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View in own window. What is known as video gaming is a recent phenomenon which emerged in the s; it became much more widespread and was transformed by the Internet in the s. The two countries that create video games are the United States and Japan. The first video game was produced in the s. The first Nintendo games console dates back to The novelty of these games is that they offer a potential space where players act within or even beyond their imagination.

Video games have now moved into a new market thanks to the Internet, resulting in new multiplayer games: massively multiplayer online role-playing games MMORPG or massively multiplayer online games MMOG. These games can last from 20 minutes to a year and are played against other players or against the machine and require the development of specific skills.

This is the most widely played online game in the world with 9 million subscribers in The game involves 2 to 40 players who move throughout all of the continents in the world. Hundreds of hours are needed to reach a given level. Rewards can be obtained on entering the game for simple tasks, followed by promises of greater rewards for the more difficult tasks. As players are always on the point of gaining new skills they increase their playing time to achieve these new rewards.

Most of the virtual world is created by the residents themselves who evolve through the avatars that they create. It is also an Internet forum in which debates, presentations, conferences, training and marriages take place. This universe is invested in heavily by organizations companies, political parties, large schools, etc. It illustrates a certain blurring of the boundaries between the games world and the economic world, places for socialization and places for gathering information.

The introduction of video games and the Internet into social life is a recent phenomenon. These games have so far been very little studied, particularly in France. This is the first time that this type of game, which is entirely new and due entirely to the extension of communication techniques, has appeared in our society.

The young age of the people who play most is interpreted as a generational effect as video games require skills that come from an IT culture. This gaming behavior is also a means of socialization between peers and a means of seeking identity reassurance. Both qualitative and quantitative work has revealed the predominantly male population in video gaming.

They are also generally of a high social-cultural level, with an average age of 26 5. According to some authors, the male over-representation is explained by the fact that most of the games on offer relate more to male socialization promoting aggression, violent games. Gambling would appear to cause more social problems in poorer populations, as the proportion of their expenditure on gambling is higher even though the amounts spent on gambling are lower.

Gambling can also dismantle community and family relationships. In the worst-case scenario, this leads to inveterate gamblers losing everything in gambling and finding themselves with no resources. The legalization of gambling has brought economic benefits and new jobs to the residents of Nevada but it also has social costs. According to Nevada residents, some people loose control of their gambling although at the same time the legalization of gambling has brought improved quality of life to their community.

However, the perception of these advantages and disadvantages varies depending on the sub-populations studied educational level, whether or not working in the gambling industry, etc. In terms of suicide and divorce rates, a survey conducted in eight regions in the United States between and did not find any significant difference between regions with a casino and control communities.

Over a longer period however , a modest positive correlation was found between suicide rates and the presence of a casino in urban areas. This result was not seen in the analysis of suicide rates before-after the legalization of gambling. Studies particularly in the United States and Canada differ in terms of the relationship between the presence of a casino in a region and an increase in the criminality rate. Problem gambling in an Australian study was 20 times higher in prison inmates than in the general population.

Another study examined suspects arrested in two American towns. Three to four times more problem gamblers were found in this study than in the general population. Calculating the social cost of gambling is designed to provide a quantitative estimate of the harmful economic and social consequences of gambling in a given geographical area at a given time. In order to have meaning it must be based on rigorous methodology.

The classic economic approach based on the teachings of welfare economics, although not the only possible approach, emerges as one of the most robust provided that one is aware of its interest and limitations. Until now the economics of gambling has not been greatly studied. The studies that specifically set out to calculate social costs are almost all Anglo-Saxon, predominantly concern casino gambling and contain a huge variety of approaches and results. The 1st international symposium on the economic and social impact of gambling Whistler, Canada, September and then the 5th Alberta annual conference on gambling research Banff, Canada, April attempted to put some order into this muddle of research approaches, although ultimately it was still impossible to reach a consensus on an analytical framework to study the economic consequences of gambling.

This lack of consensus is regrettable as adopting a common analytical framework, even if imperfect, would have many advantages, particularly improved legibility and greater comparability of the estimates produced. Four national studies conducted in the United States, Australia, Canada and Switzerland merit being quoted. The Australian study, which is the most complete, is usually used as the reference work.

This study found the total social cost of problem gambling in — to lie within a range between 1. A comparison with the social cost of drugs in Australia also shows that gambling incurs proportionally more intangible costs than legal and illegal drug abuse. Secondly, estimates of costs by type of gambling show major differences by category and reveals slot machines and to a lesser extent betting to be the greatest cost generators.

Nothing on the subject, the same as for other areas of research on gambling. At present we therefore have no other choice than to base our work on estimates made in other countries, which we can try to assess by comparing them with estimates of the social cost of drugs in France. We observe that the estimated social cost of gambling in Australia tangible costs only is almost the same as the social cost of cannabis estimated in France 15 euros per person per year.

Some useful information can also be extracted from an analysis of social costs to help construct public policies. Firstly, the estimated sum provides theoretical justification for State intervention, and to this end comparison with other types of activity may help with priority setting. Next, it is also extremely valuable to define the desirable form of State intervention.

This concept proposes to introduce policies specifically targeting the small group of problem gamblers those who both create and bear the largest proportion of the cost without penalizing others. The majority of non-dependent gamblers generates little or even no social costs and gain pleasure from gambling. If in addition we adopt the hypothesis of limited rationality associated with time-inconsistent dependent gamblers, it may be useful to promote self-control mechanisms for example voluntary bans in casinos that will allow the gamblers to not succumb to their short-run preferences and help them get out of their addiction.

Finally, it is essential that public policies target as a priority the gambling that incur the greatest costs and adapt to the development of Internet gaming and gambling. An analysis of the literature on the social cost of gambling reveals the extent of current debate and highlights the need for continued research.

Since French people appear to be increasingly drawn to gambling, and the gambling supply is undergoing great change, it would be extremely useful to have indicators for France. A number of sociological studies have examined the motivations for specific homogeneous populations. In people over 65 years old, relaxing and enjoying themselves, passing the time and combating boredom are the motivations most reported by gamblers. Other studies have analyzed for example the motivations in four ethnically different communities North African, Chinese, Haitian, and Central American in Montreal: in these communities the hope of making significant gains and improving their economic situation is an important motivation for gambling.

The desire to come closer to the culture of the host country in order not to feel excluded is also a motivation for gambling even if its practice contradicts the traditional culture of origin for example North Africa. Believing in chance and the supernatural is also a component of gambling for Chinese and Haitian cultures.

Gambling is part of social and family life from the youngest years onwards in Central American countries. Sociological studies have examined the behavior, rituals, movements, exchanges and conversation of gamblers. A detailed study of gamblers in the natural gambling situation is useful to understand the social and cultural perspective of contemporary gambling including in situations when it appears to be excessive from a commonsense perspective.

Biographical information, personal accounts and portrait are also used in the qualitative sociological studies. Freud expressly connotes the gambling passion with a pathological dimension. The gambler is to be considered as a neurotic, driven by the unconscious desire to lose, in other words by moral masochism, the unconscious need for self-punishment. This operation requires a return to the fiction of infantile all-powerfulness, and the rebellion against parental law, which directly becomes a latent rebellion against logic for the gambler.

Unconscious aggression against the parents who represent law and reality is followed by a need for self-punishment, implying the psychical necessity of loss in the gambler. The cynicism is an attempt to justify, or to attribute to everyone else, feelings as hostile as those that unconsciously the gambler harbors towards the parental figures. Just like the systems or martingales that are supposed to lead to winnings, these artifices are merely the crude expression of the infantile megalomanic belief in the capacity to steer destiny.

The primitive pastime has now become a question of life and death. The illusion of control is that the gamblers attribute the results of purely random sequences to their ability or knowledge. These two mistakes are variants of non-recognition of the independence of throws. Finally, superstitions and illusory correlations, which are extremely common and varied, are sometimes encouraged by gambling advertising or systems.

Cognitive errors are seen in all gamblers and are undoubtedly more common in excessive gamblers. This, however, does not establish a causal relationship. Greater knowledge of statistics, probabilities and the gambling systems only has very limited influence on gambling behavior itself.

Some authors describe a strategy of escape from reality or negative affect in problem gamblers and a search for distraction by involvement in a replacement activity. A vicious circle develops in the gamblers themselves, the illusion of control playing a secondary role in maintaining the process. The relationship between gambling, risk taking and sensation seeking is complex and requires the different types of gambling, the history of gambling behavior and the typology of gamblers to be taken into account.

Sensation seeking can be seen as an indicator of a tendency towards gambling but does not distinguish between problem gamblers and other gamblers. Impulsivity, which results from difficulty in self-regulation or self-control lies at the heart of the definition of pathological gambling. The relationships between problem or pathological gambling and controlled aspects of self-regulation have been examined in two ways: from questionnaires that assess impulsivity which is considered to result from weak self-regulating ability , and using cognitive tasks examining executive functions such as inhibition, planning and flexibility capacities and decision-making capacities.

Most of the studies using impulsivity questionnaires have shown higher levels of impulsivity in pathological gamblers than in control participants. These studies have identified positive links between high level impulsivity and the profile of high-risk gamblers in the general population or in populations of university students. The level of impulsivity is also a predictive factor for the severity of the symptoms of pathological gambling and is also associated with a greater likelihood of abandoning psychotherapeutic management and of psychotherapeutic management being less effective.

