ORIGINAL RESEARCH published: 26 April 2019 doi: 10.3389/fpsyg.2019.00931 A Comparison of DSM-IV-TR and DSM-5 Diagnostic Criteria for Gambling Disorder in a Large Clinical Sample Susana Jiménez-Murcia 1,2,3* , Roser Granero 2,4 , Fernando Fernández-Aranda 1,2,3 , Anne Sauvaget 5 , Andreas Fransson 6 , Anders Hakansson 6 , Gemma Mestre-Bach 1,2 , Trevor Steward 1,2 , Randy Stinchfield 7 , Laura Moragas 1 , Neus Aymamí 1 , Mónica Gómez-Peña 1 , Amparo del Pino-Gutiérrez 1,8 , Zaida Agüera 1,2 , Marta Baño 1 , Maria-Teresa Talón-Navarro 9 , Àngel Cuquerella 9 , Ester Codina 1,8 and Edited by: José M. Menchón 1,3,10 Xavier Noel, Free University of Brussels, Belgium 1 Department of Psychiatry, Bellvitge University Hospital-IDIBELL, Barcelona, Spain, 2 Ciber Fisiopatología de la Obesidad y Reviewed by: Nutrición (CIBERobn), Instituto de Salud Carlos III, Madrid, Spain, 3 Department of Clinical Sciences, School of Medicine Daniel S. McGrath, and Health Sciences, University of Barcelona, Barcelona, Spain, 4 Departament de Psicobiologia i Metodologia de les University of Calgary, Canada Ciències de la Salut, Universitat Autònoma de Barcelona, Barcelona, Spain, 5 Addictology and Liaison Psychiatry Kai Müller, Department, Nantes University Hospital, Nantes, France, 6 Faculty of Medicine, Department of Clinical Sciences Psychiatry, Johannes Gutenberg University Lund, Sweden, 7 Department of Psychiatry, University of Minnesota Medical School, Saint Paul, MN, United States, 8 Mainz, Germany Department of Public Health, Mental Health and Mother-Infant Nursing, University School of Nursing, University of Barcelona, Barcelona, Spain, 9 Institute of Legal Medicine and Forensic Sciences of Catalonia, Barcelona, Spain, 10 CIBER *Correspondence: Salud Mental (CIBERSAM), Instituto de Salud Carlos III, Madrid, Spain Susana Jiménez-Murcia sjimenez@bellvitgehospital.cat Background and Aims: Gambling-related crimes are known to be associated with Specialty section: gambling disorder (GD). Due to a lack of consensus in the scientific community regarding This article was submitted to Psychopathology, the relevance of this diagnostic criterion, it was removed from the DSM-5. The primary a section of the journal aim of this study was to investigate through structural equation modeling (SEM) whether Frontiers in Psychology higher GD severity in treatment-seeking GD patients with a criminal record is mediated Received: 03 December 2018 Accepted: 08 April 2019 through the illegal acts criterion itself, or whether it can be better explained by other Published: 26 April 2019 related clinical factors. Citation: Methods: An initial sample of 2,081 patients seeking treatment for gambling problems Jiménez-Murcia S, Granero R, Fernández-Aranda F, Sauvaget A, was included in the sample. SEM was used to evaluate the mediational role of the Fransson A, Hakansson A, illegal acts criterion between the sex, age and personality traits, gambling severity, Mestre-Bach G, Steward T, Stinchfield R, Moragas L, Aymamí N, and comorbid depression levels. Comparisons between patients with coinciding and Gómez-Peña M, del Pino-Gutiérrez A, divergent DSM criterion for GD diagnosis were carried out. Agüera Z, Baño M, Talón-Navarro M-T, Cuquerella À, Results: Illegal acts mediated the relationship between personality traits and GD Codina E and Menchón JM (2019) A severity: younger age, high levels of novelty seeking, and low levels of self- Comparison of DSM-IV-TR and DSM-5 Diagnostic Criteria transcendence increased the risk of endorsing the illegal acts criterion. No differences for Gambling Disorder in a Large between coincident-divergent groups in terms of DSM-IV and DSM-5 diagnosis Clinical Sample. Front. Psychol. 