Addiction in the Spotlight at Neuroscience 2013

Testing treatments for nicotine, heroin, and gambling addiction.

Several addiction studies were among the highlights at last month’s annual meeting of the Society for Neuroscience (SfN) in San Diego. Studies released at the gathering including therapies for nicotine and heroin addiction, as well as some notions about the nature of gambling addiction.

And now, as they say, for the news:

— Transcranial Magnetic Stimulation (rTMS), the controversial technique being tested for everything from depression to dementia, may help some smokers quit or cut down, according to research coming in from Ben Gurion University in Israel. Abraham Zangen and colleagues used repeated high frequency rTMS over the lateral prefrontal cortex and the insula of volunteers. Participants who got the magnetic stimulation quit smoking at six times the rate of the placebo group over a six-month period. Work in this area is limited, but there is some preliminary evidence that some addictions may respond to this form of treatment. azangen@bgu.ac.il

—Speaking of the insula—a site deep in the frontal lobes where neuroscientists believe that self-awareness, cognition, and other acts of consciousness are partially mediated—research now suggests that out-of-control gamblers may be suffering, in part, from an overactive insula. People with damage to the insular region are less prone to both the “near-miss fallacy (where a loss is perceived as “almost” a win) and the “gambler’s fallacy (where a run of luck is “due” to a gambler after a string of losses). The volunteer gamblers played digital gambling games while undergoing functional MRIs. Luke Clark of the University of Cambridge, along with researchers from the University of Iowa and the University of Southern California, uncovered a “specific disruption of both effects” in a study group with insula damage. This ties in with earlier research demonstrating that smokers with insula damage lost interest in their habit. This one remains a puzzler, and further research, that brave cliché’, is needed, especially since disordered, or “pathological” gambling is now classified in the DSM5 as an addiction, not an impulse control disorder.  lc260@cam.ac.uk

—And speaking of stimulation, if you go deep with rat brains, you can stimulate a drug reward area and reduce the motivation for heroin in addicted rats. Deep brain stimulation (DBS), an equally controversial treatment approach, now in use as a treatment for Parkinson’s and other conditions, is a surgical procedure involving the implantation of electrodes in the brain. When Carrie Wade and others at the Scripps Research Institute and Aix-Marseille University in France electrically stimulated the subthalamic nucleus and got addicted rats to take less heroin and become less motivated for the task of bar pressing to receive the drug. Earlier work had demonstrated a similar effect in rats’ motivation for cocaine use. “This research takes a non-drug therapy that is already approved for human use and demonstrates that it may be an option for treating heroin abuse,” Wade said in a prepared statement.  clwade@scripps.edu

—Too much stimulation leads to stress, as we know. And George Koob, recently named the director of the National Institute on Alcohol Abuse and Alcoholism, discussed his work on the ways in which dysregulated stress responses might act as triggers for increased drug use and addiction. Koob focused on the negative reinforcement of stressful emotional states: “The argument here is that excessive use of drugs leads to negative emotional states that drive such drug seeking by activating the brain stress systems with areas of the brain historically known to mediate emotions and includes the stress/fear-mediating amygdala and reward-mediating basal ganglia.” For Koob, “stress can cause addiction and addiction can cause stress.” gkoob@scripps.edu

—Finally, hardcore gamblers show a boost in reward-sensitive brain areas when they win a cash payout, but less activation when presented with rewards involving food or sex. The study features more volunteers playing games inside fMRI machines, and purports to demonstrated that problem gamblers are less motivated by erotic pictures than by monetary gains, “whereas healthy participants were equally fast for both rewards.” This “blunted sensitivity” in heavy gamblers suggests the possibility of a marker for problem gambling, in the form of a distorted sensitivity to reward, said Guillaume Sescousse of Radboud University in The Netherlands, during a mini-symposium at the conference. “It is as if the brain of gamblers interpreted money as a primary reward…. for its own sake, as if it were intrinsically reinforcing.” g.sescousse@fcdonders.ru.nl

Grab Bag of Addiction Links

Recent reading from around the net.

Can Medical Marijuana and Recreational Marijuana Coexist?

“The Washington State Liquor Control Board released recommendations for what to do with the state's medical marijuana system now that recreational marijuana is legal.” [Atlantic Cities]

Premature claims of a cannabis addiction "cure"

“Have scientists found a ‘cure’ for marijuana addiction? New treatment blocks the kick that users get from the drug,” reports the Mail Online. Based on the evidence presented in the study, which involved animals, the answer to the Mail’s question is 'not yet'. [NHS Choices]

Can Gambling Machines Prevent Addiction?