The studies that have examined controlled aspects of self-regulation using cognitive tasks have produced more inconsistent results than those based on questionnaires. Nevertheless, studies that have examined sensation seeking in gamblers have provided some useful data suggesting future avenues for research.

A positive relationship has been found between sensation seeking and the number of different gambling activities performed. Regular gamblers are also found to be different in terms of their level of sensation seeking depending on the gambling activities they perform. Gamblers who prefer casino gambling have greater sensation-seeking desires than those who bet on horse races and people who bet at racecourses have higher sensation-seeking desires than those who gamble in cafes.

In particular, this involves taking account of the complex relationships between the automatic motivational and controlled executive functions and decision-making aspects of self-regulation at different times in the creation of gambling habits. In addition, this belief has led to transversal and static investigations of people considered to belong to a distinct delineated category rather than considering problem gambling as a specific stage, which may affect a large number of people in their gambling trajectory.

Risk and vulnerability factors are firstly those factors relating to the object of addiction, or structural factors, secondly those relating to the environment and context, or situational factors, and finally factors related to the subject, or individual factors. From the perspective of the structural factors, the different types of gambling have attracted increasing attention in the international scientific literature, with the idea that not all include the same risk of addiction.

To this end, several authors believe that the shorter the time between bet and expected gains the greater is the possibility that the gambling will be repeated and the greater is the risk. This finding undoubtedly merits confirmation via correctly conducted studies. The impact of a large initial gain is one of the classical factors for the development of excessive gambling. This factor is seen in studies on pathological gamblers encountered during consultation visits.

The development of Internet gambling, which has been very evident for a few years, requires consideration to be given to the place and specific impact of this medium. The occasional studies on this subject emphasize the concepts of anonymity, accessibility, disinhibition and comfort which are liable to predispose to abuse and addiction practices.

The impact of the offer and availability of the gambling in terms of risk factors have been considered in the same way as for other addictions. From the perspective of the situational factors, it is above all the socio-economic factors which need to be stressed, with the clearly established concept that reduced social support and low level of income-employment often correlate with the prevalence of pathological gambling and high risk gambling.

Several studies have examined the position and contribution of parents in terms of risk factors or protection against excessive gambling in their children. These stress that the place and acceptance of the gambling by the parents have an impact on the frequency of gambling behavior and gambling-related problems in children, and also that supervisory authority is a more protective position than a more lax, or conversely authoritarian family situation.

From the perspective of individual factors, initiation into gambling occurs in most cases during the adolescent period. This has been shown by studies on pathological gamblers attending specialist care structures. Early contact with gambling appears to be a severity factor reflecting what is seen in psychoactive substance addictions. The elderly are a high-risk population for lotteries and slot machines. A family history of pathological gambling with the concept of family aggregation , addictive behavior, anti-social personality and, to a lesser extent, other mental disorders, appears to be more prevalent in pathological gamblers.

A past history of abuse in childhood has been found to be associated with earlier and more severe pathological gambling behavior. Similarly, psychiatric co-morbidities are undisputable risk factors for beginning gambling behavior when they pre-exist and for worsening gambling behavior in all situations. The risk and vulnerability factors appear to be similar to those found in all addictive behaviors, particularly addictions to psychoactive substances.

The person who is most at risk of becoming involved in pathological gambling behavior would therefore appear to have the profile of a young unemployed male with low income, unmarried and poorly socially and culturally integrated. Several studies have specifically examined the association between pathological gambling behavior and other addictive behaviors, notably alcohol and impulsive and delinquent behavior, particularly in young men.

These reveal that early behavioral and attention disorders precede various addictive and behavioral disorders. As with most of the other addictive behaviors pathological gambling would appear to result from a combination of different risk and vulnerability factors in variable proportions , a combination which characterizes the profile of each situation and trajectory on an individual case basis.

In terms of trajectories, there are few dedicated studies and most do not provide information about the exact chronology of the history of more or less well-controlled gambling practices. A few correctly conducted studies over recent years have however made it possible to measure a lack of stability over time in the pathological gambler. The fact that these gambling problems develop individually on a more transient and episodic basis, rather than continuous and chronic, is a strong argument for developing long-term general population cohort studies.

These studies should better identify the complex reality of these pathways and the factors involved in periods of both remission and relapse in order to extract the maximum of information in terms of prevention and treatment indications. Most of the data published in the neurosciences field concern addictions to psychoactive substances.

However, as non-substance addictions have the same symptoms and even a withdrawal syndrome, these clinical features can be considered to reflect the same cerebral dysfunction and to originate from a common pathophysiology, namely Addiction 6. The shift from occasional to chronic use and Addiction is clinically characterized by progressive loss of control of the consumption behavior and compulsive seeking craving and consumption of the object, despite the serious consequences which may occur for the individual person, his family and close friends, and despite the development of a negative affective state which precipitates relapse.

At an advanced stage of a consumption habit which becomes increasingly impulsive, the person enters an alienating spiral entirely centered on the object alone. At this end stage of the process, the person is extremely distressed and the cerebral changes are more difficult to reverse, leading to a chronic disease state of Addiction. The central stress and emotion systems characterized by different neurotransmitters contribute to a pathophysiological function which defines a powerful motivational state reflected by a shift from impulsive behavior to compulsive behavior.

It is important to stress that Addiction affects relatively few people compared to the number of occasional consumers of the object of addiction. Many authors consider that an object of addiction is only addictogenic when it is consumed by an already vulnerable person. Understanding why some people succumb to addiction and others do not up to the point of apparent resilience is an essential question.

Vulnerable people are generally polyconsumers of addiction objects. In addition, this vulnerability may occur as a result of various psychopathological co-morbidities, poor conditions in terms of education and environment, personality disorders and stressful lifestyles. In order to understand the addiction process it must therefore be examined in a whole life context and, because of its early diathesis, be examined from a very young age onwards.

Whilst vulnerability and co-morbidity have neurobiological translations, considerable progress is needed before obtaining scientific reference data. Although gambling addiction clearly has specific features it is accepted that the sources of vulnerability are the same as for other addictions. Gaming addiction particularly gambling and internet addictions is a very interesting question for the neurosciences. The key factor in gamblers is the speed between perception and execution.

Decision-making is based obviously on knowledge, skill and memories, the quality and relevance of which probably take account of the speed of decision and action. The involvement of pre-established mental sets also exists with drugs of abuse and are the cause of relapses; environment indices and mental representations almost immediately trigger imperious, impulsive, compulsive consumption and even a withdrawal syndrome in a person who has not consumed for several weeks.

Neurobiological research is being directed towards identifying the substrates involved in the two situations which appear to be based on stimuli-response associations in memories, knowledge and cognitive systems. This appears to be a central question in thinking about excessive gambling: is the gambling a drug in the same way as psychostimulants, opiates, alcohol or tobacco?

Does this type of addiction involve the same neurotransmitters? Dopaminergic neurons are not strictly speaking part of the reward circuit although their activation stimulates the circuit and provokes a sensation of satisfaction. Results of neurobiological research over recent years have convinced the main part of the scientific community that dopamine is fundamental to all pleasure-related events.

The stage which still has not been widely studied is the involvement of dopamine in drug dependency. It is in fact tempting to think that it is the pleasure produced by the drug that the consumer is no longer able to ignore. It has long been noted by clinicians that drug addicts relatively quickly lose the pleasure from drug consumption in favor of seeking a state which more closely resembles a necessary or essential relief.

Until now, all of the biochemical indices measured in animals following iterative administration of drugs have returned to normal after a few days or no more than one month after the last dose. By studying modulators other than dopamine, i. This coupling reflects an interaction between noradrenalin and seritoninergic neurons with the result that both sets of neurons mutually activate or inhibit each other, depending on the external stimuli perceived by the animal or person.

During repeated drug use this coupling disappears. The uncoupling and uncontrollable over-reactivity which it produces between the noradrenergic and serotoninergic systems may be responsible for the malaise experienced by drug addicts. Retaking the drug would then enable artificial recoupling of the neurons creating temporary relief which may explain the relapse.

The drug in this case would be the most immediate way to respond to the malaise. The question raised now is whether the uncoupling which is obtained with cocaine, morphine, amphetamine, alcohol or tobacco can be obtained by gambling. It has been clearly shown that the very great majority of excessive gamblers suffer from concomitant diseases.

These diseases, particularly addiction to substances such as tobacco and alcohol which develop in parallel to the excessive gambling behavior, may account for the pathological form of the gambling. However, psychiatrists point out that pathological gamblers exist who have no addiction or any other concomitant psychological disorders.

It is not therefore possible to exclude the possibility that simply overindulging in gambling may, as for drug abuse, cause changes to the functioning of the central nervous system such as those described above. One of the hypotheses which could be put forward is that in some people, stress and distress which the gambling can cause chronically increase glucocorticoid secretion and, in the absence of the product, reproduce neuronal activations and analogous uncoupling to what is seen with addictive substances.

Preclinical research should be conducted in order to study whether chronic stress situations or secretion of endogenous molecules such as glucocorticoids can alone reproduce the neurochemical effects produced by drug abuse. For the clinician, addiction can be defined as a condition through which behavior liable to give pleasure and relieve unpleasant feelings is adopted to an extent that it results in two key symptoms: repeated failure to control this behavior and continuation of the behavior despite its negative consequences.

Impulsivity however appears to be only one of the features of pathological gambling. Several published works also highlight the heterogeneous nature of this category in the DSM and have put forward the hypothesis that impulse control disorders belong to the behavioral addictions category, which would therefore group together pathological gambling, kleptomania, pyromania, trichotillomania, intermittent explosive disorder and also compulsive buying, compulsive sexual behavior and compulsive Internet use.

