ORIGINAL RESEARCH published: 11 September 2019 doi: 10.3389/fpsyt.2019.00625 Differences in Emotion Regulation Considering Gender, Age, and Gambling Preferences in a Sample of Gambling Disorder Patients Marta Sancho 1,2*, Marta de Gracia 2, Roser Granero 3,4, Sara González-Simarro 1, Isabel Sánchez 2,3, Fernando Fernández-Aranda 2,3,5, Joan Trujols 1,6, Núria Mallorquí-Bagué 1,2,3, Gemma Mestre-Bach 2,3, Amparo del Pino-Gutiérrez 2,3,7, Teresa Mena-Moreno 2, Cristina Vintró-Alcaraz 2, Trevor Steward 2,3, Neus Aymamí 2, Mónica Gómez-Peña 2, José Manuel Menchón 2,5,6 and Susana Jiménez-Murcia 2,3,5* 1 Department of Psychiatry, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain, 2 Department of Psychiatry, Bellvitge University Hospital-IDIBELL, L’Hospitalet de Llobregat, Spain, 3 CIBER Fisiopatología Obesidad y Nutrición (CIBERobn), Edited by: Instituto de Salud Carlos III, Madrid, Spain, 4 Department of Psychobiology and Methodology, Autonomous University of Qinghua He, Barcelona, Barcelona, Spain, 5 Department of Clinical Sciences, School of Medicine, University of Barcelona, Barcelona, Southwest University, China Spain, 6 CIBER Salud Mental (CIBERsam), Instituto de Salud Carlos III, Madrid, Spain, 7 Nursing Department of Mental Reviewed by: Health, Public Health, Maternal and Child Health, Nursing School of the University of Barcelona, Barcelona, Spain Damien Brevers, Free University of Brussels, Belgium Patrizia Velotti, Introduction: Impairments in emotion regulation are understood to be a transdiagnostic University of Genoa, Italy risk factor of suffering from compulsive and addictive behaviors. The aim of this study *Correspondence: was to investigate the role of emotion regulation deficits in gambling disorder and to Marta Sancho analyze these differences taking gender, age, and gambling activity preferences into msanchona@santpau.cat Susana Jiménez-Murcia account. Methods: The sample included n = 484 patients seeking treatment for gambling sjimenez@bellvitgehospital.cat disorder at a specialized outpatient service. Main outcomes were sociodemographic Specialty section: variables, emotion regulation, and gambling severity. Results: Differences between sexes This article was submitted to Psychopathology, were found in non-acceptance of emotions. Older patients obtained higher levels in a section of the journal non-acceptance of emotions, lack of emotion regulation strategies, emotional clarity, Frontiers in Psychiatry and global emotion regulation scores. No differences were found in emotion scores Received: 17 April 2019 considering gambling preferences (non-strategic versus strategic). Path analysis showed Accepted: 05 August 2019 Published: 11 September 2019 that emotion regulation scores and age had a direct effect on gambling disorder severity, Citation: while emotion regulation and gambling preference were not mediational variables in the Sancho M, de Gracia M, Granero R, relationships of gender and age with gambling severity. Conclusions: Emotion regulation González-Simarro S, Sánchez I, Fernández-Aranda F, Trujols J, impairments differ in patients seeking treatment for gambling problems. Early prevention Mallorquí-Bagué N, Mestre-Bach G, and intervention programs should incorporate the different dimensions of this process, del Pino-Gutiérrez A, Mena-Moreno T, taking into account clinical phenotypes. Vintró-Alcaraz C, Steward T, Aymamí N, Gómez-Peña M, Keywords: behavioral addiction, emotion regulation, gambling disorder, risk, severity, age, gender Menchón JM and Jiménez-Murcia S (2019) Differences in Emotion Regulation Considering Gender, Age, and Gambling INTRODUCTION Preferences in a Sample of Gambling Disorder Patients. Impairments in emotion regulation (ER) are understood to be a transdiagnostic risk factor for the Front. Psychiatry 10:625. onset and maintenance of addictions (1–5). According to Gross (6, p. 275), ER refers to “those doi: 10.3389/fpsyt.2019.00625 processes for which individuals exert an influence on their emotions, when have them and how Frontiers in Psychiatry | www.frontiersin.org 1 September 2019 | Volume 10 | Article 625 Sancho et al. ER in Gambling Disorder experience and express them.” Other models such as that by gambling preference/s seem to be clinically significant and Gratz and Roemer (7) focus on difficulties in ER, underlying provide a way of subtyping individuals with gambling-related that healthy ER should consist in the capacity to modulate rather problems (27–29). than suppress negative emotional states (8). These authors name Other variables, such as gender or age, have a core role in several components of emotional dysregulation, such as impaired