A 32-year-old man comes to the office for a routine annual examination and is accompanied by his wife. He has no new medical problems, and the physical examination is unremarkable. At the end of the visit, the patient's wife asks to speak with the physician and expresses concern that her husband was recently placed on probation for poor work performance. Over the past few years, the patient has become increasingly irritable and less interested in his work as an insurance agent. She says, "He misses work at least once a week because he stays up all night playing poker online and then sleeps in during the day. He talks nonstop about his betting strategies and how clever they are." The patient has lost a lot of money, and they have started borrowing from her parents to pay the bills. The patient denies that he has any problems and says, "I've just been a little down these past few weeks. I know I can be on top again if I just get out of this slump. I'm one of the best poker players around." Which of the following is the best explanation for this patient's behavior?

Question

A 32-year-old man comes to the office for a routine annual examination and is accompanied by his wife.  He has no new medical problems, and the physical examination is unremarkable.  At the end of the visit, the patient's wife asks to speak with the physician and expresses concern that her husband was recently placed on probation for poor work performance.  Over the past few years, the patient has become increasingly irritable and less interested in his work as an insurance agent.  She says, "He misses work at least once a week because he stays up all night playing poker online and then sleeps in during the day.  He talks nonstop about his betting strategies and how clever they are."  The patient has lost a lot of money, and they have started borrowing from her parents to pay the bills.  The patient denies that he has any problems and says, "I've just been a little down these past few weeks.  I know I can be on top again if I just get out of this slump.  I'm one of the best poker players around."  Which of the following is the best explanation for this patient's behavior?

Quizplus · Accepted Answer

Gambling disorder is defined as persistent and maladaptive gambling behavior that results in impairment or distress. It is considered a nonsubstance behavioral addiction, implying many shared features (eg, anticipatory craving, chronic relapsing course) with substance use disorders. Mood symptoms related to gambling behavior (ie, irritability, feeling "a little down") are common, as seen in this patient. The diagnosis requires ≥4 characteristics related to problematic gambling behavior. This patient exhibits the following 4: preoccupation with gambling, frequent return to gambling to attempt to recover past losses, tendency to damage relationships or jeopardize employment, and reliance on others to make up for financial losses. Additional criteria listed in DSM-5 include: gambling when distressed, depressed, or anxious; increased gambling to achieve the desired excitement; irritability/distress when trying to cut back on gambling; and repeated, unsuccessful attempts to cut back on and conceal the extent of the behaviors. Treatment approaches include cognitive-behavioral therapies and participation in self-help programs (eg, Gamblers Anonymous). (Choice A) Adjustment disorder is characterized by emotional or behavioral symptoms in response to an identifiable stressor that has occurred within the past 3 months. Although this patient has the recent stressor of being placed on probation at work, there is evidence that he has had problematic gambling behaviors for several years. (Choice B) Patients with bipolar disorder may gamble and spend large sums of money during a manic episode. Mania, however, is episodic and unlikely to be persistent over ≥1 year. Diagnosis requires the presence of other manic symptoms, including increased energy, general decreased need for sleep (not associated only with gambling), increased goal-oriented activity, flight of ideas, and pressured speech. (Choices C and F) Cyclothymic disorder is characterized by >2 years of cyclical mood disturbances characterized by periods of hypomanic and depressive symptoms that do not meet the full criteria for hypomanic or depressive episodes. Persistent depressive disorder (dysthymia) involves a chronically depressed mood for >2 years. This patient's moods are related to his gambling behavior (eg, excitement and overconfidence while gambling followed by dysphoria and irritability). (Choice E) This patient's grandiose beliefs that he can win money are typical of gambling disorder. Narcissistic personality disorder is characterized by a pattern of grandiosity that is more pervasive in nature, as well as by a need to be the center of attention and admired. Educational objective: Gambling disorder is characterized by persistent and recurrent maladaptive gambling behavior that results in impairment or distress. Significant financial losses and damaged relationships are common consequences. References: A review of gambling disorder and substance use disorders. (http://www.ncbi.nlm.nih.gov/pubmed/27051333) Gambling disorder: an integrative review of animal and human studies. (http://www.ncbi.nlm.nih.gov/pubmed/28486792) Gambling disorder and other behavioral addictions: recognition and treatment. (http://www.ncbi.nlm.nih.gov/pubmed/25747926)

A 32-Year-Old Man Comes to the Office for a Routine