There are many arguments however in the other direction: obsessive gambling ideas in the gambler are egosyntonic driven by seeking well being whereas the obsessive ideas in OCD are by definition intrusive and egodystonic they cannot be ignored and are a source of distress. There are also no clear epidemiological arguments showing co-occurrence of OCD and pathological gambling.

Neuropsychological findings are discordant, some works showing similar deficits in executive functions related to the frontal lobe in people with OCD and pathological gamblers, whereas these similarities have not been found in other studies. Ultimately there are no formal arguments to enable pathological gambling to be seen as an OCD related disorder even though the compulsive dimension of the behavior is apparent.

In most of the recent publications, pathological gambling is considered to be a behavioral addiction. There are clinical arguments to support this position: the clinical phenotypes of the gambling and substance addiction DSM-IV-TR are very similar, including the presence of withdrawal symptoms and changes in tolerance increased challenges over time in the gamblers.

High rates of co-morbidities between pathological gambling and addictions and also between pathological gambling and numerous mental and personality disorders are reported in all of the studies. There are therefore many clinical, epidemiological, biological and therapeutic arguments to consider pathological gambling as a non-drug addiction.

Like all addictive diseases, the behavior requires impulsion and compulsion. The questions of screening and diagnosis must be considered with reference to their objectives: is the purpose to consider primary prevention activities, with the ambition of making the largest number of people at risk from their behavior aware of the situation, or is the purpose to identify behavior which is already sufficiently problematic to have resulted in a certain amount of characteristic damage in order to justify a specific treatment approach?

The SOGS is the reference tool used to identify pathological gambling which is by far the most widely used in the world. However, some limitations of this tool are regularly emphasized in terms of its psychometric properties. Several authors refer to a certain over-estimation of the prevalence of pathological gambling. As it is already an old tool some diagnostic changes have not been incorporated. Finally, the relevance of the tool in the youngest populations is debated despite the existence of a version adapted for adolescents the SOGS-RA.

In terms of its psychometric properties the reliability and validity of the DSM-IV-gambling have been demonstrated in many studies. The CIM gambling is very widely used in clinical practice and very little used in research.

There are few publications describing its psychometric properties. The Gamblers Anonymous self-completed questionnaire GA is a twenty question self-evaluation tool very widely used in the United States and in many other countries, although there are practically no validation studies available for it.

It is nevertheless considered to be very poorly discriminatory. Screening and diagnostic tools for pathological gambling have therefore existed for around twenty years and are described in validation studies which guarantee good psychometric properties for several of these tools this applies particularly to the SOGS, DSM-IV and CPGI.

Nevertheless, important differences in terms of the prevalence of pathological gambling and high risk gambling are found in some studies using these different tools, which raises questions about thresholds and calls for further studies. Similarly, the relevance of these tools in younger and older populations is currently hotly debated. More than prevalence surveys were found in the international literature, conducted mostly in North America, Australia and New Zealand.

The great majority of these were specific surveys centered on the question of gambling. The problem was examined in some instances as part of a broader investigation on a health or mental health subject. This approach offers additional value as it allows an in-depth analysis of the relationships between determinants and individual health characteristics and problem gambling behavior.

This is due both to the difficulty of correctly measuring the former, which is more sensitive to memory problems and also to the fact that the conceptual basis on which it was constructed is fragile. Interest for this concept has waned since the chronic nature of pathological gambling has been put in question. There is a very wide range of identification tests used in the prevalence surveys, meeting a similar wide range of concepts.

Similarly, two concepts emerged:. The vast majority of the prevalence surveys on problem gambling involve adults. Most of the international literature examines the question of gambling. Studies on Internet addiction or video games playing are more recent, fewer in number and still centered on conceptual and methodological problems.

This point was identified by some authors of meta-analyses and surveys which have simultaneously used several identification tools. However, it remains very controversial in the literature. This situation does not facilitate prevalence comparisons in problem gambling in the different countries which have conducted national surveys on the subject. Differences in prevalence between countries are still widely debated. The most common hypothesis put forward is differences in accessibility to gambling.

Average prevalence values for adults 2. These estimates should be seen as orders of magnitude. There is considerable dispersion of results around these mean values, particularly for adolescents. Prevalence also depends on the population used as the denominator: the entire population, all gamblers or regular gamblers. It is difficult to extract clear trends in the change in prevalence of problem gambling from a chronological analysis of the results produced by the surveys conducted over the last twenty years.

Countries, states or provinces which have been able to repeat the surveys have found contradictory trends, which are difficult to compare in view of differences in the legal context or accessibility to gambling. In this context, an increase in problem and pathological gambling was seen in the United States during the s. Over the same period in New Zealand the problem remained stable. Internal trends in the United States, within the States which had been able to reproduce these surveys over time, are discordant: falls, no change or increases are reported.

In the United States, however, the large number of local studies available makes it possible to compare the levels reported by the oldest studies with those from the most recent ones. This comparison appears to show some increase in the prevalence of pathological gambling, problem gambling remaining stable. Overall, however, we can assume it is relatively stable.

This is not inconsistent with other findings showing limited increases in prevalence over time and increasing accessibility with prevalence returning to its previous level in the longer term. These very general trends hide a few subtle changes showing that the phenomenon of problem gambling is constantly changing. Many studies have shown that when sub-groups of the population are examined different trends may be found. The prevalence of gambling in general and problem gambling in particular appears to have increased in women with the increase in the range of gambling offered.

Prevalence in young people may be increasing. Within a given country, the social categories most affected by the phenomenon can change. All of the epidemiological general population surveys identify males as being the gender most associated with problem gambling. In the opinion of some authors, however, this finding relates more to the fact that more men gamble and that it depends on the type of gambling. These gender differences are also tending to disappear. Age is also an associated factor seen frequently in prevalence surveys.

The prevalence level for problem and pathological gambling is higher among young people adolescents and young adults than among adults. This may be associated with an overall phenomenon of more common risk behavior at these ages. A comparison of the different social data available about factors associated with problem gambling does not reveal any invariant factor in the different cultures or social organizations in countries which have conducted these surveys as strongly associated with pathological gambling as sex and age young male adults.

In fairly general terms, whilst social factors play a role we must not forget that pathological gambling is seen in all social environments. The relationship between the availability of gambling and the prevalence of problem gambling is complex. It has been interpreted in ways which can appear contradictory.

Some analyses tend to show that countries or provinces where access is more limited also have a lower prevalence of problem or pathological gambling. There are few general population studies on the relationships between pathological gambling and other addictions or psychiatric disorders, and the available studies are mostly North American. No data are currently available for the general population in France.

All of the general population studies published show that pathological gambling is very commonly associated with other addictions. Amongst the addictions, smoking is the one found most commonly in pathological gamblers. Other addictions alcohol, illegal drugs generally precede the onset of pathological gambling particularly in men. Pathological gamblers with a past history of drug addiction usually have a more severe problem associated with pathological gambling. Many pathological gamblers have concomitant psychiatric disorders.

These are most commonly associated with mood disorders, anxiety disorders or personality disorders. As with most addictive behavior, pathological gambling is closely associated with personality disorders obsessive compulsive, avoidance, antisocial and schizoid. Antisocial personality appears to be associated with more severe pathological gambling.

Of the mood disorders, bipolar disorder is the most commonly associated with pathological gambling. Mood disorder often precedes pathological gambling and persists after it has stopped. The close association with mood disorder could also explain the high level of suicidal ideation and risk of suicide in pathological gamblers.

Of the anxiety disorders, panic disorder and post-traumatic stress syndrome are the most commonly associated with pathological gambling in the general population. No significant relationship has been found with obsessive-compulsive disorder. Some psychiatric disorders are also risk factors for pathological gambling. The risk of developing pathological gambling behavior is three times higher than in a general population for people with substance abuse or use, and 1.

People suffering from bipolar disorder are twice as likely to develop a gambling addiction than people with another mood disorder. These significant associations are not clearly explained. The existence of co-morbidity with other psychiatric disorders addictions, depression, personality disorders etc… is a severity indicator for pathological gambling, justifying appropriate management. Of the psychological techniques proposed for the treatment of pathological gambling, cognitive behavioral techniques have been examined in controlled studies.

These studies are few in number and they are based on modest population numbers. Most have been for a relatively short observation period rarely more than one year and involve patients with few co-morbidities. Of the behavioral therapies, only imagination sensitization techniques have been shown to have some effect. These cognitive techniques have been found to be significantly more effective in controlling pathological gambling behavior than no psychological intervention at all.

The question of type of management individual or group has also been assessed in the literature. The results appear to show that cognitive behavioral therapy on an individual or group basis produce almost equivalent immediate results. Individual management appears to be superior to group management to prevent relapses. Whilst cognitive behavioral therapy appears to be effective in some pathological gamblers, the high level of poor adherence to this type of treatment is a limitation.

The transtheoretical behavioral change model identifies different stages:. In order describe movement from one stage to another other concepts are used which provide an understanding of how a person moves from one stage to the other:. This type of management appears to be effective in some patients. All of the available data on psychotherapies in pathological gambling strengthen the concept that total abstinence from gambling is not a reasonable or realistic objective for most pathological gamblers.