the relationship between ER and GD. Studies carried out in the awareness of emotions or an inability to refrain from impulsive general population showed significant differences in ER profiles behavior when experiencing negative emotions. Studies focusing related to age and gender. Positive emotional experiences and on clinical samples have shown that individuals with ER the use of strategies to maintain them are more frequent with age deficits often engage in maladaptive behaviors to downregulate (30, 31), whereas more negative and changing emotional states or to escape from their emotions (1, 5, 9). These difficulties in are experienced during adolescence (32–34). In this regard, managing emotions can lead to a lack of coping skills and bring older people refer to a greater ability in using ER strategies (35, about errors in self-regulation and impulse control, which 36). However, ER competence decreases among older people constitute a risk factor for several disorders such as behavioral with high levels of emotion activation, for example, in those addictions (5, 10, 11). who have experienced negative life events (35, 36). In relation Concerning gambling disorder (GD; 12), although different to gender, a greater tendency toward rumination in women subgroups can be identified, with differentiated clinical, could account for increased anxiety and affective disorders (37, psychopathological, and personality characteristics, ER problems 38). It has also been suggested that women’s higher scores in are usually present in most people affected by this disorder distraction could lead them to use gambling more frequently (13–15). Rogier and Velotti (8) conceptualize this addiction as a way to escape or to avoid stressful situations and daily life in a model that integrates ER components described in Gratz frustrations (39–41). and Roemer’s model and the timeline model by Sheppes et al. Previous research has mainly focused on gambling (16) of healthy ER processing. In this way, these authors refer preferences and GD profiles. However, no study to date has to difficulties in ER processes among the individuals with GD. addressed underlying mechanisms (including direct and indirect For instance, pathological gamblers show deficits in identifying effects) between ER and other variables, such as gender and age. emotions because of a failure in emotional awareness, a difficulty ER impairments can have a significant impact on the treatment in accepting emotional states, and poor ER self-efficacy. In line outcome (42, 43). For this reason, identifying the variables with these results, Williams et al. (1) found a lack of emotional associated with ER difficulties is crucial for designing treatments clarity and emotional awareness as well as a high impulsivity in that are more specific and tailored to each patient, with the aim a sample with GD. Other authors reported greater difficulties in of increasing the response to treatment (43). Therefore, those describing feelings as well as higher scores in externally oriented patients with greater ER difficulties could benefit from specific thinking in this population compared to healthy controls (17– treatments such as mindfulness (42, 43) or serious games aimed 19). Orlowski et al. (20) associated a lack of reappraisal or an at improving these capabilities (44). accepting attitude toward negative emotions with the number of Based on the theoretical framework mentioned above, the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition aims of the current study were: a) to evaluate differences in (DSM-5) symptoms, indicating a greater GD severity. Consistent ER domains based on gender, age, and gambling preferences; with previous studies, GD is defined as an affect regulation b) to examine the predictive capacity of ER domains on GD disorder in which the gambling serves as a coping strategy (21). severity and to explore the potential moderating role of gender, These findings emphasize the role that emotion dysregulation age, and gambling subtype; and c) to conduct a path analysis and other related constructs, such as alexithymia, play in the model valuing the underlying mechanism between gender, vulnerability to GD (9). age, gambling preference, ER, and gambling severity. We A potentially addictive behavior like gambling could be hypothesized that female gender, strategic gambling, and young used as a coping strategy in the presence of negative emotional age would predict ER deficits, and that these difficulties would be states (22, 23), especially in the case of emotionally vulnerable associated with greater gambling severity. problem gamblers (13). Along these lines, GD