10:931. were found with regards to sex (p = 0.878), education level (p = 0.387), or civil doi: 10.3389/fpsyg.2019.00931 status (p = 0.792). Frontiers in Psychology | www.frontiersin.org 1 April 2019 | Volume 10 | Article 931 Jiménez-Murcia et al. Illegal Acts and DSM Discussion and Conclusion: The results obtained in the present study offer new insights into the utility of using a history of illegal acts, their different personality characteristics, and psychopathology to categorize GD patients. Our findings suggest that patients who engage in criminal behavior may require a more comprehensive intervention. Keywords: DSM-IV-TR, DSM-5, gambling disorder, criminal behaviors, severity, personality, psychopathology INTRODUCTION (Petry et al., 2013). However, studies have shown that treatment- seeking GD patients tend to report the illegal acts criterion Gambling-related crimes are known to be associated with at much higher proportions than compared to population- gambling disorder (GD), allowing individuals with this disorder based samples of ordinary gamblers (Toce-Gerstein et al., to obtain funding to continue with the gambling behavior or 2003; Petry et al., 2013; Granero et al., 2014). Still, research to solve financial problems stemming from it (Petry et al., targeting possible consequences of removing this criterion 2013; Laursen et al., 2016; May-Chahal et al., 2017; Mestre- in a clinical setting of treatment-seeking patients has up to Bach et al., 2018a). Some risk factors, such as sociodemographic now been scarce or based on patient populations seeking features (Abbott and McKenna, 2005), personality disorders treatment for any addictive disorder (Denis et al., 2012; (e.g., antisocial personality disorder) and traits (Turner et al., Petry et al., 2013). 2009; Pastwa-Wojciechowska, 2011) and the co-occurrence of Data from clinical samples have demonstrated that substance use (Gorsane et al., 2017) have been highlighted patients with GD who endorse the illegal acts criterion when taking GD, and criminal behavior into account. All show higher GD severity at baseline and throughout these factors would be associated with a pattern of behavior treatment, indicating that this clinical group may need characterized by a greater risk-taking (Bornovalova et al., 2005; further interventions (Potenza et al., 2000; Strong and Adolphe et al., 2018). Kahler, 2007; Mestre-Bach et al., 2018a,b). Correspondingly, The DSM-IV-TR, therefore, included a criterion focused Turner et al. (2016) demonstrated the relevance of assessing on these illegal acts carried out for gambling-related reasons, criminal behavior in problematic gamblers in a criminal specifically assessing whether the subject “has committed justice population. illegal acts such as forgery, fraud, theft, or embezzlement to In order to delve into the repercussions of this change at finance gambling” (American Psychiatric Association, 2000). a clinical level, the primary aim of the present study was to Nevertheless, the more recent version of the DSM-5 and, more investigate through path analysis implemented in structural specifically, the Pathological Gambling Committee opted to both equation modeling (SEM) whether higher GD severity seen lower the cut-off score from five to four and to remove the in treatment-seeking GD patients with a criminal history is illegal acts criterion (American Psychiatric Association, 2013). mediated through the illegal acts criterion itself, or whether it can These two changes were completely separate and were not related be better explained by other related clinical factors. to each other. Research related to the removal of the illegal acts criterion have demonstrated that this has had little impact on the number of patients being diagnosed with the disorder, that the illegal acts criterion was the criterion least commonly MATERIALS AND METHODS endorsed by patients, and that patients who met this criterion in the DSM-IV-TR generally also met a sufficient number of other Participants and Procedure criteria to meet diagnosis without the presence of illegal acts The sample included 2,081 patients seeking treatment for (Zimmerman et al., 2006; Strong and Kahler, 2007; McBride et al., gambling problems from the Department of Psychiatry at 2010; Weinstock et al., 2013; Granero et al., 2014). Moreover, Bellvitge University Hospital in Barcelona, Spain. Diagnosis most researchers consider it should not have been categorized was carried out according to DSM-IV-TR criteria (American as an independent diagnostic criterion, but as an indicator of Psychiatric Association, 2000), through the Stinchfield diagnostic GD severity (Jiménez-Murcia et al., 2009; Petry et al., 2013; questionnaire, based on the DSM-IV criteria (Stinchfield, 2003) Granero et al., 2014). Likewise, the cut-off for the diagnosis adapted and validation to Spanish (Jiménez-Murcia et al., 2009). of this disorder was changed