“Today's digital slot machines and poker screens in casinos and at online gambling sites are capable of amassing a wealth of behavioral data on individual players, and they are on the verge of altering game play on the fly.” [Scientific American Mind]

Food for thought: UF researcher’s book lays out evidence for food addiction

“For some, the famous potato chip slogan “Betcha can't eat just one” isn’t a wager — it’s a promise.” [University of Florida Health]

New Zealand’s bold experiment with regulating recreational drugs

“It’s been nearly a century since the United States began its experiment in prohibiting recreational drugs besides alcohol, caffeine and tobacco — and virtually no one sees the trillion dollar policy as a success.” [Reuters]

More Than 1,000 Meet in Denver to Develop Drug War Exit Strategy

“Which state will be next to legalize marijuana? What do the Obama administration's recent announcements about marijuana legalization and mandatory minimums really mean?” [Huffington Post]

This Is Why Social Media and Drinking Alcohol Don't Mix (Infographic)

“Engaging with peers and customers on social platforms can be dangerous. Doing so while you’re under the influence of alcohol is downright irresponsible. “ [Entrepreneur]

Economists Predict Marijuana Legalization Will Produce "Public-Health Benefits"

“In their 2012 book Marijuana Legalization: What Everyone Needs to Know, Jonathan Caulkins and three other drug policy scholars identify the impact of repealing pot prohibition on alcohol consumption as the most important thing no one knows.” [Forbes]

Photo Credit: http://lifeonthebalcony.com/

Addiction Machines: How Slots are Designed for Compulsive Play

Your player card, please.

The image of the compulsive gambler has traditionally been the male poker player, drink in hand, recklessly betting the night away. Slot machines? Those were for amateurs, the out-of-towners, the meek and the mild. But that irritating clang and buzz coming from over the card player’s shoulder is not just the sound of new money—it’s the sound of a new technology tuned to a ruthless edge.

Digital slots and poker machines have become the new games of choice for pathological gamblers. In 1999, Harvard addiction researcher Howard Shaffer predicted that, “as smoking crack cocaine changed the cocaine experience, I think electronics is going to change the way gambling is experienced.”

Modern gambling machines drive the casino gambling industry, and generate far more revenue than “table” gambling. Because of the manner in which they “facilitate the dissociative process,” as one psychologist puts it, excessive gambling is built into the design and structural characteristics of the technology itself. One physician has even suggested that machine gambling produces a trance state by closely matching human breathing patterns with its “basal slot play rate.” We don’t have to wait for the Singularity to observe the merging of man and machine.

By 2000, digital gambling machines were generating twice the revenues of “live” games. Today, the modern slot machine “drives the industry,” said the president of the American Gaming Association in Natasha Dow Schull’s book, Addiction by Design: Machine Gambling in Las Vegas. They are allowed, in one form or another, in at least 41 states. Journalist Marc Cooper, who covered Las Vegas in his book, The Last Honest Place in America, said in 2005: “The new generation of gambling machines has, predictably, produced a new generation of gambling addicts: not players who thrive on the adrenaline rush of a high-wager roll of the dice or turn of a card but, rather, zoned-out ‘escape’ players who yearn for the smooth numbness produced by the endlessly spinning reels.”

“A gaming machine is a very fast, money-eating device,” according to a spokesperson for Bally. “The play should take no longer than three and a half seconds per game.” Gambling engineers attempt to fine-tune the “capacitive logic of haptics,” by, for example, designing chairs that tingle and pulse in response to events in the game. The ideal is to achieve an “embodied relation,” in which a gambling machine becomes an extension of the gambler’s own cognitive capacities and spatial skills. Professor Schull of MIT’s Program in Science, Technology, and Society sees a digital gambling machine as “an interactive force that powerfully exerts its program for ‘player extinction’ and in so doing constrains the possible outcomes of play.”

At the simplest level, gambling machines function as Skinner boxes for human rats. Intermittent reinforcement, as psychologists showed long ago, is an effective way of shaping behavior. “If the number of responses required to receive a stimulus varies,” writes biologist Jason Goldman at his Scientific American blog, The Thoughtful Animal,“then you are using a variable ratio schedule. The best example for this is a slot machine, which has a fixed probability of delivering a reward over time, but a variable number of pulls between rewards. It is no wonder that variable ratio reinforcement schedules are the most effective for quickly establishing and maintaining a desired behavior.”