research has described different groups of gamblers depending on the nature of ER motivations. For instance, McCormick and METHODS Taber (24) described two types of gamblers based on arousal levels: over-stimulated or under-stimulated gamblers. This Participants last type is similar to gamblers with alexithymia, described The sample consisted of 484 patients (450 men and 34 women) by Bonnaire et al. (25, 26), who are characterized by a need with gambling-related problems, consecutively recruited and for continuous stimulation, participating in exciting activities receiving outpatient treatment at the Gambling Disorder Unit such as strategic gambling (e.g., sport bets or poker) (27). In at the Department of Psychiatry of Bellvitge University Hospital addition, these individuals present greater GD severity than between 2015 and 2017. All patients were over 18 years of age. those with a preference for non-strategic gambling (e.g., slot Exclusion criteria were the presence of an organic medical illness machines or bingo). This passive gambling (non-strategic or neurodegenerative condition (such as Parkinson’s disease); a gambling) is understood as an avoidance strategy when faced psychotic disorder; and current (or history of) brain injury, a with depressive symptoms. As a whole, this suggests that neurological disease, or intellectual disabilities. Frontiers in Psychiatry | www.frontiersin.org 2 September 2019 | Volume 10 | Article 625 Sancho et al. ER in Gambling Disorder Measures TABLE 1 | Sample description (n = 484). Diagnostic Questionnaire for Pathological Gambling according to Sociodemographic variables n % DSM criteria (45). This scale includes 19 items to assess DSM Gender Female 34 7.0% diagnostic criteria for GD, based on both the DSM, Fourth Edition, Male 450 93.0% Text Revision (DSM-IV-TR) and DSM-5. The Spanish adaptation Origin Spain 447 92.4% of the questionnaire has good psychometric properties (α = 0.81 Other country 37 7.6% for general population and α = 0.77 for GD clinical sample; 46). Marital status Single 221 45.7% This study analyzed the total number of DSM-5 criteria for GD as Married/partner 192 39.7% Separated/divorced 71 14.7% a measure of gambling behavior severity. Education level Primary 273 56.4% Difficulties in Emotion Regulation Scale (DERS; 7). This self- Secondary 177 36.6% report questionnaire contains 36 items that assess difficulties University 34 7.0% in regulating emotions. It is composed of six first-order scales: Social index Medium-high to 38 7.8% 1) non-acceptance of emotional responses, 2) difficulties engaging high Medium 48 9.9% in goal-directed behavior, 3) impulse-control difficulties, Medium-low 190 39.3% 4) lack of emotional awareness, 5) limited access to effective ER Low 208 43.0% strategies, and 6) lack of emotional clarity. A total scale is also Employment Unemployed 171 35.3% available as a global measure of emotion dysregulation. This Employed 313 64.7% study used the Spanish version of the questionnaire, which has Clinical variables α Mean SD demonstrated adequate psychometric features (47). Age (years) 41.27 13.21 Sociodemographic and Clinical Variables. Patients completed GD onset (years) 29.07 11.80 a semi-structured face-to-face interview regarding GD, GD duration (years) 5.83 5.86 psychopathological symptoms, and personality traits (48). Mean bets—episode (euros) 167 542 Maximum bets—episode (euros) 2,000 6,561 The same interview also collected sociodemographic data Cumulate debts, present (euros) 9,681 20,745 (e.g., education, occupation, marital status) and additional DSM-5 total criteria .821 6.99 2.00 clinical information, such as gambling preferences (non-strategic DERS non-acceptance of emotions .886 17.38 6.73 versus strategic gambling). Social status was measured using the DERS goal-directed behaviors .797 14.11 4.82 Hollingshead index, a survey based on educational level and DERS impulse control .840 14.03 5.71 DERS lack of emotional awareness .714 16.63 4.52 occupational prestige (49). DERS emotion regulation .891 19.56 7.84 Table 1 includes the internal consistency (Cronbach’s alpha, α) DERS emotional clarity .755 11.94 4.18 for the psychometric scales used in the study. Effect sizes for DERS total score .930 93.52 24.87 these coefficients, according to Cicchetti (50), were in the fair SD, standard deviation; α, Cronbach’s alpha in the current study. range (α = 0.714 for DERS lack of emotional awareness scale) to excellent (α = 0.930 for DERS total scale). and |d| > 0.8 was large; 51). In this study, Finner’s procedure was used to control type I error due to multiple comparisons Procedure (this method is included in the family-wise