from five to four criteria, based Diagnoses were made by psychologists and psychiatrists with on a series of studies published in the early 2000s showing more than 20 years of clinical experience in the assessment that this change improved classification accuracy and reduced and treatment of GD. Other socio-demographic, clinical, and the false negative rate from 0.08 to 0.05 (Stinchfield, 2003; socio/family variables related to gambling were measured using Jiménez-Murcia et al., 2009). a semi-structured face-to-face clinical interview. This interview The implications of omitting the illegal acts criterion in explored motivations for gambling, age of onset of recreational the general population have been evaluated, most significantly gambling, age of onset of symptoms of problematic, preferred in the National Epidemiological Survey of Alcohol and form of gambling (or several if applicable), gambling frequency, Related Conditions, using a large American study sample maximum bet, average, reinvestment of wins, magical and Frontiers in Psychology | www.frontiersin.org 2 April 2019 | Volume 10 | Article 931 Jiménez-Murcia et al. Illegal Acts and DSM distorted thinking, gambling-related debts, periods of abstinence, those that showed a significant association with other indicators gambling episode behavior, etc. analyzed in this study were finally selected for the SEM. Table 1 A total of 152 patients did not meet either DSM-IV criteria or includes Cronbach’s alpha in the sample of the study. the DSM-5 criteria, and were therefore not considered for further statistical analyses. Additional Data Patients included in the study were initially assessed by trained Demographic, clinical, and social/family variables related and licensed psychologists and psychiatrists with experience to gambling were measured using a semi-structured in this behavioral addiction. Information regarding gambling face-to-face clinical interview described elsewhere behavior was gathered through a semi-structured face-to-face (Jiménez-Murcia et al., 2006). interview. The assessment was conducted prospectively at baseline in a single session. Patients filled out the SOGS, TCI-R, Statistical Analysis and SCL-90-R before initiating outpatient treatment. All statistical analyses were carried out with STATA 15 for The present study was carried out in accordance with the latest Windows. Comparison between patients with coinciding and version of the Declaration of Helsinki. The Bellvitge University divergent DSM criterion for GD diagnosis was done through chi- Hospital Ethics Clinical Research Committee approved the study. square tests for categorical features and t-tests for quantitative Signed, informed consent was obtained from all patients. outcomes. Effect-size of the comparisons was measured through Cohen’s-d coefficient, considering |d| < 0.50 to be poor effect- Measures size, |d| > 0.50 to be moderate, and |d| > 0.80 to be high. South Oaks Gambling Screen (SOGS) (Lesieur and The mediational role of the variables of interest was examined Blume, 1987) through Structural Equation Models. Overall goodness-of-fit The SOGS is a 20-item questionnaire used to screen for statistics were assessed through χ2 test, the Root Mean Squared GD, predominantly in clinical settings. The total score of the Error of Approximation (RMSEA), baseline comparison indexes questionnaire is calculated by adding endorsed items, with a (Comparative Fit Index [CFI], Tucker-Lewis Index [TLI]), and total score of 20, where a cut-off score of 5, or more is residuals size (Standardized Mean Squared Residual [SMSR]). indicative of probable GD. The Spanish validation of SOGS Fit was considered good if (Kline, 2011): a non-significant result showed adequate psychometric properties (test-retest reliability, (p > 0.05) was obtained on the χ2 test, the RMSEA was lower 0.98; internal consistency, 0.94; and convergent validity, 0.92) than 0.08, the CFI-TLI coefficients were higher than 0.90 and (Echeburúa et al., 1994). In the present study, only total scale SRMR was limited to 0.08. The equation level goodness-of-fit score was used for analyses. Table 1 includes Cronbach’s alpha and the effect sizes were also estimated through R2 coefficients in the sample of the study. for each equation and for the global model including the set of