Casinos were early adopters of biometric surveillance methods, and now have the capability of offloading much of this work to distributed digital devices like player loyalty cards. Theoretically, machines could achieve and maintain an active feedback loop with each gambler. The machine could compile data on betting patterns, recent outcomes, time of day, and rhythm of play. The machine would have the ability to “automatically alter the volatility level for gaming events to match the general player preferences at specific times,” in the words of one patent application. The longer you play, the more the machine would understand your style, and offer more of what will keep your ass in the seat.

The advent of poker playing machines brought in more players aiming for time-on-device rather than supersized jackpots. Poker machines gave out some kind of reward on 45% of plays—the perfect intermittent reward, if you asked Pavlov. And there was a razor-thin component of skill to the gambling machines. But all of the trademark features of addictive play are present in Draw Poker machines as well.

Here’s what casinos currently depend on to keep compulsive gamblers at their machines:

—Faster play. The key introduction was the virtual reel, which allowed play to take place faster than mechanical reels could spin. The use of touch screens is on the upswing, to further increase play speed. And the “BET MAX” button is always nearby.

—Longer “time-on-device”. One industry expert said: “If the chase lights on the slot signs are running too fast, they make people nervous; if they run too slow, they put them to sleep. If the machine sound is too loud, it hurts the player’s ears; if it’s not loud enough, the energy level of the room suffers.”

—Upping the ante. So that players can spend their money more easily, designers have engineered bill acceptors, digital credit counters, loyalty program cards, and other ways to reduce the actual handling of coins and cash and eliminate physical payouts at the device site. But what about the continued popularity of the nickel slot? “A nickel game isn’t a nickel game,” said one game developer, “when you’re betting ninety nickels at a time."

—Disguising the odds. The wonders of the random number generator are perfectly disguised in digital machines. Virtual reel mapping, or “weighted reels,” is credited to mathematician Inge Telnaes. It describes a system in which there is no logical correlation between the actual number of choices seen by the player and the number of stops contained on the virtual reel. Blank reel spaces help increase the confusion, while a secondary mapping program translates the virtual stops selected by the RNG microchips into the actual stops visible to players onscreen.

Something has to give, since recent research seems to show that machine gambling pushes gamblers into an addictive relationship with gambling at a rate three times faster than gamblers who stick to live table games. Back in the skunk works, where the machines are designed and manufactured by companies like IGT, the nation’s leading maker of gambling machines, weakening the hold of the machines would mean limiting near-miss effects, coming clean about virtual reel mapping, and placing restrictions on building ATM access into upcoming models. But maybe none of that will matter. As a software designer who moved from slot machines to games for kids told Professor Schull, “it wasn’t that big of a leap, in fact it was very similar. That really struck me. I saw it as appealing to the same part of the mind, a really simplistic instinct for distraction. Similar types of customers—toddlers and gamblers.”

Photo credit: http://www.all-slot-machines.com/

How I Quit Gambling

Projectile vomiting can be your friend.

I never should have found myself inside casinos in the first place. As a former alcoholic, cigarette smoker, and drug abuser, taking up gambling does not, in retrospect, sound like a solid life plan. But in my addictive heyday, gambling was definitely a part of my life. I would go the casino, stand inside the entrance, gaze out across the dark, jangling world of the slot machine floor, populated by solitary figures seated on stools, busily drinking and smoking cigarettes, and mutter: “My kinda people.”

And they were. Lurking out there were a significant number of fellow addicts, as I now understand. They weren’t there to have fun, to play games, to be entertained, or to quit while they were ahead. They were there to experience the act of risking more money than they intended to—more money than they wanted to lose. They were self-medicating with machines, as I had learned to do. The money bought you time on the machine, and the time on the machine was the medicine. The money had less to do with it than you might think. The money was only the means.