The approaches proposing gambling control and not abstinence need to be better assessed. Management deriving from psychoanalysis or from Gamblers Anonymous, despite being frequently used, have not yet undergone robust evaluation. In addition, the criteria defining success or failure differ between authors and studies: the most simple and readily accessible criteria is total abstinence, following the Gamblers Anonymous GA concept. However, a number of authors promote the concept of controlled gambling and consider a reduction in gambling activities particularly as measured by the amount of money spent as success.

Participation in the Gamblers Anonymous association meetings is described as one of the most widely used treatments, if not the most widely used throughout the world, for pathological gambling. It is embryonic in France but very important in North America where it has existed since This organization does not appear to be far from the spirit of GA, which it encourages its members to attend. This is a specific vision of the disease, considered to be incurable, and of the treatment, based on continued daily abstinence.

This approach is based on mutual aid, goodwill, voluntary help and the particular socialization of groups in which the people support each other in their abstinence project. The program is based on twelve stages defining the principles of the structure of these voluntary associations and are a guarantee against possible sectarian diversions.

Evaluation, investigation and objective demonstration are totally contradictory to the concerns of the members of Gamblers Anonymous, and this makes the approach structurally very difficult to assess. Many protocols include the possibility of taking part in GA meetings in parallel or following other treatments. Some studies tend to show that group participation is an additional success factor. Few authors propose specific psychodynamic therapy for pathological gambling.

It is a question of determining the reasons which led the person to over-indulge in gambling in order to work on deep determinants of behavior. As in the case of narcissistic disorders, psychoanalysts stress specific transfer and counter-transfer methods in analyzing gamblers which are characterized both by idealization and by attempts to control.

Data on the use of psychotropic treatments in pathological gambling are still in the preliminary stages. No medical treatments for this indication have yet received marketing authorization. Three classes of medications have been studied: selective serotonin reuptake inhibitor antidepressants SSRI , mood regulators and opiate antagonists.

The use of other molecules atypical antipsychotics, etc. The conclusions of published studies are limited by several sources of methodological bias: few studies have been conducted placebo-controlled and double-blind; the observation period is generally short rarely more than 16 weeks ; various efficacy end points are used; the number of patients lost to follow up or who drop out of treatment is high; patients included are mostly male without major psychiatric co-morbidity.

A significant improvement compared to placebo was found in pathological gambling behavior in four double blind, placebo-controlled studies on the SSRI fluvoxamine, paroxetine, citalopram. It is still difficult to distinguish a specific effect on gambling from an effect on depression or anxiety. Pathological gamblers with hyperactive characteristics may respond favorably to another type of antidepressant, namely bupropion.

Only one placebo-controlled trial is available for mood regulators, using lithium salts. The very significant effects of lithium on pathological gambling in this study were partly independent of its effect on mood. The most widely studied opioid antagonist is naltrexone. Contradictory results are reported. The use of another antagonist, nalmefene, appears to be more promising in reducing some symptoms of pathological gambling, particularly impulses and craving irresistible impulses to play.

It is difficult to generalize the results of the studies published in practice. A given pharmacological class can currently only be chosen empirically. Consideration of co-morbidities may guide towards certain types of pharmacological treatments. It would appear therefore that pathological gambling patients with bipolar co-morbidity would benefit from mood regulator treatment, mainly lithium. Studies are needed to compare different classes of treatment. In practice, it would seem to be important for a patient to be able to benefit from a set of services, be they psychotherapeutic, pharmacological or social.

A number of programs are proposed by teams who also deal with other forms of addiction alcohol, drugs and include various treatment methods, involving both hospitalization and outpatient care. As for all addictions, the treatment must incorporate a very wide range of dimensions. The attention and advice of family and friends are particularly important. The social component can include legal advice, the question of the protection of goods trusteeship , and finally but not strictly as an initial measure assistance with establishing a debt file relapses may lead to an inextricable situation.

One of the major problems in the management of pathological gamblers is their low demand for care. This finding requires actions to be put in place to improve management of these patients. In some countries Canada, New Zealand , public health programs centered on pathological gambling have tried to improve amongst other things access to care.

Of the measures intended to improve access to care, the idea of not having abstinence as the sole treatment objective and of not constructing care programs based on this single objective can be put forward. As is proposed in other addictions, the objective of care should also be to offer programs intended to limit the damage associated with the gambling behavior.

It is possible to reduce gambling expenditure and some of the social consequences of pathological gambling, by offering some pathological gamblers an intervention based on gambling control. In Quebec and New Zealand the recommendations stress being able to offer a diverse range of care options and develop varied treatment programs.

Amongst the possibilities for diversifying care, apart from strategies targetting controlled gambling, the development of validated short management techniques has been proposed. These brief intervention techniques, even if conducted by telephone, have been shown to be effective in controlling features of pathological gambling. They are usually based on the transtheoretical change model. A suggestion has also been made to put treatment programs on the Internet.

This method probably helps to reduce reluctance about access to care because of its anonymity and ease of access. Many advice and care formats are already available on the Internet such as online therapy, cybertherapy and e-therapy. The question of training first line caregivers general practitioners, psychologists, social workers, etc. Since in New Zealand a government plan intended to minimize the health suicides, psychological and medical disorders and social overindebtedness, etc.

Training first line practitioners to identify pathological gambling is proposed in the measures intended to improve management and access to care. The great majority of general practice patients will agree to fill in self-completed questionnaires to screen for pathological gambling.

The general practitioner emerges as a major partner in the identification and management of pathological gamblers, particularly those who complain of depression and anxiety. General practitioners are, however, not the only first line caregivers to be trained. Training programs to identify pathological gambling are offered in some countries Canada, Australia, etc to first line mental health workers psychologists and social workers.

These programs are generally short a few days maximum but must be followed by more in-depth workshops. These are usually not identified and the patients are not managed specifically for this problem. There are several explanations for the low level of management of pathological gambling: limited understanding of the disorder, lack of staff training, lack of knowledge of effective strategies for possible treatment.

The importance of the association between pathological gambling and other addictions justifies the training of workers in the field of addiction to identify and manage pathological gambling. The rapid spread of gambling over the last ten years and the exponential increase in the sums invested in these gambling have caused a whole range of socio-economic problems, including pathological gambling. Several governments have acknowledged that pathological gambling has become a true public health issue.

Since the years —, Canada, Spain and New Zealand have had tight legislation on gambling and surveillance and control organizations have been set up, under the auspices of the Ministry for Health New Zealand or Ministry of the Interior Spain. In Canada, Quebec applied the Montreal strategic plan between and In New Zealand, a preventive policy was funded by a tax paid by 4 gambling operators and the responsibilities for excessive gambling were transferred in to the Ministry for Health.

Since , in Spain the Department for Gambling Control, which reports to the General Commission of the Criminal Investigation Department at the Ministry of the Interior, publishes on the internet a very detailed annual report on gambling, which includes preventive activities. The preventive policies of Canada and New Zealand follow a three-level plan: levels 1 and 2 involve preventing and informing and level 3 involves therapeutic intervention for pathological gamblers.

The strategies used in these two countries are intended to improve knowledge about the emerging problem of pathological gambling and its prevention by epidemiological and sociological studies, to improve the training of public and private sector caregivers involved in gambling addiction, to act by projects tailored to specific contexts information media appropriate for the different ethnic groups, targeted groups such as the elderly.

The actions can be classified according to three main themes. The first involves reducing the dangerousness of highly-addictive gambling, which are therefore also growing most quickly particularly electronic machines , by reducing their number, trying to make these gambling less addictive, prohibiting access to them by minors and finally setting up hotlines for gamblers in trouble. The second area of intervention is the dissemination of information to young people in schools, associations and also to parents.

No part of this publication may be reproduced, stored in a retrieval system or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the prior written permission of the author. The material contained in this book is general in nature and is not intended to be specific advice, unless otherwise stated. The author and publisher expressly disclaim any and all liabilities to any persons whatsoever in respect of anything done by any such person in reliance, whether in whole or in part, on this book.

The author supports responsible gambling at all times. What a delight for a Casino Manager to be asked to write a Foreword for a book on roulette! Martin Blakey is a mathematician by profession. His other published books have been used as textbooks for schools in the State of Victoria.

His painstaking research has taken many years. In fact, if he missed a weekend at Launceston Federal we'd wonder what had happened to him, and ask for a note! It just wouldn't be the same without him. Martin: you've been very successful, and I'm proud to be able to add your book to my library.

It was merely a word, like coincidence, for events incapable of explanation by the then currently accepted laws of nature. One day they would be. New laws would emerge. It was just a question of time before such events, no matter how complicated, would be explicable, predictable, and understandable. I slogged away in ancient libraries and modern laboratories desperately trying to contribute. My ponderous progress and lack of financial reward finally resulted in my abandoning the halls of academia and embarking on a different career: I became the biggest marijuana smuggler in the world.

I forgot my philosophical and scientific training and flirted with Lady Luck, who made me a massive amount of money, some requiring laundering before spending it. Casinos were the obvious choice: chuck in a big pile of cash, grab some chips, sit at a table, try not to lose too much, cash in the chips, and walk out with a bag of seemingly legitimately made money. Although I never lost much at the tables, I never made a single penny and puzzled as to anyone else could.

I assumed all the players were laundering illegally accrued assets. No one was trying to win. Everyone knew the casinos always did that. Gambling was for mugs. As English writer and journalist George Augustus Sala stated, A gambler with a system must be, to a greater or lesser extent, insane.