variables and their relationship pattern (these coefficients valued Temperament and Character Inventory-Revised the fraction of the variance explained by indicator/s), multiple (TCI-R) (Cloninger, 1999) correlation (mc) and Bentler-Raykov multiple correlation (mc2 The TCI-R is a 240-item questionnaire with a five-point Likert Bentler and Raykov, 2000). These last two coefficients report the scale format used to measure four temperament (harm avoidance, relatedness of each dependent variable with the model’s linear novelty seeking, reward dependence, and persistence) and three prediction (in non-recursive models mc2 is computed to avoid character dimensions (self-directedness, cooperativeness, and the problem of obtaining inconsistent negative mcs). self-transcendence) of personality. The Spanish adaptation of the TCI-R has showed acceptable reliability of the seven dimensions, with alphas between 0.74 and 0.87 (Gutiérrez-Zotes et al., 2004). For the SEM we only used total scores dimensions that showed RESULTS a significant association with other indicators analyzed in this study. Table 1 includes Cronbach’s alpha in the study sample. Sample Characteristics Participants’ mean age was 42.23 years old (SD = 13.3), with a Symptom Checklist-90-R (SCL-90-R) mean age of GD onset of 36.26 years (SD = 13.2), and a mean GD (Derogatis, 1990) duration of 5.64 years (SD = 6.13). Most participants were male This is a widely used, self-report 90-item inventory measuring (90.4 %) and had a primary school level of education (57.6%). psychological distress and psychopathology. The inventory Regarding the problematic gambling activities in the sample, measures nine symptom dimensions: somatization, obsessive- 85.9% of the participants reported using slot machines, 12.3% compulsive, interpersonal sensitivity, depression, anxiety, bingo, 9.9% lotteries, 6.1% casinos, 3.9% cards, 3.8% bets on the hostility, phobic anxiety, paranoid ideation, and psychoticism. Internet, and 2.5% bets on sports or horses. The mean number of The global score (Global Severity Index [GSI]) is a widely used problematic gambling activities in the sample was 1.3 (SD = 0.6; index of psychopathological distress. The SCL-90-R has been 81.1% of the patients reported a single problematic activity, 13.9% validated in a Spanish population obtaining adequate internal two problematic activity, and the remaining 5.0% at least three consistency of the items ranging between 0.81 and 0.90, and an problematic activity). Moreover, 76.74% of the sample did not acceptable mean internal consistency of 0.75 (Derogatis, 2002). endorse the criminal acts criterion, while 23.26% did. In this Primary symptom dimensions score were evaluated, but only vein, more than one third of women and more than half of men Frontiers in Psychology | www.frontiersin.org 3 April 2019 | Volume 10 | Article 931 Jiménez-Murcia et al. Illegal Acts and DSM reported that they had been involved in illegal acts in order to severity: young age was associated with higher novelty seeking, finance their gambling behavior. lower self-transcendence scores, and SOGS-total scores. High levels of depression symptoms (measured by SCL-90-R) were Mediational Role of Illegal Acts in the associated with high GD severity, as well as with old age, being female, and low self-transcendence scores. Gambling Profile Table 1 and Figure 1 show the results for the SEM valuing the mediational role of the illegal acts criterion between the sex, Comparison Between Patients With age and TCI-R scores, gambling severity (SOGS-total score), Coincident and Divergent DSM Criteria and the level of comorbid depression (SCL-90-R, depression In the initial sample of 2,081 patients, two binary conditions were score). Goodness-of-fit was obtained: χ2 = 3.93 (p = 0.140), defined according to the DSM-IV and DSM-5 criteria for GD: RMSEA = 0.023 (95%CI: 0 to 0.057), CFI = 0.999, TLI = 0.990, (a) DSM-IV criteria present versus absent (at least five of the 10 and SRMR = 0.006. The global predictive capacity was very gambling behaviors described in the taxonomy was considered good (coefficient of determination CD = 0.447, a measure of the present, including in the count the A8 criterion assessing the total R2 for the model). Illegal acts mediated the relationship presence of illegal acts); and (b) DSM-5 criteria present versus between personality traits (age, TCI-R novelty seeking and self- absent (individuals exhibiting at least four of the 9 gambling transcendence levels) and GD severity: young age, high levels of behaviors described in the taxonomy was considered present, novelty seeking, and low levels of self-transcendence increased excluding illegal acts). No patient was included in the joint the risk of endorsing the illegal acts criterion. Furthermore, the condition DSM-IV = present and DSM-5 = absent. presence of the illegal acts criterion predicted higher SOGS-total All remaining GD patients (n = 1,929) met the scores. Age and TCI-R scores also showed a direct effect on GD DSM-5_criteria. In this cohort, n = 1,822 (94.5%) also met TABLE 1 | SEM results for the pathways valuing the mediational role of illegal acts: standardized coefficients (structural). Coeff. SE z p 95% CI (coeff.) Illegal acts Age (yrs-old) −0.155 0.0235 −6.61 < 0.001 −0.201 −0.109 Sex (male) 0.005 0.0230 0.2 0.841 −0.041 0.050 TCI-R: novelty seeking 0.179 0.0243 7.35 < 0.001 0.131 0.226 TCI-R: −0.114 0.0238 −4.81 < 0.001 −0.161 −0.068 self-directedness constant 0.385 0.3078 1.25 0.21 −0.218 0.989 SOGS-total Illegal acts 0.194 0.0212 9.14 < 0.001 0.152 0.235 Age (yrs-old) −0.064 0.0218 −2.02 0.043 −0.087 −0.001 Sex (male) 0.008 0.0209 0.4 0.693 −0.033 0.049 TCI-R: novelty seeking 0.258 0.0221 11.66 < 0.001 0.215 0.302 TCI-R: −0.243 0.0213 −11.41 < 0.001 −0.285 −0.202 self-directedness constant 2.710 0.2849 9.51 < 0.001 2.152 3.268 Depression SOGS-total 0.202 0.0205 9.87 < 0.001 0.162 0.242 Age (yrs-old) 0.073 0.0196 3.71 < 0.001 0.034 0.111 Sex (male) −0.165 0.0194 −8.5 < 0.001 −0.203 −0.127 TCI-R: −0.442 0.0190 −23.3 < 0.001 −0.479 −0.405 self-directedness Constant 3.862 0.1828 21.13 < 0.001 3.504 4.220 Covariances Age, Novelty-seeking −0.258 0.0221 −11.67 < 0.001 −0.301 −0.214 Age, Sex −0.176 0.0229 −7.68 < 0.001 −0.221 −0.131 Age, Self-directedness 0.007 0.0237 0.3 0.765 −0.039 0.053 Novelty-seek., Sex −0.019 0.0236 −0.82 0.413 −0.066 0.027 Novelty-seek., −0.317 0.0213 −14.89 < 0.001 −0.359 −0.275 Self-direct Sex, Self-directedness 0.105 0.0234 4.51 < 0.001 0.060 0.151 Equation level goodness-of-fit Variance fitted Variance predicted Variance residual R2 mc mc2 Observed Illegal acts 0.183 0.018 0.166 0.097 0.311 0.097 SOGS-total score 10.164 2.603 7.562 0.256 0.506 0.256 Depression 0.817 0.284 0.533 0.348 0.590 0.348 mc: correlation between dependent variable and its prediction. mc2 : Bentler-Raykov squared multiple correlation coefficient. Frontiers in Psychology | www.frontiersin.org 4 April 2019 | Volume 10 | Article 931 Jiménez-Murcia et al. Illegal Acts and DSM Age (yrs-old) -.16 -.064 Illegal acts .073 .19 Sex (male) .0046 .0082 -.16 GD severity: SOGS-total .18 .20 TCI-R: .26 Novelty seeking SCL-90R: Depression -.11 -.24 TCI-R: -.46 Self-directedness FIGURE 1 | SEM to value the mediational role of illegal acts on gambling severity. Dash-line, italic font: non-significant coefficient. the DSM-IV criteria, resulting in 107 patients (5.5%) not worse psychopathological state (higher mean scores on meeting this cut-off (these patients reported exactly four of SCL-90-R scales). the maladaptive gambling behaviors described in the DSM). These two groups were labeled as “coinciding DSM_criteria” versus “divergent DSM_criteria” and were compared in terms of DISCUSSION sociodemographic features and clinical measures. No patients in the divergent DSM_criteria group reported This study analyzed whether the higher GD severity seen illegal acts, while 26% of patients in the coinciding DSM_criteria in treatment-seeking patients with GD who had committed group endorsed the illegal acts criterion. No difference between gambling-related illegal acts is mediated through the DSM illegal coincident-divergent groups was found with regards to sex acts criterion itself, or whether it can be better explained by a (p = 0.878), education level (p = 0.387), or civil status (p = 0.792). mediating role of other clinical features. The first part of Table 2 contains the results of the The main results of the present study indicated that 76.74% comparison between coincident and divergent DSM criteria of the sample did not endorse the criminal acts criterion, groups, the presence of other