My spell as a compulsive gambler was nasty, brutish, and short. The extent of my losses is classified. It’s not a well-known fact, but addicted individuals who compulsively gamble tend to prefer the machines to the tables these days. Table gambling—blackjack, roulette, poker—requires a level of social interaction that is the opposite of what the pathological gambler is seeking: total immersion in a null state marked by regularity and the absence of human interactions. Give a cursory glance around any major casino’s slot room, and you will quickly notice that slot and machine poker players don’t talk to each other. They don’t even sit next to each other, if they can help it. Like an alcoholic on a secret binge, they DO NOT WISH TO BE DISTURBED. Even the periodic interchange with a cocktail server can feel like an unwarranted intrusion into the gambler’s zone.

I used to say, only partly in jest, that there is nothing quite like the sick thrill of wagering money you can’t afford to lose. The traditional trajectory has the gambler setting a limit on what she’s willing to lose, then going past that limit and resetting it, repeatedly, until her money is gone. Slot machine players know they are going to lose. They aren’t brain-damaged. (Well, in a way, they are, but that’s another story). They know perfectly well what the house percentage is. Sure, they hope to hit a jackpot against all odds—but they are also playing for time. One of the sacred casino industry metrics is “time on device,” and addicts put up some impressive numbers, since they are known to do things like pee their pants or ignore a medical emergency, rather than give up their machine.

In the old days, a roulette wheel was more likely to lead to the same result. In the words of the stricken protagonist in Dostoevsky’s The Gambler:

I had lost everything then, everything. I was going out of the Casino, I looked, there was still one gulden in my waistcoat pocket: ‘Then I shall have something for dinner,’ I thought. But after I had gone a hundred paces I changed my mind and went back… there really is something peculiar in the feeling when, alone in a strange land, far from home and from friends, not knowing whether you will have anything to eat that day—you stake your last gulden, your very last! I won, and twenty minutes later I went out of the Casino, having a hundred and seventy guldens in my pocket. That’s a fact! That’s what the last gulden can sometimes do! And what if I had lost heart then? What if I had not dared to risk it?...

I once won a $900 jackpot, and remember being irritated that it took the attendants so long to show up and pay out. Or maybe “pay” is not really the right word. What was that money, exactly? First, it wasn’t $900, it was really $500, since I was down $400 for the evening when I hit. The night before, I was down $250 when I quit. Not big numbers by any means, for a weekend in Vegas, but illustrative of how the numbers work. My $900 payday added up to a net of $250, drinks and room not included. This is an example of the “false jackpot,” a cousin to the “near miss.” A false jackpot occurs when the winnings are less than the wager. A near miss is a design technique where the reels frequently stop so that high-paying symbols appear just above or below the pay line—meaningless from a statistical point of view, but oh-so-close from the gambler’s perspective. 

I have serious tinnitus, the intrusive ringing-in-the-ear condition that can be brought on by a variety of causes, both environmental and neurobiological. Years ago I came down with a version of the condition, called cochlear hydrops, which often evolves into a set of additional symptoms including dizziness, nausea, complete loss of balance, vertigo, and vomiting. Remember that ears are essential for balance and navigation through space, so when things go wrong, it can be very debilitating indeed. But other than hearing loss and that constant roaring in one ear, I had none of the vestibular symptoms.

One weekend at Bally’s, after several hours planted in front of a single slot machine, the old kind, with three reels and cherries and 7s, I uncharacteristically felt like I’d had enough. In fact, I didn’t feel very good at all. And when I finally looked up from the machine, the curving lines of other machines and the swirling pattern of the casino carpet weren’t helping me feel any better. I decided to go to my room and rest for a while. On the way to the elevators, I lurched into a cocktail waitress, spilling drinks off her tray. In my room, I flung myself on the bed just in time to watch the walls beginning to spin. An interesting experience, when you haven’t had any alcohol to drink in years. This was nothing like seasickness, or a hangover. This was an express ride to hell without moving a muscle. Full-on vertigo. Faster and faster went the walls. And when I finally got up and staggered to the bathroom for a glass of water, I made it just inside the bathroom door before an episode of projectile vomiting (my first) convinced me that my gambling days were over.

I have no idea what happened, exactly, or how I have managed so far to have only one major vertigo event due to ear problems. I’m pretty sure that the spinning reels on the hit-the-button-and-go slots set me up for it. I haven’t been back to repeat the experiment. If there’s any better aversive training than vertigo and projectile vomiting, I don’t want to hear about it. Call it serendipity, a not-so-gentle push in the direction of recognizing that casinos were not a healthy place for me to be. Impulse control, risk/reward, anticipation, long-term thinking: these systems are all malfunctioning during active addiction. For recovering addicts, all those buzzes and whistles on the slot machines are like Pavlov’s bells, recalling the old mindset, and priming you for a fall that costs more than money. They now have digital slot machines with 100 pay lines. So I’ve heard. I don’t go there any more.