Even Albert Einstein commented, You cannot beat a roulette table unless you steal money from it. The inevitable happened: law enforcement agencies from fourteen countries set up a task force dedicated to busting me. Then the surprising happened: the United States Federal Government let me go after seven years. I wrote a best-selling book, Mr Nice , about my illegal activities, and in the eyes of the global marijuana smoking community, became a celebrity. At the latter, I met a young Australian marijuana botanist named Scott Blakey, who had won virtually every trophy in the cannabis competition.

We got on very well with each other. I must introduce you to my dad, Martin, he said. Martin extended his hand as his eyes sparkled, indicating his soul was predisposed to fun, rather than seriousness. For hours, we discussed physics, botany, mathematics, probability, randomness, and gambling. I explained how my academic research had been largely focused on confirmation theory — what observations can be said to confirm which scientific hypotheses.

Martin explained his D. Phil was simply how to develop a system to win at a roulette table. He had been successful. Full of fascination and, I have to admit, slightly sceptical, I asked if I could accompany him one day to a casino and see him in action.

Martin agreed. Some months later, by which time we had become firm and close friends, Martin and I met in Mayfair and visited one of the main local casinos. We sat at a roulette table and started placing chips on numbers. I employed my money laundering strategy and lost steadily but modestly. Martin seemed not to have any particular strategy other than to place his bets immediately before the ball stopped spinning, then scribbling and calculating furiously between spins.

In less than an hour, he had trebled his stake money. It could have been a fluke, a one off, but any such illusion disappeared when he displayed similar successes at the next three casinos. Then we got drunk. He explained his system to me. Overcoming my prejudices and my ingrained inability to cope with the complex structure of randomness, I think I understood it - at least enough to realise it required an enormous amount of hard work.

In the following pages, Martin explains it to us all, and whenever needed, aids our comprehension by fresh articulations and insights into the nature of chaos, and randomness, topics only recently partially understood by professional scientists. This is an extraordinary book by an extraordinary man. I am honoured and proud to write a foreword to it and look forward to its adorning my bookshelves.

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Finally, it is essential that public policies target as a priority the gambling that incur the greatest costs and adapt to the development of Internet gaming and gambling. An analysis of the literature on the social cost of gambling reveals the extent of current debate and highlights the need for continued research. Since French people appear to be increasingly drawn to gambling, and the gambling supply is undergoing great change, it would be extremely useful to have indicators for France.

A number of sociological studies have examined the motivations for specific homogeneous populations. In people over 65 years old, relaxing and enjoying themselves, passing the time and combating boredom are the motivations most reported by gamblers. Other studies have analyzed for example the motivations in four ethnically different communities North African, Chinese, Haitian, and Central American in Montreal: in these communities the hope of making significant gains and improving their economic situation is an important motivation for gambling.

The desire to come closer to the culture of the host country in order not to feel excluded is also a motivation for gambling even if its practice contradicts the traditional culture of origin for example North Africa. Believing in chance and the supernatural is also a component of gambling for Chinese and Haitian cultures. Gambling is part of social and family life from the youngest years onwards in Central American countries.

Sociological studies have examined the behavior, rituals, movements, exchanges and conversation of gamblers. A detailed study of gamblers in the natural gambling situation is useful to understand the social and cultural perspective of contemporary gambling including in situations when it appears to be excessive from a commonsense perspective. Biographical information, personal accounts and portrait are also used in the qualitative sociological studies. Freud expressly connotes the gambling passion with a pathological dimension.

The gambler is to be considered as a neurotic, driven by the unconscious desire to lose, in other words by moral masochism, the unconscious need for self-punishment. This operation requires a return to the fiction of infantile all-powerfulness, and the rebellion against parental law, which directly becomes a latent rebellion against logic for the gambler.

Unconscious aggression against the parents who represent law and reality is followed by a need for self-punishment, implying the psychical necessity of loss in the gambler. The cynicism is an attempt to justify, or to attribute to everyone else, feelings as hostile as those that unconsciously the gambler harbors towards the parental figures.

Just like the systems or martingales that are supposed to lead to winnings, these artifices are merely the crude expression of the infantile megalomanic belief in the capacity to steer destiny. The primitive pastime has now become a question of life and death.

The illusion of control is that the gamblers attribute the results of purely random sequences to their ability or knowledge. These two mistakes are variants of non-recognition of the independence of throws. Finally, superstitions and illusory correlations, which are extremely common and varied, are sometimes encouraged by gambling advertising or systems. Cognitive errors are seen in all gamblers and are undoubtedly more common in excessive gamblers.

This, however, does not establish a causal relationship. Greater knowledge of statistics, probabilities and the gambling systems only has very limited influence on gambling behavior itself. Some authors describe a strategy of escape from reality or negative affect in problem gamblers and a search for distraction by involvement in a replacement activity.

A vicious circle develops in the gamblers themselves, the illusion of control playing a secondary role in maintaining the process. The relationship between gambling, risk taking and sensation seeking is complex and requires the different types of gambling, the history of gambling behavior and the typology of gamblers to be taken into account. Sensation seeking can be seen as an indicator of a tendency towards gambling but does not distinguish between problem gamblers and other gamblers.

Impulsivity, which results from difficulty in self-regulation or self-control lies at the heart of the definition of pathological gambling. The relationships between problem or pathological gambling and controlled aspects of self-regulation have been examined in two ways: from questionnaires that assess impulsivity which is considered to result from weak self-regulating ability , and using cognitive tasks examining executive functions such as inhibition, planning and flexibility capacities and decision-making capacities.

Most of the studies using impulsivity questionnaires have shown higher levels of impulsivity in pathological gamblers than in control participants. These studies have identified positive links between high level impulsivity and the profile of high-risk gamblers in the general population or in populations of university students. The level of impulsivity is also a predictive factor for the severity of the symptoms of pathological gambling and is also associated with a greater likelihood of abandoning psychotherapeutic management and of psychotherapeutic management being less effective.

The studies that have examined controlled aspects of self-regulation using cognitive tasks have produced more inconsistent results than those based on questionnaires. Nevertheless, studies that have examined sensation seeking in gamblers have provided some useful data suggesting future avenues for research. A positive relationship has been found between sensation seeking and the number of different gambling activities performed.

Regular gamblers are also found to be different in terms of their level of sensation seeking depending on the gambling activities they perform. Gamblers who prefer casino gambling have greater sensation-seeking desires than those who bet on horse races and people who bet at racecourses have higher sensation-seeking desires than those who gamble in cafes.

In particular, this involves taking account of the complex relationships between the automatic motivational and controlled executive functions and decision-making aspects of self-regulation at different times in the creation of gambling habits. In addition, this belief has led to transversal and static investigations of people considered to belong to a distinct delineated category rather than considering problem gambling as a specific stage, which may affect a large number of people in their gambling trajectory.

Risk and vulnerability factors are firstly those factors relating to the object of addiction, or structural factors, secondly those relating to the environment and context, or situational factors, and finally factors related to the subject, or individual factors.

From the perspective of the structural factors, the different types of gambling have attracted increasing attention in the international scientific literature, with the idea that not all include the same risk of addiction. To this end, several authors believe that the shorter the time between bet and expected gains the greater is the possibility that the gambling will be repeated and the greater is the risk. This finding undoubtedly merits confirmation via correctly conducted studies.

The impact of a large initial gain is one of the classical factors for the development of excessive gambling. This factor is seen in studies on pathological gamblers encountered during consultation visits. The development of Internet gambling, which has been very evident for a few years, requires consideration to be given to the place and specific impact of this medium.

The occasional studies on this subject emphasize the concepts of anonymity, accessibility, disinhibition and comfort which are liable to predispose to abuse and addiction practices. The impact of the offer and availability of the gambling in terms of risk factors have been considered in the same way as for other addictions.

From the perspective of the situational factors, it is above all the socio-economic factors which need to be stressed, with the clearly established concept that reduced social support and low level of income-employment often correlate with the prevalence of pathological gambling and high risk gambling. Several studies have examined the position and contribution of parents in terms of risk factors or protection against excessive gambling in their children.

These stress that the place and acceptance of the gambling by the parents have an impact on the frequency of gambling behavior and gambling-related problems in children, and also that supervisory authority is a more protective position than a more lax, or conversely authoritarian family situation. From the perspective of individual factors, initiation into gambling occurs in most cases during the adolescent period. This has been shown by studies on pathological gamblers attending specialist care structures.

Early contact with gambling appears to be a severity factor reflecting what is seen in psychoactive substance addictions. The elderly are a high-risk population for lotteries and slot machines. A family history of pathological gambling with the concept of family aggregation , addictive behavior, anti-social personality and, to a lesser extent, other mental disorders, appears to be more prevalent in pathological gamblers.

A past history of abuse in childhood has been found to be associated with earlier and more severe pathological gambling behavior. Similarly, psychiatric co-morbidities are undisputable risk factors for beginning gambling behavior when they pre-exist and for worsening gambling behavior in all situations. The risk and vulnerability factors appear to be similar to those found in all addictive behaviors, particularly addictions to psychoactive substances.

The person who is most at risk of becoming involved in pathological gambling behavior would therefore appear to have the profile of a young unemployed male with low income, unmarried and poorly socially and culturally integrated. Several studies have specifically examined the association between pathological gambling behavior and other addictive behaviors, notably alcohol and impulsive and delinquent behavior, particularly in young men.

These reveal that early behavioral and attention disorders precede various addictive and behavioral disorders. As with most of the other addictive behaviors pathological gambling would appear to result from a combination of different risk and vulnerability factors in variable proportions , a combination which characterizes the profile of each situation and trajectory on an individual case basis. In terms of trajectories, there are few dedicated studies and most do not provide information about the exact chronology of the history of more or less well-controlled gambling practices.