comorbid problems and the while 23.26% presented it. Engagement in criminal behavior substances abuse/use. In the coincident DSM criteria group, during the course of the disease has been associated with there was a statistically higher prevalence of participants greater severity and worse prognosis, which yields implications who perceived having mental health problems (35.1% for treatment interventions (Strong and Kahler, 2007; Turner vs 20.0%, p = 0.002), alcohol abuse (15.3% vs 7.14%, et al., 2016; Mestre-Bach et al., 2018a,b). These findings are p = 0.028), and a history of psychiatric problems (44.2% in line with the results of the present study, which indicate vs. 28.0%, p = 0.001). In addition, this group reported a that patients with a history of criminal behavior have a higher higher proportion of patients who had undergone previous level of GD severity compared to patients who do not endorse treatment due to gambling problems (48.4% vs. 36.6%, this criterion. The results also show that some personality p < 0.001), and gambling using slot machines (86.5% vs. characteristics were positively associated with the presence of 78.6%, p = 0.026). criminal behavior while others were inversely associated. One The second part of the table contains the results example is the case of harm avoidance and self-transcendence, comparing the two groups of the study (age, age of characteristics opposite to the profile of the patient who commits onset and duration of gambling problems, GD severity, criminal acts. Comorbidity with other mental disorders may psychopathological state, and personality traits). Overall, also affect the prognosis of the disease, often making it difficult the group with coincident DSM criteria included younger to address the main disorder if secondary disorders have patients, younger age of onset of gambling problems, and not been treated. longer GD duration. In addition, this group presented Some authors have indicated that the reduction in diagnostic higher GD severity (measured with the SOGS scale) and criteria for GD in the new version of the manual would have Frontiers in Psychology | www.frontiersin.org 5 April 2019 | Volume 10 | Article 931 Jiménez-Murcia et al. Illegal Acts and DSM TABLE 2 | Clinical comparison of patients with coinciding and divergent DSM criterion. DSM5_A = Present DSM5_A = Present p |d| DSM-IV_A = Present DSM-IV_A = Absent Coinciding; n = 1,822 Divergent; n = 107 Previous treatments for GD; % 48.4 36.6 <0.001 0.24 Gambling: slot machines; % 86.5 78.6 0.026 0.21 Gambling: bingo; % 12.5 11.7 0.809 0.02 Gambling: lotteries; % 9.70 10.7 0.743 0.03 Gambling: casino; % 6.42 3.88 0.301 0.11 Gambling: cards; % 3.89 3.88 0.998 0.00 Gambling: sports or horse races; % 2.31 3.88 0.311 0.09 Gambling: internet; % 4.06 2.91 0.564 0.07 Gambling: other; % 1.98 3.92 0.181 0.11 Presence of secondary activity; % 21.7 22.2 0.896 0.01 Mental comorbidities at present; % 35.1 20.0 0.002 0.34 Smoker; % 74.8 66.0 0.051 0.19 Alcohol abuse; % 15.3 7.14 0.028 0.26 Substances abuse; % 10.3 9.18 0.712 0.04 Other addictive behaviors; % 8.12 6.06 0.546 0.08 Personal psychiatric history; % 44.2 28.0 0.001 0.34 Family psychiatric history; % 60.9 61.0 0.978 0.00 Age (years-old); mean (SD) 41.5 (12.8) 45.9 (15.1) 0.001 0.00 Age of onset (years-old); mean (SD) 35.5 (12.7) 41.5 (15.1) <0.001 0.43 Duration of gambling probl. (years); mean (SD) 5.84 (6.25) 3.99 (4.30) 0.005 0.34 Maximum bets (euros); mean (SD) 940.6 (2,471.9) 747.4 (2,084.0) 0.460 0.08 Mean bets (euros); mean (SD) 185.4 (790.2) 154.5 (507.1) 0.753 0.05 Cumulate bets (euros); mean (SD) 9,860 (27,183) 14,444 (60,740) 0.178 0.10 Own income (euros); mean (SD) 1,198 (674) 1,390 (1,046) 0.009 0.22 Family income (euros); mean (SD) 2,100 (1,179) 2,361 (3,621) 0.120 0.10 Previous consultations for gambling; mean (SD) 0.80 (3.63) 0.49 (2.34) 0.431 0.10 Gambling severity-level: SOGS-total; mean (SD) 10.7 (2.89) 7.30 (2.56) <0.001 1.23∗ Gambling severity-level: DSM_A-total; mean 7.54 (1.47) 4.00 (0.00) <0.001 3.41∗ (SD) SCL-90: Somatization; mean (SD) 0.98 (0.81) 0.58 (0.60) <0.001 0.56∗ SCL-90: Obsessive/compulsive; mean (SD) 1.17 (0.81) 0.76 (0.66) <0.001 0.55∗ SCL-90: Interpersonal sensitivity; mean (SD) 1.07 (0.82) 0.60 (0.62) <0.001 0.65∗ SCL-90: Depressive; mean (SD) 1.53 (0.90) 0.90 (0.71) <0.001 