Photo Credit:  http://vancouvernotvegas.ca/Creative Commons

Is Gambling the Opiate of the Masses?

 
Two new books tackle gambling’s addictive mysteries.

Charles Fey, the American who invented the three-reel slot machine in 1898, is a well-known part of gambling history. But few people have heard of Inge Telnaes, the mathematician credited with the invention of the “virtual reel” almost 90 years later, in 1984. The virtual reel worked like this: The Telnaes patent allowed slot machine makers to store the various symbols on the spinning reels as digital data on microprocessor chips. After that, random number generating software produced the actual results in the form of three-symbol sets. So far so good. But inherent in the process was another step—the “virtual stop.” And this idea was a real killer. As gambling guru Donald Catlin wrote at Casino City Times:

Virtual reels contained more stops than were contained on the real reels, which meant that the probability of a particular symbol appearing on the pay line had nothing to do with its frequency on the real reels and everything to do with its frequency on the virtual reels.  If this seems deceptive to you, consider the following quote taken from the Telnaes patent submission: "Thus, it is important to make a machine that is perceived to present greater chances of payoff than it actually has within the legal limitations that games of chance must operate."

Pretty straightforward. You could program a thousand stops per reel, if you wanted to. The advantage was that you could post huge jackpots without the fear of anyone hitting them very often, because when gamblers thought about a line of 7s on those three reels, they were in fact facing many more spin combinations than they realized.

But I digress. We all know the house wins. Gamblers know it, too. Gambling can be defined as an activity in which something of value is put at risk in a situation where the outcome is uncertain. That’s really all there is to it. And for most people, it all adds up to little more than an evening of escapist fun.

So how do pathological gamblers gets so turned around? Viewing their behavior from the outside, it’s hard to have sympathy with them—the same way it can be hard to have sympathy for alcoholics. Willful self-destruction often looks like the only way to account for it. 

Heavy gamblers, the kind of gamblers who get into major debt, are people who get an unnatural buzz out of winning and losing money. Like most things having to do with addiction, it’s complicated, and involves a spiral of negative, damaging behavior that transcends bad habits or lack of self-control. They’re the ones in the casinos well past midnight, drink in hand, cigarette burning in the ashtray, and perhaps making the occasional sprint to the restroom for a snort of cocaine or meth. Slot attendants tell stories about gamblers who would rather urinate in their clothes than leave a machine. What, exactly, accounts for that kind of behavior?

For one thing, gambling and alcohol go together like…. cigarettes and alcohol. Gambling is being proposed as an addition to the bible of psychiatry, the DSM-5. All three habits often function together as a set of multiple addictions. The reason for this may be biological. Consider the unexpected side effects caused by certain dopamine-active medications for Parkinson’s. Some seniors who take the drugs begin to feel an uncontrollable urge to, that’s right, go to the casino and gamble. They prefer slot machines, and sometimes lose a lot of money. When they go off the medications, they lose interest in their new hobby—which lends a certain weight to the argument that some compulsive gamblers act the way they do because of innate biochemical dysfunctions. They do it, Howard Shaffer believes, because gambling is one manifestation of the disease he calls “addiction syndrome.”

Howard J. Shaffer and Ryan Martin, writing in the Annual Review of Clinical Psychology, note that just as there are divisions between alcoholic drinking, heavy drinking, and social drinking, there are also differences between pathological gambling, excessive gambling, and social gambling. Pathological gambling has proven to be “a more complex and unstable disorder than originally and traditionally thought.” Once the neurophysiology of the gambling state of mind came under scrutiny, the parallels with addiction cropped up everywhere. Shaffer, a professor of psychiatry at Harvard Medical School and director of the Division on Addiction at Cambridge Health Alliance  (see my interview with him here), notes that “the rate of pathological gambling in America has remained relatively constant for the past 35 years, despite a huge expansion in the opportunities on offer.” 

Change Your Gambling, Change Your Life, by Howard Shaffer, written with Ryan Martin, John Kleschinsky, and Liz Neporent, follows a relaxed workbook approach to problem gambling. Perhaps the most useful aspect of the book’s organization is its division into what we could call co-morbid chapters. Gamblers with anxiety, mood disorders, impulse control problems, or drug addictions each warrant their own section of the book, in order to personalize the advice. Organized in this way, the authors explicitly recognize the likelihood that problem gamblers do not normally suffer the condition in isolation from other mental health and substance use issues.