error rate stepwise The assessment was conducted prospectively upon arrival to procedures and offers a more powerful test than Bonferroni the treatment unit and prior to treatment during a face-to-face correction; 52). interview (with a mean duration of 90 min), in which the tests The predictive capacity of ER dimensions (DERS scores, mentioned above were administered. defined as the independent variable) on GD severity (DSM-5 In this study, the differentiation between strategic versus total criteria for GD, defined as the criterion) was assessed with non-strategic gambling was based on gambling activity, which a lineal multiple regression. Independent models were obtained represented the highest impairment for the participants and was considering DERS first-order scales and DERS total scales, and reported as the main reason for seeking treatment. the modeling was run in three blocks: a) the first block included and set the participants’ gender, age, and gambling preference; Statistical Analysis b) the second block added DERS scale scores; and c) the third Statistical analysis was carried out with Stata15 for Windows. block added and tested the interactions between each DERS Comparisons for mean scores on DERS scales were based on scale and gender, age, and gambling subtype. The final model analysis of variance (ANOVA) procedures. Gender comparisons only retained those significant interaction parameters (p ≤ 05), (women versus men) were adjusted for the covariates age and obtained main effects for DERS scales that had no significant GD severity (DSM-5 total criteria). Group age comparisons (two interaction parameters and single effects for DERS scales with groups were compared based on the age median in the sample) significant interactions. The predictive capacity of the final were adjusted for patients’ gender and GD severity. Comparisons model was measured through the adjusted R2 coefficient, and for gambling preference (non-strategic vs. strategic) were the predictive capacity of each block through the change in the adjusted for patients’ gender, age, and GD severity. The effect size adjusted R2. for mean differences was estimated through Cohen’s d coefficient Structural equation modeling (SEM) was conducted to test (|d| > 0.20 was considered poor effect size, |d| > 0.5 was moderate, the underlying mechanisms between the patients’ gender, age, Frontiers in Psychiatry | www.frontiersin.org 3 September 2019 | Volume 10 | Article 625 Sancho et al. ER in Gambling Disorder gambling preference (non-strategic vs. strategic), ER levels The mean age was 41.3 years (SD = 13.2), the mean age of GD (DERS scale scores), and GD severity (DSM-5 total criteria). onset was 29.1 years (SD = 11.8), and the mean duration of GD Specifically, path analysis was run using the maximum was 5.8 years (SD = 5.9). Regarding gambling variables, the mean likelihood (ML) estimator, and the overall goodness-of-fit number of DSM-5 criteria for GD was 7 (SD = 2), and 56.8% of was evaluated through standard statistical measures (53): the the patients reported debts related to gambling behaviors. Based root mean square error of approximation (RMSEA), Bentler’s on the GD severity classification of DSM-5, n = 31 patients were comparative fit index (CFI), the Tucker–Lewis index (TLI), in the problematic group (6.4% of the participants did not meet and the standardized root mean square residual (SRMR). clinical criteria for GD diagnosis and reported between one and RMSEA < 0.10, TLI > 0.9, CFI > 0.9, and SRMR < 0.1 were three symptoms), n = 66 in the low-severity group (13.6%, with considered adequate model fit. four or five symptoms), n = 158 in the moderate-severity group (32.6%, with six or seven symptoms), and n = 229 in the severe group (47.3%, with eight or nine symptoms). RESULTS Sample Characteristics Associations Between Emotion Regulation Table 1 includes the description of the sociodemographic and and Gender, Age, and clinical variables of the study sample. Most participants were Gambling Preference men (93%), born in Spain (92.4%), single (45.7%) or married Table 2 contains the results of the ANOVA procedures (adjusted (or living with a stable partner, 39.7%), with low education levels for age and GD severity) in the study [all the models fulfilled (56.4% completed primary schools), employed (64.7%), and goodness-of-fit, with non-significant results (p > .05) in the lack- with middle-low (39.3%) to low (43.0%) social position index. of-fit tests]. The upper part of this table includes the comparison TABLE 2 | Comparison of the DERS scores based on gender, age, and gambling preference. Women Men ANOVA adjusted for patients’ age (n = 34) (n = 450) and gambling severity Mean SD Mean SD MD F-stat p |d| DERS non-acceptance of emotions 15.13 5.17 17.55 6.82 2.42 4.655 .031* 0.40 DERS goal-directed behaviors 13.93 4.54 14.12 4.85 0.19 .058 .810 0.04 DERS impulse control 14.50 5.57 13.99 5.72 0.50 .287 .593 0.09 DERS lack of emotional awareness 16.82 3.78 16.62 4.57 0.20 .058 .810 0.05 DERS emotion regulation 18.85 6.37 19.62 7.94 0.77 .343 .558 0.11 DERS emotional clarity 11.99 4.49 11.94 4.16 0.05 .005 .942 0.01 DERS total score 91.20 20.69 93.70 25.18 2.50 .380 .538 0.11 1 Age: 18–40 1 Age: 41–75 ANOVA adjusted for gender (n = 252) (n = 232) and gambling severity Mean SD Mean SD MD F-stat p |d| DERS non-acceptance of emotions 16.19 6.61 18.68 6.80 2.48 18.251 <.001* 0.37 DERS goal-directed behaviors 13.85 4.86 14.39 4.79 0.53 1.623 .203 0.11 DERS impulse control 13.75 5.90 14.33 5.50 0.58 1.434 .232 0.10 DERS lack of emotional awareness 16.41 4.38 16.87 4.67 0.47 1.200 .274 0.10 DERS emotion regulation 18.28 7.79 20.97 7.85 2.69 15.754 <.001* 0.34 DERS emotional clarity 11.56 4.10 12.37 4.27 0.81 4.642 .032* 0.19 DERS total score 89.83 25.16 97.61 24.50 7.77 13.611 <.001* 0.31 Non-strategic Strategic ANOVA adjusted for gender, age, (n = 346) (n = 138) and gambling severity Mean SD Mean SD MD F-stat p |d| DERS non-acceptance of wemotions 17.63 17.72 16.76 16.54 0.88 1.667 .197 0.05 DERS goal-directed behaviors 13.87 13.80 14.71 14.88 0.84 2.968 .086 0.06 DERS impulse control 13.89 13.82 14.37 14.56 0.48 .698 .404 0.03 DERS lack of emotional awareness 16.57 16.66 16.79 16.57 0.22 .201 .654 0.01 DERS emotion regulation 19.61 19.65 19.46 19.35 0.15 .036 .849 0.01 DERS emotional clarity 11.95 11.97 11.93 11.88 0.03 .004 .952 0.00 DERS total score 93.26 93.38 94.14 93.87 0.88 .130 .719 0.01 1Groups of age defined by the median of the chronological age in the sample (40 years old). SD, standard deviation; MD, mean difference. *Bold: significant comparison (.05). Frontiers in Psychiatry | www.frontiersin.org 4 September 2019 | Volume 10 | Article 625 Sancho et al. ER in Gambling Disorder of mean DERS scores for both genders (ANOVA adjusted for Material, contains complete model results). The independent age and GD severity). Significant differences were only found for variables of the model were gender (0 = female, 1 = male) and the non-acceptance of emotions scale: men showed higher mean age (years). The dependent variable was GD severity (DSM-5 scores than women (17.6 versus 15.1, p = .031). total criteria), and the mediational variables were gambling The middle section of Table 2 contains the mean comparisons preference (0 = non-strategic; 1 = strategic) and ER levels (a between the two age groups (classification that was based on latent variable was defined as a global measure of ER difficulties the median—percentile 50—age of the sample, 40 years old), based on the raw scores on the first-order factors of the DERS). adjusted for gender and GD severity. Higher means corresponded Adequate goodness-of-fit was obtained: RMSEA = 0.054 (95% to participants in the older age group for DERS non-acceptance CI: 0.037 to 0.072), CFI = 0.978, TLI = 0.961, and SRMR = 0.035. of emotions, limited access to effective ER strategies, lack of The global predictive capacity for the model was around 19%. emotional clarity, and total scales. Regarding the latent variable, all DERS subscales obtained The lower part of Table 2 includes the comparison of DERS significant and high loadings (higher than 0.30), except for the subscale scores based on gambling preferences (non-strategic awareness dimension. DERS scores obtained a direct effect on versus strategic). No statistically significant differences between GD severity (the higher the scores, the higher the GD severity), both groups were found. and age also registered a direct effect on this criterion (the younger the patients, the higher the number of GD DSM-5 criteria). No direct effect of gender and gambling preference Predictive Model on gambling severity was found. DERS scores and gambling Table 3 includes the two models valuing the predictive capacity preference were not mediational variables between gender or age of ER dimensions on GD severity, as well as the potential and gambling severity. moderating role of gender, age, and gambling preference. The block assessing the interaction parameters between DERS scores and participants’ gender, age and, gambling preference was not significant (block/step 3 of model 1: F = 1.18, df = 18/440, DISCUSSION p = .272; block/step 3 of model 2: F = 1.27, df = 3/460, p = .285), The present study analyzed the role of ER, as measured on the indicating that the