0.78∗ SCL-90: Anxiety; mean (SD) 1.05 (0.82) 0.53 (0.55) <0.001 0.74∗ SCL-90: Hostility; mean (SD) 0.94 (0.83) 0.49 (0.60) <0.001 0.62∗ SCL-90: Phobic anxiety; mean (SD) 0.52 (0.68) 0.24 (0.53) <0.001 0.46 SCL-90: Paranoid Ideation; mean (SD) 0.92 (0.75) 0.60 (0.70) <0.001 0.44 SCL-90: Psychotic; mean (SD) 0.93 (0.75) 0.50 (0.56) <0.001 0.65∗ SCL-90: GSI; mean (SD) 1.09 (0.69) 0.62 (0.53) <0.001 0.76∗ SCL-90: PST; mean (SD) 48.0 (21.0) 32.8 (19.3) <0.001 0.75∗ SCL-90: PSDI; mean (SD) 1.90 (0.59) 1.58 (0.50) <0.001 0.59∗ TCI-R: Novelty seeking; mean (SD) 110.4 (13.9) 98.7 (11.9) <0.001 0.91∗ TCI-R: Harm avoidance; mean (SD) 102.1 (17.1) 95.2 (16.3) <0.001 0.42 TCI-R: Reward dependence; mean (SD) 99.6 (15.6) 102.2 (14.1) 0.120 0.17 TCI-R: Persistence; mean (SD) 109.8 (20.8) 114.1 (18.6) 0.050 0.22 TCI-R: Self-directedness; mean (SD) 125.2 (20.9) 140.5 (17.5) <0.001 0.80∗ TCI-R: Cooperativeness; mean (SD) 131.4 (17.7) 138.1 (15.3) <0.001 0.41 TCI-R: Self-Transcendence; mean (SD) 65.1 (15.3) 63.2 (14.6) 0.232 0.13 SD: standard deviation. ∗ Bold: moderate (|d| > 0.50) to high (|d| > 0.80) effect-size. Frontiers in Psychology | www.frontiersin.org 6 April 2019 | Volume 10 | Article 931 Jiménez-Murcia et al. Illegal Acts and DSM an important impact on the prevalence ratio of the disease, necessary to perform the diagnosis of the disorder in both and even more so in youth populations (Mitzner et al., 2011). versions of the manual. Through this knowledge we could However, this indication was not found in the present study, have studied more precisely what has been the change since the diagnosis of only 5.55% of the total sample shifts regarding the suppression of the criterion related to the in the current version of the manual. Regarding the omission commission of criminal acts in GD, in DSM-5. It would of the criterion of criminal acts, the authors promote this also have been very interesting to know the requirements decision because of its low prevalence in the surveys carried by which the clinic is governed to establish the level of out in the population. In our study, the criterion related to the severity of the disorder and thus to be able to review in commission of illegal acts supposes a compliance of 23.26% of DSM-5 if the diagnostic modifications made have caused the sample. Further studies have verified the limited usefulness significant changes in the levels of severity of the disorder, of the item in diagnosis, considering it to serve more as an taking into account the consequences they could cause indicator of disorder severity than as an independent diagnostic at the clinical level. Future research should also assess criterion (Petry et al., 2013; Granero et al., 2014; Wejbera et al., GD-related crimes and their legal implications in depth. 2017). Moreover, it has been suggested that GD-related criminal Moreover, being that data were obtained via a face-to-face behaviors seldom take place in the absence of other GD criteria clinical interview, they could be subject to social desirability (Jiménez-Murcia et al., 2009). bias, and, consequently, false negatives are likely due to However, the results in the present study suggest that the unreported criminal behaviors. Finally, our sample was assessment of the illegal acts criterion might be clinically relevant, only made up of a clinical population, specifically patients not so much to diagnose a patient with GD, but as an aid in who sought treatment for GD. Future studies would measuring the severity and possible prognosis of the disorder, benefit from also including gamblers from the general as well as in the decision of which therapeutic interventions population, to obtain a more exhaustive perspective of different to advocate. It is true that this criterion is important since existing phenotypes. many of the patients in which if the appearance of illegal acts in their diagnosis are involved in the legal system because Clinical Implications they use all kinds of strategies to get the funding they need In terms of clinical implications, having a psychological and (theft, fraud, etc.). This is in line with the opinion of some behavioral profile of patients diagnosed with GD, taking into authors who consider the illegal acts criterion to be essential account the compliance of the DSM criterion of commission