Should pathological gambling and obesity be considered addictive disorders? A factor analytic study in a nationally representative sample
Introduction
Inclusion of pathological gambling (renamed as gambling disorder) in the substance-related and addictive disorders chapter of the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) has brought to the fore considerations of which disorders or behaviors are best conceptualized as addictive disorders. This debate is important because the nosological status of a disorder is an important determinant of its lines of research (Blanco et al., 2009, Moreyra et al., 2002), treatment models (Greene et al., 2011, Petry et al., 2006) and approaches to policy and funding for treatment and research (Petry and Blanco, 2013).
Among the potential candidates that were considered to join the substance related and addictive disorders category in DSM-5, few garnered more attention than pathological gambling (PG) and obesity, possibly due to their devastating impact and recent increases in prevalence (Swinburn et al., 2011, Ziauddeen et al., 2012). Clinical experience and research evidence have suggested that PG shares many features with substance use disorders. These include high levels of comorbidity in clinical (Black and Moyer, 1998, Ibanez et al., 2001) and epidemiological samples (Kessler et al., 2008, Petry et al., 2005), shared genetic variance (Blanco et al., 2012, Slutske et al., 2000), high levels of impulsivity (Blanco et al., 1996, Blanco et al., 2009, Petry, 2001), performance in biobehavioral studies (Leeman and Potenza, 2012) and brain imaging studies (Leeman and Potenza, 2012, van Holst et al., 2010). Furthermore, both pharmacological (Grant et al., 2006, Kim et al., 2001) and psychotherapy treatments for PG have been often based on its conceptualization as an addictive disorder (Hodgins et al., 2001, Petry et al., 2006).
Data supporting the consideration of obesity as an addictive disorder have been more mixed. Some empirical studies and reviews have supported the conceptualization of obesity as an addiction based on data suggesting overlapping molecular and cellular mechanisms and reward brain circuits as well as shared genetic vulnerabilities (Galanti et al., 2007, Grucza et al., 2010, Kenny, 2011a, Kenny, 2011b, Lilenfeld et al., 2008, Volkow et al., 2011, Weller et al., 2008), but other studies have provided countervailing evidence (Fernandez-Castillo et al., 2010, Haltia et al., 2007, Munafo et al., 2009, Smith et al., 2008, Ziauddeen et al., 2012).
We sought to contribute to those lines of research by conducting a factor analysis using data from the National Epidemiologic Survey on Alcohol and Related Conditions, a large, nationally representative sample of US adults. We hypothesized that substance use disorders, i.e., nicotine dependence, alcohol dependence and drug use dependence, would load on a single factor, consistent with prior analyses (Kessler et al., 2011, Krueger et al., 1998). Furthermore, we hypothesized that if PG and obesity were addictive disorders, they would load on the same factor as substance use disorders. By contrast, failure to load on the addictive factor would not support their conceptualization as addictive disorders, at least not as defined within this dataset.
Section snippets
NESARC sample
The 2001–2002 NESARC is a survey of a representative sample of the United States sponsored by the NIAAA (Grant et al., 2003b, Grant and Kim, 2002). The target population was individuals age 18 years and older in the civilian non-institutional population residing in households and group quarters. The survey included those residing in the continental United States, District of Columbia, Alaska and Hawaii. Face-to-face personal interviews were conducted with 43,093 respondents. The survey response
Results
The 12-month prevalence of obesity, nicotine dependence, alcohol dependence, drug dependence, and pathological gambling were 21.8 (95% CI = 21.0–22.6), 12.8% (95% CI = 12.0–13.6), 3.8% (95% CI = 3.5–4.1), 0.6% (95% CI = 0.4–0.8), and 0.16% (95% CI = 0.12–0.20), respectively. The mean BMI in the sample was 26.7 (95% CI = 26.6–26.9). Bivariate analyses indicated that PG was significantly and positively associated to nicotine, alcohol and drug dependence, with ORs ranging from 2.82 for drug dependence to 8.17
Discussion
In a large, nationally representative sample of US adults, nicotine, alcohol and drug dependence and pathological gambling loaded on the same factor. By contrast, the loading of obesity on the addictive factor was very low. Furthermore, the findings were robust to model specification as indicated by the results of sensitivity analyses that used disordered gambling and DSM-5 gambling disorder as indicators of the factor.
Consistent with our first hypothesis, we found that nicotine, alcohol and
Author disclosures
Role of funding sources
Funding for this study was provided in parts by NIH grants DA019606 and CA133050 and the New York State Psychiatric Institute (Dr. Blanco). The NIH and the NYSPI had no further role in the study design, collection, analysis or interpretation of the data, the writing of the manuscript or the decision to submit the paper for publication.
Contributors
Carlos Blanco designed the study and wrote the initial draft of the manuscript. Shuai Wang and Melanie Wall undertook the
Conflict of interest
All the authors declare that they have no conflicts of interest.
References (74)
- et al.
A pilot study of impulsivity and compulsivity in pathological gambling
Psychiatry Res.
(2009) - et al.
Reliability of the alcohol and drug modules of the Alcohol Use Disorder and Associated Disabilities Interview Schedule—Alcohol/Drug-Revised (AUDADIS-ADR): an international comparison
Drug Alcohol Depend.
(1997) - et al.
Concordance of DSM-IV alcohol and drug use disorder criteria and diagnoses as measured by AUDADIS-ADR, CIDI and SCAN
Drug Alcohol Depend.
(1997) - et al.
The Alcohol Use Disorder and Associated Disabilities Interview Schedule-IV (AUDADIS-IV): reliability of alcohol consumption, tobacco use, family history of depression and psychiatric diagnostic modules in a general population sample
Drug Alcohol Depend.
(2003) - et al.
The Alcohol Use Disorder and Associated Disabilities Interview schedule (AUDADIS): reliability of alcohol and drug modules in a general population sample
Drug Alcohol Depend.
(1995) Reward mechanisms in obesity: new insights and future directions
Neuron
(2011)- et al.
Double-blind naltrexone and placebo comparison study in the treatment of pathological gambling
Biol. Psychiatry
(2001) - et al.
A family history study of binge-eating disorder
Compr. Psychiatry
(2008) - et al.
Concordance between ICD-10 alcohol and drug use disorder criteria and diagnoses as measured by the AUDADIS-ADR, CIDI and SCAN: results of a cross-national study
Drug Alcohol Depend.
(1997) - et al.
Using a Rasch model to examine the utility of the South Oaks Gambling Screen across clinical and community samples
Addict. Behav.
(2004)