Elsevier

Psychiatry Research

Volume 206, Issue 1, 30 March 2013, Pages 111-113
Psychiatry Research

Brief report
Deep transcranial magnetic stimulation for the treatment of pathological gambling

https://doi.org/10.1016/j.psychres.2012.09.045Get rights and content

Abstract

Five pathological gamblers received deep transcranial magnetic stimulation (DTMS). Evaluations included rating scales and collateral anamnesis. Despite initial improvement in ratings, collateral anamnesis demonstrated failure to respond. DTMS to the pre-frontal cortex using an H1 coil was an ineffective treatment. Our study is preliminary, and additional studies are required.

Introduction

Pathological gambling is classified in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, as an impulse-control disorder (American Psychiatric Association, 2000). Pathological gambling is a chronic, progressive, male-dominant disorder, causing great personal and social consequences such as suicide attempts, job loss, marital and family problems, legal problems and criminal behaviors (Dannon et al., 2006).

A range of psychopharmacological options are available for the treatment of pathological gambling. Short-term randomized, double-blind trials, as well as open-label trials, have assessed pharmacotherapy for the treatment of pathological gambling.

Current evidence implicates the involvement of multiple neurotransmitter systems (dopaminergic, serotonergic, noradrenergic, opioidergic) in the pathophysiology of gambling disorders (Hodgins et al., 2011). This evidence may underlie the wide range of psychopharmacological agents being used to treat PG, including the following: selective serotonin reuptake inhibitors (SSRIs), mood stabilizers, bupropion SR, and the opioid receptor antagonists' naltrexone-nalmefene. Psychopharmacological studies show overall mixed success; some have shown that remission is sustained in most treated patients and that active treatments are superior to the control condition (Dannon et al., 2006), while several double-blind studies failed to show short-term efficacy (Dannon et al., 2011).

There are non-pharmacological treatment approaches to gambling disorders, among which are psychoanalytic or psychodynamic therapy, Gamblers Anonymous, behavioral treatments, cognitive and cognitive-behavioral therapies, brief, motivational, and self-directed interventions, and family therapy approaches (Stea and Hodgins, 2011).

To date, animal and human imaging studies have revealed discrete circuits that mediate the addiction cycle and have suggested disruption of the inhibitory control of the dorsolateral prefrontal cortex (DLPFC) (Koob and Volkow, 2010). Various drugs of abuse mediate their acute reinforcing affects through (but not only through) the prefrontal cortex via dopaminergic and glutamatergic pathways (Feltenstein et al., 2008). Hence, the rationale that stimulation of the prefrontal cortex may lead to amelioration of addiction.

Transcranial magnetic stimulation (TMS) is a noninvasive tool that stimulates nerve cells in superficial areas of the brain. TMS induces a magnetic field that can produce a substantive electrical field in the brain causing depolarization of nerve cells, which results in the stimulation or disruption of local brain activity. Low-frequency repetitive TMS (rTMS) (∼1 Hz) induces in most cases a decrease in cortical excitability, whereas high-frequency rTMS (>5 Hz) generally increases excitability (Feil and Zangen, 2010).

Pathological gambling involves risk-taking behavior. The DLPFC is involved in decision-making processes (Rorie and Newsome, 2005). These processes are altered by direct current stimulation of both left and right DLPFC (Fecteau et al., 2007) and increased risk-taking by low-frequency rTMS over the right DLPFC (Knoch et al., 2006a, Knoch et al., 2006b).

Several studies showed positive preliminary results using TMS to treat addictions (Politi et al., 2008, Amiaz et al., 2009, Mishra et al., 2010). Because TMS is a potential treatment for addictions, and because frontal cortex activity may be abnormal in pathological gamblers compared with controls, we decided to use TMS to stimulate the prefrontal cortex.

A review article by van Holst et al. found an increased activation of the prefrontal cortex in subjects exposed to gambling-related stimuli in cue-exposure paradigms (van Holst et al., 2010); therefore, we decided to stimulate the left prefrontal cortex with an inhibiting frequency of 1 Hz.

Our study is the first to explore the neuromodulation treatment option for pathological gambling.

Section snippets

Materials and methods

Five participants diagnosed as suffering from pathological gambling, according to DSM-IV-TR, were recruited through out-patient clinics all over Israel. All patients gave written informed consent to take part in the study, which was approved by the Beer-Yaakov Ethics Committee and the Ministry of Health.

Of the five patients enrolled, one was treated twice and one dropped out. All patients were males. The average age of patients was 39 (Table 1). The average at which gambling began was 21.8

Results

The results 24 h after session 15 were as follows: the HDRS average score dropped from 6.6±5.3 to 3±2.5, and the HARS average score dropped from 1.8±2.1 to 1.6±2. The average score of the CGI-I was 3.2 (score “3” in CGI-I means “Moderately improved”). The DAGS score dropped from 70.8±18.5 to 42.2±26.3. The VAS score dropped from 5.2±3.5 to 3.2±2.6. The Y-BOCS score dropped from 5.8±4.6 to 2.4±2.5. The SAS average score changed from 40±15.2 to 39.2±17.9.

In addition to improvement in average

Discussion

Deep transcranial stimulation to the DLPFC at 1 Hz failed to demonstrate effectiveness in pathological gambling in this pilot study. The possible reasons for the failure are the following: relatively small sample size, treatment parameters including treatment location, frequency (perhaps, patients should have been treated with a stimulating frequency rather than an inhibiting one), session duration and number of sessions, total pulses, stimulation pattern or that the etiological mechanism is

Conclusions

We found that deep rTMS directed over the PFC using an H1 type coil does not appear to be an effective treatment for pathological gambling. However, our study is a preliminary one, and additional studies are required before definitive conclusions can be drawn.

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