of for clinical practice (Mitzner et al., 2011). They suggest that the criminal acts could be very beneficial to inform the treatment underreporting of criminal behaviors in a clinical assessment, and the mode of intervention. This description of both profiles possibly associated to the social desirability bias, may partially would be very interesting considering the salient aspects that explain the low prevalence rates of this criterion, which was would emerge in the diagnosis, using both versions of the manual one of the motives for eliminating this criterion in the DSM-5 and checking if taking into account or not said criterion could (Rash and Petry, 2016). influence the patient’s clinic. One of the most interesting findings in the present The main treatment used in patients diagnosed with GD relies study was the high percentage of patients that endorsed on cognitive behavioral therapy (CBT) based on live exposure the illegal acts criterion, where more than one third of techniques. Response prevention and the control of stimuli women and more than half of the men indicated that they are intended to provoke the desire to gamble and allow the had participated in illegal acts to finance their gambling. patient to learn to resist and control those desires progressively Previous research has demonstrated that both sexes show (Oei et al., 2010, 2017; Rash and Petry, 2014; Jiménez-Murcia common risk factors for criminal behavior, such as low et al., 2015). Patients who engage in criminal behavior may education levels or substance abuse (Freudenberg et al., 2008; require a more extensive type of intervention. It is also very Herbst et al., 2016). important to consider the risk of suicide, since the prevalence Finally, the data of this study indicate that the variables of suicidal attempts among GD patients endorsing the illegal related to the financing of the gambling were not related to acts criterion has been found to be higher (Potenza et al., 2000; the commission of illegal acts. That is, financing or debts Ledgerwood et al., 2005). were not directly related to criminal conduct. These results contradict previous findings by asserting associations between debts and crime and suggesting that financial difficulties could increase the likelihood of GD related criminal behaviors, CONCLUSION to find relief from financial hardship (Hoeve et al., 2014; Mestre-Bach et al., 2018b). In conclusion, the results obtained in the present study provide an increased insight to GD patients, their different personality characteristics and psychopathology in relation to the DSM illegal LIMITATIONS AND FUTURE RESEARCH acts criterion. Future studies focusing on admission processes and the design of individual treatments for GD patients is The main limitation of the study is the lack of knowledge recommended, in which the results presented in this study could about the prevalence of compliance with each of the criteria serve a beneficial role. Frontiers in Psychology | www.frontiersin.org 7 April 2019 | Volume 10 | Article 931 Jiménez-Murcia et al. Illegal Acts and DSM ETHICS STATEMENT FUNDING The present study was carried out in accordance with the Financial support was received through the Ministerio de latest version of the Declaration of Helsinki. The Bellvitge Economía y Competitividad (PSI2015-68701-R) (co-funded by University Hospital Ethics Clinical Research Committee European Regional Development Fund–ERDF, a way to build approved the study. Signed, informed consent was obtained Europe). FIS PI17/01167 and 18MSP001 – 2017I067 received aid from all patients. from the Ministerio de Sanidad, Servicios Sociales e Igualdad. CIBER Fisiología Obesidad y Nutrición (CIBERobn) and CIBER Salud Mental (CIBERSAM), both of which are initiatives of AUTHOR CONTRIBUTIONS ISCIII. GM-B is supported by a predoctoral AGAUR grant (2018 FI_B2 00174), grant co-funded by the European Social SJ-M, FF-A, AS, AH, RS, and JMM contributed to the Fund (ESF) “ESF,” investing in your future. With the support development of the study concept and design. RG performed of the Secretariat for Universities and Research of the Ministry the statistical analysis. SJ-M, RG, FF-A, AF, AH, GM-B, TS, LM, of Business and Knowledge of the Government of Catalonia. 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