaluated for their suitability for inclusion in the review. A search of PubMed, Web of Science, and Scopus databases initially found 182 articles, 26 of which were selected for full-text viewing, and 6 were excluded. Because of the notable variation between the included studies in the sample, the means of assessing gambling problems, the methods of classifying participants as alexithymic or non-alexithymic, and statistical analysis, we propose a qualitative synthesis rather than a meta-analysis. Data collection was performed under the following headings: sample characteristics, including age, sex, and sample size; study design; tools used; and research results. The results were compared, and all differences were resolved by mutual agreement.

Results

Twenty studies were considered acceptable and received for this review. Most studies (N = 15) were conducted in Europe. Three studies were conducted in Canada, one in the United States, and one in Australia. All studies were transverse. Among the included studies, only two [7,8] used mediation analysis, which allows testing potential association pathways, including other variables. No research has been conducted on gambling and alexithymia.

In all included studies, alexithymia was assessed using one version of the Toronto alexithymia scale, most of which with a 20-point version (TAS-20) [9]. TAS-20 is the most commonly used tool for the assessment of alexithymia and is considered the gold standard in this field. It has a total score and 3 factor scores corresponding to three aspects of alexithymia (DIF, difficulty determining feelings; DDF, difficulty describing feelings; EOT, outwardly oriented thinking), as well as a marginal score for determining levels of moderate (50 -60) and high (> 60) alexithymia.

Problems with gambling were assessed mainly using the South Oaks Gambling Screen [7,10-24], which is the most frequently used tool in the research literature. In four studies, the Canadian Problem Gambling Index [8,25], the Problem Gambling Severity Index [26], or the Kurzfragebogen zum Glücksspielverhalten [16], some of which added DSM criteria for gambling disorders.

Most studies have found a higher level of alexithymia in pathological players recruited in the community sample (students, community, poker, slot machines, casinos, bookmakers, and betting players) compared to problem players or healthy subjects [12,14,19,23,24,27]. When the TAS-20 thresholds were used, high alexithymia was detected in pathological players in the range of 31-52%. Only one study found no association between alexithymia and gambling [22]. Moreover, distress and impulsivity have shown a positive relationship between alexithymia and the severity of gambling [8].

Four studies measured the unique effect of alexithymia over variance due to other relevant variables, such as anger expression, attachment, impulsivity, personality disorders, and clinical syndromes [17,20,21]. The total score of TAS-20 was recognized as an important predictor of the severity of the game disorder. One study [16] failed to find such a link after adjusting attachment styles to anxiety addiction, which became the only predictor of gambling severity.

Conclusion

Our main results show that alexithymia predominates in dose-dependent subjects with gambling problems, with a prevalence of 31-52% in pathological players from the community sample and 34-67% in clinical subjects with the game disorder. According to these data, the prevalence is probably higher among players with clinical disorders.

Subsequent results of this review showed that alexithymia may increase the severity of symptoms and the risk of pathological gambling. Finally, alexithymia showed clinically significant interactions with maladaptive personality (sensation, impulsivity, and aggression), psychopathological (depression, anxiety, and personality disorders), and cognitive (gambling, motivation, strategic and non-strategic aspects).

The results correspond to high levels of alexithymia, which is manifested both in disorders associated with the use of psychoactive substances [28,29] and in behavioral addiction, such as Internet addiction [30] and compulsive shopping [31].

A number of limitations do not allow generalizing the results of the relationship of alexithymia with problematic game behavior. Studies published over the past two decades have used a cross-sectional design, which makes it difficult to determine the direction of causation. Alexithymia can be a causal factor in the development of playful behavior or a consequence of maladaptive habits. A third independent factor, such as comorbid psychopathology or the social environment, may also explain the relationship between alexithymia and problem play. Future research on the role of possible unexplored mediator and/or moderator factors that may explain this relationship as the background of the player environment or general and non-general genetic factors should be examined.

Therefore, the results obtained during this review suggest that alexithymia should be considered in the clinical evaluation of play behavior. Because alexithymia has been found to respond positively to psychological intervention [21], and gambling problems can also be effectively reduced through multiple treatment strategies. Assessing alexithymia in these subjects may help in planning more effective individually adjusted treatment protocols.