A few correctly conducted studies over recent years have however made it possible to measure a lack of stability over time in the pathological gambler. The fact that these gambling problems develop individually on a more transient and episodic basis, rather than continuous and chronic, is a strong argument for developing long-term general population cohort studies.

These studies should better identify the complex reality of these pathways and the factors involved in periods of both remission and relapse in order to extract the maximum of information in terms of prevention and treatment indications. Most of the data published in the neurosciences field concern addictions to psychoactive substances. However, as non-substance addictions have the same symptoms and even a withdrawal syndrome, these clinical features can be considered to reflect the same cerebral dysfunction and to originate from a common pathophysiology, namely Addiction 6.

The shift from occasional to chronic use and Addiction is clinically characterized by progressive loss of control of the consumption behavior and compulsive seeking craving and consumption of the object, despite the serious consequences which may occur for the individual person, his family and close friends, and despite the development of a negative affective state which precipitates relapse.

At an advanced stage of a consumption habit which becomes increasingly impulsive, the person enters an alienating spiral entirely centered on the object alone. At this end stage of the process, the person is extremely distressed and the cerebral changes are more difficult to reverse, leading to a chronic disease state of Addiction.

The central stress and emotion systems characterized by different neurotransmitters contribute to a pathophysiological function which defines a powerful motivational state reflected by a shift from impulsive behavior to compulsive behavior. It is important to stress that Addiction affects relatively few people compared to the number of occasional consumers of the object of addiction.

Many authors consider that an object of addiction is only addictogenic when it is consumed by an already vulnerable person. Understanding why some people succumb to addiction and others do not up to the point of apparent resilience is an essential question. Vulnerable people are generally polyconsumers of addiction objects. In addition, this vulnerability may occur as a result of various psychopathological co-morbidities, poor conditions in terms of education and environment, personality disorders and stressful lifestyles.

In order to understand the addiction process it must therefore be examined in a whole life context and, because of its early diathesis, be examined from a very young age onwards. Whilst vulnerability and co-morbidity have neurobiological translations, considerable progress is needed before obtaining scientific reference data.

Although gambling addiction clearly has specific features it is accepted that the sources of vulnerability are the same as for other addictions. Gaming addiction particularly gambling and internet addictions is a very interesting question for the neurosciences. The key factor in gamblers is the speed between perception and execution. Decision-making is based obviously on knowledge, skill and memories, the quality and relevance of which probably take account of the speed of decision and action.

The involvement of pre-established mental sets also exists with drugs of abuse and are the cause of relapses; environment indices and mental representations almost immediately trigger imperious, impulsive, compulsive consumption and even a withdrawal syndrome in a person who has not consumed for several weeks. Neurobiological research is being directed towards identifying the substrates involved in the two situations which appear to be based on stimuli-response associations in memories, knowledge and cognitive systems.

This appears to be a central question in thinking about excessive gambling: is the gambling a drug in the same way as psychostimulants, opiates, alcohol or tobacco? Does this type of addiction involve the same neurotransmitters? Dopaminergic neurons are not strictly speaking part of the reward circuit although their activation stimulates the circuit and provokes a sensation of satisfaction. Results of neurobiological research over recent years have convinced the main part of the scientific community that dopamine is fundamental to all pleasure-related events.

The stage which still has not been widely studied is the involvement of dopamine in drug dependency. It is in fact tempting to think that it is the pleasure produced by the drug that the consumer is no longer able to ignore. It has long been noted by clinicians that drug addicts relatively quickly lose the pleasure from drug consumption in favor of seeking a state which more closely resembles a necessary or essential relief.

Until now, all of the biochemical indices measured in animals following iterative administration of drugs have returned to normal after a few days or no more than one month after the last dose. By studying modulators other than dopamine, i. This coupling reflects an interaction between noradrenalin and seritoninergic neurons with the result that both sets of neurons mutually activate or inhibit each other, depending on the external stimuli perceived by the animal or person.

During repeated drug use this coupling disappears. The uncoupling and uncontrollable over-reactivity which it produces between the noradrenergic and serotoninergic systems may be responsible for the malaise experienced by drug addicts. Retaking the drug would then enable artificial recoupling of the neurons creating temporary relief which may explain the relapse. The drug in this case would be the most immediate way to respond to the malaise.

The question raised now is whether the uncoupling which is obtained with cocaine, morphine, amphetamine, alcohol or tobacco can be obtained by gambling. It has been clearly shown that the very great majority of excessive gamblers suffer from concomitant diseases. These diseases, particularly addiction to substances such as tobacco and alcohol which develop in parallel to the excessive gambling behavior, may account for the pathological form of the gambling. However, psychiatrists point out that pathological gamblers exist who have no addiction or any other concomitant psychological disorders.

It is not therefore possible to exclude the possibility that simply overindulging in gambling may, as for drug abuse, cause changes to the functioning of the central nervous system such as those described above. One of the hypotheses which could be put forward is that in some people, stress and distress which the gambling can cause chronically increase glucocorticoid secretion and, in the absence of the product, reproduce neuronal activations and analogous uncoupling to what is seen with addictive substances.

Preclinical research should be conducted in order to study whether chronic stress situations or secretion of endogenous molecules such as glucocorticoids can alone reproduce the neurochemical effects produced by drug abuse. For the clinician, addiction can be defined as a condition through which behavior liable to give pleasure and relieve unpleasant feelings is adopted to an extent that it results in two key symptoms: repeated failure to control this behavior and continuation of the behavior despite its negative consequences.

Impulsivity however appears to be only one of the features of pathological gambling. Several published works also highlight the heterogeneous nature of this category in the DSM and have put forward the hypothesis that impulse control disorders belong to the behavioral addictions category, which would therefore group together pathological gambling, kleptomania, pyromania, trichotillomania, intermittent explosive disorder and also compulsive buying, compulsive sexual behavior and compulsive Internet use.

There are many arguments however in the other direction: obsessive gambling ideas in the gambler are egosyntonic driven by seeking well being whereas the obsessive ideas in OCD are by definition intrusive and egodystonic they cannot be ignored and are a source of distress. There are also no clear epidemiological arguments showing co-occurrence of OCD and pathological gambling. Neuropsychological findings are discordant, some works showing similar deficits in executive functions related to the frontal lobe in people with OCD and pathological gamblers, whereas these similarities have not been found in other studies.

Ultimately there are no formal arguments to enable pathological gambling to be seen as an OCD related disorder even though the compulsive dimension of the behavior is apparent. In most of the recent publications, pathological gambling is considered to be a behavioral addiction. There are clinical arguments to support this position: the clinical phenotypes of the gambling and substance addiction DSM-IV-TR are very similar, including the presence of withdrawal symptoms and changes in tolerance increased challenges over time in the gamblers.

High rates of co-morbidities between pathological gambling and addictions and also between pathological gambling and numerous mental and personality disorders are reported in all of the studies. There are therefore many clinical, epidemiological, biological and therapeutic arguments to consider pathological gambling as a non-drug addiction.

Like all addictive diseases, the behavior requires impulsion and compulsion. The questions of screening and diagnosis must be considered with reference to their objectives: is the purpose to consider primary prevention activities, with the ambition of making the largest number of people at risk from their behavior aware of the situation, or is the purpose to identify behavior which is already sufficiently problematic to have resulted in a certain amount of characteristic damage in order to justify a specific treatment approach?

The SOGS is the reference tool used to identify pathological gambling which is by far the most widely used in the world. However, some limitations of this tool are regularly emphasized in terms of its psychometric properties. Several authors refer to a certain over-estimation of the prevalence of pathological gambling. As it is already an old tool some diagnostic changes have not been incorporated. Finally, the relevance of the tool in the youngest populations is debated despite the existence of a version adapted for adolescents the SOGS-RA.

In terms of its psychometric properties the reliability and validity of the DSM-IV-gambling have been demonstrated in many studies. The CIM gambling is very widely used in clinical practice and very little used in research. There are few publications describing its psychometric properties. The Gamblers Anonymous self-completed questionnaire GA is a twenty question self-evaluation tool very widely used in the United States and in many other countries, although there are practically no validation studies available for it.

It is nevertheless considered to be very poorly discriminatory. Screening and diagnostic tools for pathological gambling have therefore existed for around twenty years and are described in validation studies which guarantee good psychometric properties for several of these tools this applies particularly to the SOGS, DSM-IV and CPGI. Nevertheless, important differences in terms of the prevalence of pathological gambling and high risk gambling are found in some studies using these different tools, which raises questions about thresholds and calls for further studies.

Similarly, the relevance of these tools in younger and older populations is currently hotly debated. More than prevalence surveys were found in the international literature, conducted mostly in North America, Australia and New Zealand.

The great majority of these were specific surveys centered on the question of gambling. The problem was examined in some instances as part of a broader investigation on a health or mental health subject. This approach offers additional value as it allows an in-depth analysis of the relationships between determinants and individual health characteristics and problem gambling behavior.

This is due both to the difficulty of correctly measuring the former, which is more sensitive to memory problems and also to the fact that the conceptual basis on which it was constructed is fragile. Interest for this concept has waned since the chronic nature of pathological gambling has been put in question.

There is a very wide range of identification tests used in the prevalence surveys, meeting a similar wide range of concepts. Similarly, two concepts emerged:. The vast majority of the prevalence surveys on problem gambling involve adults. Most of the international literature examines the question of gambling. Studies on Internet addiction or video games playing are more recent, fewer in number and still centered on conceptual and methodological problems.

