Slot machines and the cingulate cortex

From the green towers of the world’s largest casino rising up from the Connecticut farmland to the smash-hit television program Who Wants to Be a Millionaire, a culture that promotes and glorifies gambling is all around us.

But until recently, little has been done to investigate gambling addiction, a significant health problem that may be as prevalent as some other major psychiatric illnesses such as schizophrenia, according to Marc N. Potenza, Ph.D. ’93, M.D. ’94, an assistant professor of psychiatry and director of the Problem Gambling Clinic at Yale.

Research suggests a rise in the rate of pathological gambling during the explosive growth of legalized gambling in the United States, which began with state lottery systems in the 1960s, proliferated with riverboat gambling and casinos on Native American reservations two decades later, and now continues to expand with Internet gambling and video poker.

While historically viewed simply as a sin or vice, pathological gambling has symptoms similar to those of drug addiction, said Potenza, who is using brain imaging and drug trials to better understand its causes and to develop more effective treatments.

“The gambling industry is huge,” he said. The $51 billion generated from casinos, lotteries and horse race betting exceeds the revenues of the movie, theme park and music industries combined. One estimate pegs the societal cost of problem gambling—including legal fees for divorces and incarceration, as well as health bills—at $5 billion a year. Potenza believes the price could run far higher.

While it is estimated that 86 percent of adults have gambled at some point in their lives, fewer than 10 percent develop a problem and fewer than 3 percent of those become pathological gamblers, he said. Still, many compulsive gamblers report devastating troubles—their lives torn apart by bankruptcy, divorce and criminal activity. About a fifth of pathological gamblers attempt suicide.

Problem and pathological gamblers, though, have had few treatment options available. For example, about 85 percent of callers to the Connecticut Council on Problem Gambling’s hotline reported never having received any prior help for a gambling problem. Potenza is working to change that.

The Problem Gambling Clinic, a collaboration between Yale’s Department of Psychiatry and the Connecticut Mental Heath Center, is one of only four sites in the U.S. to participate in the first multicenter trial of a drug to treat compulsive gambling. Initial data from the trial evaluating the effects of paroxetine (Paxil) are encouraging, said Potenza. He is also using functional magnetic resonance imaging to monitor the brain activity of both gamblers and healthy subjects who have viewed videotaped cues intended to spark the urge to gamble. Only in the pathological gamblers did viewing the cues lead to lower activity in the anterior cingulate cortex, a brain region which has been repeatedly implicated in previous studies of drug craving and mood states. While further study is needed, the neuroimaging study may help identify a possible intervention point for patients with the addiction.