Shaffer gives a variety of useful advice concerning triggers, and methods for controlling urges. He believes that the risk of developing addiction syndrome involves “a complex interaction of genetic, psychological, social, and other factors.” Shaffer estimates that about two million Americans suffer from some level of addictive gambling disorder, with another 3.5 million gamblers with problem behaviors that don’t meet the addictive threshold.

In fact, the overlap between problem gambling, mental health problems, and other forms of addiction is staggering. According to numbers from the National Epidemiologic Survey on Alcohol and Related Conditions cited in the book, more than 11 percent of heavy gamblers suffer from generalized anxiety disorder; up to 50 percent have exhibited mood disorders; 40 percent qualified for an impulse control disorder; and 50 percent can be classified as “alcohol dependent."

Professor Shaffer takes a nonjudgmental stance on the question of moderation versus abstinence, while cautioning the problem gambler about the realities of having “the self-control to bet a little when he has the urge to bet a lot.” To attempt moderation, a gambling addict (or alcoholic for that matter) must be willing to accept the consequences of being unsuccessful. However, some research shows that those who engaged in disordered gambling “move on from excessive gambling to less gambling over time,” according to Shaffer. There may be a simple explanation for this: “Many people with gambling disorders eventually run out of money.” (Back when I used to gamble regularly in casinos, I often joked that there was nothing quite like the uneasy thrill of risking money you really couldn’t afford to lose.)

But if you are serious about quitting, warns Shaffer, “you also need to be prepared for people who, for their own selfish reasons, deliberately entice you to gamble.” Really? This may sound unlikely, but I recall that in my own case, when I first stopped drinking, an older friend used to pour me drinks and leave them nearby—just in case I came to my senses. If you are a gambling addict, and know it, there are self-exclusion programs at most casinos, designed to allow gamblers to bar themselves for a specified period, in an arrangement rather like Linus and his blanket.

Shaffer also points to continuing work on various drugs for problem gamblers. Naltrexone, used for opiate and alcohol addiction, is one such candidate. (A University of Minnesota study showed that 40 percent of pathological gamblers abstained from gambling for at least a month while taking naltrexone.) So is nalmefene, which also operates on opiate brain receptors. Other medications under study include common SSRI antidepressants like Prozac and Celexa.

Change Your Gambling, Change Your Life is a structured, clearly written, nonjudgmental approach for motivated people wishing to deal seriously with their “disordered gambling.”
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Another book on gambling turned up in the book bag recently. In his e-book called Slots: Praying to the God of Chance, David V. Forrest, M.D., notes that casinos can clear as much as $2,500 per day from a popular slot machine. Not considered sexy or the domain of the high roller, slot machine action accounts for roughly 70 to 80 % of casino income. To attract young players, who tend to favor table games, slot machine manufacturers are experimenting with joysticks and a dollop of skill-based play—but it’s not clear, says Forrest, that older, established slot players want to substitute “a competitive mind-set for the meditative trance induced by the random spinning and stopping of the reels.” (Note: The last time your humble narrator played the slots in Las Vegas, the spinning induced an attack of intense vertigo and dizziness due to a chronic ear disorder. Talk about negative conditioning.)

How do you know if you’re a slot addict, like former Drug Czar William Bennett? “Looking forward to slot playing as the best thing in your future is not a good sign,” Forrest helpfully suggests. One casino on the East Coast uses the ominous advertising tag line: “You’ll Come Back.” Forrest mischievously notes that both “the American Psychiatric Association and the American College of Psychiatrists have traditionally refused to hold their annual conventions in Las Vegas for fear of seeming to endorse a behavior that can become pathological.”

Here are some of Dr. Forrest’s suggestions for the problem gambler:

-- Avoid playing alone.

--Play out your time, not your money.

--Break the hypnotic spell through thought and activity.

--Beware the dangers of comorbidity.

With this final admonition, Dr. Forrest lines up squarely with Howard Shaffer: “In my psychiatric experience,” he writes, “some of the most defenseless to the excesses of gambling have been bipolar patients in the manic phase of their illness.”

Photo credit: http://www.marketmixup.com