This point was identified by some authors of meta-analyses and surveys which have simultaneously used several identification tools. However, it remains very controversial in the literature. This situation does not facilitate prevalence comparisons in problem gambling in the different countries which have conducted national surveys on the subject. Differences in prevalence between countries are still widely debated.

The most common hypothesis put forward is differences in accessibility to gambling. Average prevalence values for adults 2. These estimates should be seen as orders of magnitude. There is considerable dispersion of results around these mean values, particularly for adolescents. Prevalence also depends on the population used as the denominator: the entire population, all gamblers or regular gamblers.

It is difficult to extract clear trends in the change in prevalence of problem gambling from a chronological analysis of the results produced by the surveys conducted over the last twenty years. Countries, states or provinces which have been able to repeat the surveys have found contradictory trends, which are difficult to compare in view of differences in the legal context or accessibility to gambling.

In this context, an increase in problem and pathological gambling was seen in the United States during the s. Over the same period in New Zealand the problem remained stable. Internal trends in the United States, within the States which had been able to reproduce these surveys over time, are discordant: falls, no change or increases are reported.

In the United States, however, the large number of local studies available makes it possible to compare the levels reported by the oldest studies with those from the most recent ones. This comparison appears to show some increase in the prevalence of pathological gambling, problem gambling remaining stable.

Overall, however, we can assume it is relatively stable. This is not inconsistent with other findings showing limited increases in prevalence over time and increasing accessibility with prevalence returning to its previous level in the longer term. These very general trends hide a few subtle changes showing that the phenomenon of problem gambling is constantly changing.

Many studies have shown that when sub-groups of the population are examined different trends may be found. The prevalence of gambling in general and problem gambling in particular appears to have increased in women with the increase in the range of gambling offered.

Prevalence in young people may be increasing. Within a given country, the social categories most affected by the phenomenon can change. All of the epidemiological general population surveys identify males as being the gender most associated with problem gambling.

In the opinion of some authors, however, this finding relates more to the fact that more men gamble and that it depends on the type of gambling. These gender differences are also tending to disappear. Age is also an associated factor seen frequently in prevalence surveys.

The prevalence level for problem and pathological gambling is higher among young people adolescents and young adults than among adults. This may be associated with an overall phenomenon of more common risk behavior at these ages. A comparison of the different social data available about factors associated with problem gambling does not reveal any invariant factor in the different cultures or social organizations in countries which have conducted these surveys as strongly associated with pathological gambling as sex and age young male adults.

In fairly general terms, whilst social factors play a role we must not forget that pathological gambling is seen in all social environments. The relationship between the availability of gambling and the prevalence of problem gambling is complex. It has been interpreted in ways which can appear contradictory. Some analyses tend to show that countries or provinces where access is more limited also have a lower prevalence of problem or pathological gambling.

There are few general population studies on the relationships between pathological gambling and other addictions or psychiatric disorders, and the available studies are mostly North American. No data are currently available for the general population in France. All of the general population studies published show that pathological gambling is very commonly associated with other addictions. Amongst the addictions, smoking is the one found most commonly in pathological gamblers. Other addictions alcohol, illegal drugs generally precede the onset of pathological gambling particularly in men.

Pathological gamblers with a past history of drug addiction usually have a more severe problem associated with pathological gambling. Many pathological gamblers have concomitant psychiatric disorders. These are most commonly associated with mood disorders, anxiety disorders or personality disorders. As with most addictive behavior, pathological gambling is closely associated with personality disorders obsessive compulsive, avoidance, antisocial and schizoid.

Antisocial personality appears to be associated with more severe pathological gambling. Of the mood disorders, bipolar disorder is the most commonly associated with pathological gambling. Mood disorder often precedes pathological gambling and persists after it has stopped. The close association with mood disorder could also explain the high level of suicidal ideation and risk of suicide in pathological gamblers. Of the anxiety disorders, panic disorder and post-traumatic stress syndrome are the most commonly associated with pathological gambling in the general population.

No significant relationship has been found with obsessive-compulsive disorder. Some psychiatric disorders are also risk factors for pathological gambling. The risk of developing pathological gambling behavior is three times higher than in a general population for people with substance abuse or use, and 1. People suffering from bipolar disorder are twice as likely to develop a gambling addiction than people with another mood disorder. These significant associations are not clearly explained.

The existence of co-morbidity with other psychiatric disorders addictions, depression, personality disorders etc… is a severity indicator for pathological gambling, justifying appropriate management. Of the psychological techniques proposed for the treatment of pathological gambling, cognitive behavioral techniques have been examined in controlled studies. These studies are few in number and they are based on modest population numbers.

Most have been for a relatively short observation period rarely more than one year and involve patients with few co-morbidities. Of the behavioral therapies, only imagination sensitization techniques have been shown to have some effect. These cognitive techniques have been found to be significantly more effective in controlling pathological gambling behavior than no psychological intervention at all.

The question of type of management individual or group has also been assessed in the literature. The results appear to show that cognitive behavioral therapy on an individual or group basis produce almost equivalent immediate results. Individual management appears to be superior to group management to prevent relapses. Whilst cognitive behavioral therapy appears to be effective in some pathological gamblers, the high level of poor adherence to this type of treatment is a limitation.

The transtheoretical behavioral change model identifies different stages:. In order describe movement from one stage to another other concepts are used which provide an understanding of how a person moves from one stage to the other:.

This type of management appears to be effective in some patients. All of the available data on psychotherapies in pathological gambling strengthen the concept that total abstinence from gambling is not a reasonable or realistic objective for most pathological gamblers. The approaches proposing gambling control and not abstinence need to be better assessed.

Management deriving from psychoanalysis or from Gamblers Anonymous, despite being frequently used, have not yet undergone robust evaluation. In addition, the criteria defining success or failure differ between authors and studies: the most simple and readily accessible criteria is total abstinence, following the Gamblers Anonymous GA concept.

However, a number of authors promote the concept of controlled gambling and consider a reduction in gambling activities particularly as measured by the amount of money spent as success. Participation in the Gamblers Anonymous association meetings is described as one of the most widely used treatments, if not the most widely used throughout the world, for pathological gambling. It is embryonic in France but very important in North America where it has existed since This organization does not appear to be far from the spirit of GA, which it encourages its members to attend.

This is a specific vision of the disease, considered to be incurable, and of the treatment, based on continued daily abstinence. This approach is based on mutual aid, goodwill, voluntary help and the particular socialization of groups in which the people support each other in their abstinence project. The program is based on twelve stages defining the principles of the structure of these voluntary associations and are a guarantee against possible sectarian diversions.

Evaluation, investigation and objective demonstration are totally contradictory to the concerns of the members of Gamblers Anonymous, and this makes the approach structurally very difficult to assess. Many protocols include the possibility of taking part in GA meetings in parallel or following other treatments. Some studies tend to show that group participation is an additional success factor.

Few authors propose specific psychodynamic therapy for pathological gambling. It is a question of determining the reasons which led the person to over-indulge in gambling in order to work on deep determinants of behavior. As in the case of narcissistic disorders, psychoanalysts stress specific transfer and counter-transfer methods in analyzing gamblers which are characterized both by idealization and by attempts to control.

Data on the use of psychotropic treatments in pathological gambling are still in the preliminary stages. No medical treatments for this indication have yet received marketing authorization. Three classes of medications have been studied: selective serotonin reuptake inhibitor antidepressants SSRI , mood regulators and opiate antagonists.

The use of other molecules atypical antipsychotics, etc. The conclusions of published studies are limited by several sources of methodological bias: few studies have been conducted placebo-controlled and double-blind; the observation period is generally short rarely more than 16 weeks ; various efficacy end points are used; the number of patients lost to follow up or who drop out of treatment is high; patients included are mostly male without major psychiatric co-morbidity.

A significant improvement compared to placebo was found in pathological gambling behavior in four double blind, placebo-controlled studies on the SSRI fluvoxamine, paroxetine, citalopram. It is still difficult to distinguish a specific effect on gambling from an effect on depression or anxiety. Pathological gamblers with hyperactive characteristics may respond favorably to another type of antidepressant, namely bupropion.

Only one placebo-controlled trial is available for mood regulators, using lithium salts. The very significant effects of lithium on pathological gambling in this study were partly independent of its effect on mood. The most widely studied opioid antagonist is naltrexone. Contradictory results are reported. The use of another antagonist, nalmefene, appears to be more promising in reducing some symptoms of pathological gambling, particularly impulses and craving irresistible impulses to play.

It is difficult to generalize the results of the studies published in practice. A given pharmacological class can currently only be chosen empirically. Consideration of co-morbidities may guide towards certain types of pharmacological treatments. It would appear therefore that pathological gambling patients with bipolar co-morbidity would benefit from mood regulator treatment, mainly lithium.

Studies are needed to compare different classes of treatment. In practice, it would seem to be important for a patient to be able to benefit from a set of services, be they psychotherapeutic, pharmacological or social. A number of programs are proposed by teams who also deal with other forms of addiction alcohol, drugs and include various treatment methods, involving both hospitalization and outpatient care.

As for all addictions, the treatment must incorporate a very wide range of dimensions. The attention and advice of family and friends are particularly important. The social component can include legal advice, the question of the protection of goods trusteeship , and finally but not strictly as an initial measure assistance with establishing a debt file relapses may lead to an inextricable situation.

One of the major problems in the management of pathological gamblers is their low demand for care. This finding requires actions to be put in place to improve management of these patients. In some countries Canada, New Zealand , public health programs centered on pathological gambling have tried to improve amongst other things access to care.

Of the measures intended to improve access to care, the idea of not having abstinence as the sole treatment objective and of not constructing care programs based on this single objective can be put forward. As is proposed in other addictions, the objective of care should also be to offer programs intended to limit the damage associated with the gambling behavior. It is possible to reduce gambling expenditure and some of the social consequences of pathological gambling, by offering some pathological gamblers an intervention based on gambling control.

In Quebec and New Zealand the recommendations stress being able to offer a diverse range of care options and develop varied treatment programs. Amongst the possibilities for diversifying care, apart from strategies targetting controlled gambling, the development of validated short management techniques has been proposed. These brief intervention techniques, even if conducted by telephone, have been shown to be effective in controlling features of pathological gambling. They are usually based on the transtheoretical change model.

A suggestion has also been made to put treatment programs on the Internet. This method probably helps to reduce reluctance about access to care because of its anonymity and ease of access. Many advice and care formats are already available on the Internet such as online therapy, cybertherapy and e-therapy.

The question of training first line caregivers general practitioners, psychologists, social workers, etc. Since in New Zealand a government plan intended to minimize the health suicides, psychological and medical disorders and social overindebtedness, etc. Training first line practitioners to identify pathological gambling is proposed in the measures intended to improve management and access to care.

The great majority of general practice patients will agree to fill in self-completed questionnaires to screen for pathological gambling. The general practitioner emerges as a major partner in the identification and management of pathological gamblers, particularly those who complain of depression and anxiety. General practitioners are, however, not the only first line caregivers to be trained. Training programs to identify pathological gambling are offered in some countries Canada, Australia, etc to first line mental health workers psychologists and social workers.

These programs are generally short a few days maximum but must be followed by more in-depth workshops. These are usually not identified and the patients are not managed specifically for this problem. There are several explanations for the low level of management of pathological gambling: limited understanding of the disorder, lack of staff training, lack of knowledge of effective strategies for possible treatment.

The importance of the association between pathological gambling and other addictions justifies the training of workers in the field of addiction to identify and manage pathological gambling. The rapid spread of gambling over the last ten years and the exponential increase in the sums invested in these gambling have caused a whole range of socio-economic problems, including pathological gambling.

Several governments have acknowledged that pathological gambling has become a true public health issue. Since the years —, Canada, Spain and New Zealand have had tight legislation on gambling and surveillance and control organizations have been set up, under the auspices of the Ministry for Health New Zealand or Ministry of the Interior Spain. In Canada, Quebec applied the Montreal strategic plan between and In New Zealand, a preventive policy was funded by a tax paid by 4 gambling operators and the responsibilities for excessive gambling were transferred in to the Ministry for Health.

Since , in Spain the Department for Gambling Control, which reports to the General Commission of the Criminal Investigation Department at the Ministry of the Interior, publishes on the internet a very detailed annual report on gambling, which includes preventive activities. The preventive policies of Canada and New Zealand follow a three-level plan: levels 1 and 2 involve preventing and informing and level 3 involves therapeutic intervention for pathological gamblers.

The strategies used in these two countries are intended to improve knowledge about the emerging problem of pathological gambling and its prevention by epidemiological and sociological studies, to improve the training of public and private sector caregivers involved in gambling addiction, to act by projects tailored to specific contexts information media appropriate for the different ethnic groups, targeted groups such as the elderly.

The actions can be classified according to three main themes. The first involves reducing the dangerousness of highly-addictive gambling, which are therefore also growing most quickly particularly electronic machines , by reducing their number, trying to make these gambling less addictive, prohibiting access to them by minors and finally setting up hotlines for gamblers in trouble. The second area of intervention is the dissemination of information to young people in schools, associations and also to parents.

Finally, actions intended to increase population awareness of the questions relating to gambling in order to create a favorable climate for prevention. Both Canada and New Zealand stress local community action, which is considered to be the only truly effective form of action.

Two preventive policies have been studied experimentally. The first one was educational and set up in Canada Quebec. The second policy, tested in New Zealand, and which has regular financial backing from gambling tax, supports continuing research, launches campaigns in the media and organizes public debates. Studies and actions are incorporated into the Public Health Monitoring Center. The policies followed by Spain, Canada and New Zealand are firstly based on improved knowledge of the phenomenon of pathological gambling.

In addition, Canada and New Zealand have developed preventive social policies placing an emphasis on information before developing addiction care policies. It must be noted, however, that the results of these recent policies still need to be assessed over a longer period of time in order to better measure their effectiveness. Documents committing operators to responsible gambling protocol to promote responsible gambling for casinos, code of conduct for the three operators have been drafted.

It was decided that the staff and distributors in contact with gamblers should be informed about the features of excessive gambling and that people responsible for dealing with problem gambling should be designated within the gambling structures. The casinos were the first to put in place specific actions to combat excessive gambling and inform their clientele about the risks associated with gambling abuse.

The professional casino unions have undertaken to better block those prohibited from gambling and put in place preventive and information measures concerning excessive gambling in their establishments. The actions taken by FDJ to apply its gambling regulation policy and promote responsible gambling are mostly recent — In more general terms, these findings have not enabled the social, economic, historical and cultural issue which gambling represents to be understood.

The Internet and the passion which Internet video games arouse appear to be directly due to their technical features combined with the typical social phenomena of our modern age: performance and sensation seeking, living in the present, instant gratification and urgency.

For some people, video games are potentially addictive although there is as yet too little research to answer the question of addiction. Others consider that the object of addiction is of limited importance and that it is the anxiety-depressive co-morbidity which may result in a person turning to the game and not vice versa. In fact, many authors stress the ambiguous dimension of the Internet and video games: positive for socially well-integrated people and negative for isolated people and people suffering from psychological difficulties.

A national survey in the general adult population in the United States found problem Internet use to be equivalent to 0. All of the qualitative and quantitative studies note the predominance of the male population in video gaming, generally of high socio-cultural status and with an average age of The addictive use of online stock market sites was identified in , some mixing stock market and gambling.

Playing video games is believed to often lead to playing slot machine games. As with gambling, the use of the computer accelerates subjective time. Is the particular attraction of video games not the fact that they combine the illusion of control or even power and the control of meaning?

The only requirement in the games is logic and they then give access to a coherent world. According to some authors video games lead to delocalization although others consider that it is the ability to establish friendship links with the Internet which promotes excessive use. A further group of people consider that making contact through games prevents any risk of dependency. However, overall it is the quest for feelings of excitement and release which form the main risk of addiction.

These Internet games alter the usual game regulation modes by releasing the players from their social space and time constraints, and by shielding them from the inhibiting view of others. Threats to social relations are low for video games. Authors therefore differ in their assessment and analysis of excessive IT-based gambling.

According to some, dependency is caused by the medium itself, the computer or Internet, whereas others consider that it is caused by the content video game, gambling, chat, etc. There are also differences as to the origin of the problem: the features of the game on these new supports, the features of the population concerned, the interaction between these different dimensions. It would currently seem essential to endeavor to better understand this new phenomenon which is complex and has been inadequately studied.

Technology has always played a role in the development of gaming and gambling practices. Informing the population about risks is essential. The content must consider the initial symptoms of abuse, addiction and relationship consequences. Joint multidisciplinary thought is needed on the risks from some of the games offered:. From this perspective much needs to be done to understand the specific features of Internet and video games time between the bet and obtaining a possible gain, possible repetitive frequency of the game in particular.

For young people, the emphasis must be placed on their skills, informing them about technological features and supporting the development of their critical mind, independence of thought, developing an argument and the ability to debate. Parents have a key role: limiting time, mediation, checking content when the game is purchased, informing about the risks of excessive use, how to distance oneself and above all time to discuss the content of the games and programs.

Technology may be used for health promotion using the Internet and video games on CD-Rom. Gambling sites may contain links to awareness sites. Internet sites such as YouthBet. Advice on time management, money management, perception of risk and gambling self-assessment are given. Telephone numbers and online help about gaming and gambling can be accessed by young people who feel they have problems with gaming and gambling. Many have said that this site made them realize that they were playing too much.

In addition, Internet gambling site designers should design home pages that present the logo of their socially responsible partner and a link to the partner, with information about sites providing assistance. Together this could constitute a code of good conduct. Gambling has become a true social phenomenon. The considerable change in what is offered makes the damage which gambling can cause in vulnerable people more visible.

Against this backdrop, the difficulty of public policy is to reconcile the development of gambling which provide funds to the state, respecting the freedom of gamblers and protecting vulnerable people. Problem gambling and pathological gambling have individual family and occupational consequences, causing worry and distress in the people affected. Therefore, it would appear necessary to continue increasing the awareness of public bodies and training health professionals in the management of gamblers with a gambling problem.

However, it appears difficult to separate the question of problem and pathological gambling from all of the economic, political, social and ethical questions which gambling raise. There is a need for coherence in public policies. At the public health level, there is a desire to combine medical and social action, and individual and community interventions..

These actions must be defined for the populations concerned and according to the different levels of risk.

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Sports betting systems bookshelves Please review our privacy policy. The relationship between the availability of gambling and the prevalence of problem gambling is complex. Amazon Payment Products. An enormous amount of time and effort has been spent on computer analysis and program writing. Van Der Heijden
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