contribution of ER to gambling severity is DERS, on GD severity and the potential differences in gender, not dependent on/moderated by these features. Considering the age, and gambling preference. The main results of our study regression including DERS first-order scales, gambling severity demonstrate higher levels of the non-acceptance of emotions was higher for younger patients and those with greater levels in among men, worse ER scores in older patients, and no ER scales measuring non-acceptance of emotions and impulse significant differences in ED regarding gambling preferences control. Regarding the regression modeling for DERS total (comparing non-strategic versus strategic activities). Path scale (model 2), gambling severity was also higher for younger analysis showed direct effects of age and ER scores on GD participants and those with higher DERS total scores. severity and that ED and gambling preference did not mediate the relationship between gender or age and GD severity. Pathways Analysis Contrary to hypothesized, the comparison of ER profiles Figure 1 includes the path diagram with the standardized by gender showed more difficulties in ER for men compared coefficients obtained in SEM (Table S1, Supplementary to women (specifically, men had poorer performance in the TABLE 3 | Predictive capacity of emotion regulation on gambling severity (DSM-5 total criteria). Model 1: DERS first-order scales B SE Beta T p 95% CI for B Gender (0 = women/1 = men) −0.184 0.322 −0.024 −0.570 .569 −0.817 0.450 Age (years) −0.031 0.007 −0.202 −4.459 <.001* −0.044 −0.017 Gambling type (0 = non-strategic/1 = strategic) 0.096 0.195 0.022 0.493 .622 −0.286 0.478 DERS: non-acceptance of emotions 0.040 0.019 0.135 2.147 .032* 0.003 0.077 DERS: goal-directed behaviors 0.044 0.026 0.106 1.692 .091 −0.007 0.094 DERS: impulse control 0.064 0.022 0.184 2.888 .004* 0.020 0.107 DERS: lack of emotional awareness 0.017 0.020 0.038 0.830 .407 −0.023 0.056 DERS: emotion regulation 0.018 0.020 0.071 0.912 .362 −0.021 0.057 DERS: emotional clarity 0.025 0.024 0.052 1.014 .311 −0.023 0.073 Model 2: DERS total score B SE Beta T p 95% CI for B Gender (0 = women/1 = men) −0.202 0.320 −0.026 −0.630 .529 −0.831 0.427 Age (years) −0.032 0.007 −0.210 −4.709 <.001* −0.045 −0.019 Gambling type (0 = non-strategic/1 = strategic) 0.117 0.192 0.027 0.611 .542 −0.260 0.495 DERS: total 0.036 0.003 0.453 11.179 <.001* 0.030 0.043 B, non-standardized parameter; SE, standard error; Beta, standardized parameter. *Bold: significant parameter (.05 level). Frontiers in Psychiatry | www.frontiersin.org 5 September 2019 | Volume 10 | Article 625 Sancho et al. ER in Gambling Disorder FIGURE 1 | Sem model for the whole sample, standardized coefficients. Note. 1EmDis: emotional dysregulation (latent variable defined with the DERS first order scales). Continous line: significant coefficient (.05 level). Dash-line: non-significant coefficient. Grey: covariance parameter. non-acceptance of emotions domain). A possible explanation of No significant differences between gambling preference this finding could be due to the fact that men tend to adopt less (comparing non-strategic and strategic gambling) and ER adaptive strategies, namely, emotional suppression rather than profile in our sample were found. A possible explanation for our cognitive reappraisal (54). On the contrary, women show greater results could be the psychometric measures used. Perhaps the predisposition to report their emotional states and to use more inclusion of other measures of ER and related constructs would adaptive ER strategies than men (55–58). This greater emotional yield different results. In line with this, studies have related awareness has been observed in women even from an early age gambling preference with alexithymia. For instance, Bonnaire (59–61). Similarly, some studies suggest non-aware and automatic et al. (26) demonstrated problems of alexithymia in individuals ER in men on leisure activities (62–64), showing a tendency to with a preference for strategic gambling (e.g., sport bets or suppress emotional experience (35). This increased difficulty in poker) and depressive symptoms in those with a preference for accepting emotions could drive men to get involved in distracting non-strategic gambling (e.g., slot machines or bingo). Similarly, activities as an experiential avoidance strategy and also lead to other authors (28, 29, 65) found a subtype of addicted gamblers other forms of psychopathology (such as alcohol abuse) (39). who experience high levels of excitement and narcissistic traits. Also, contrary to our hypothesis regarding age, in this These individuals would be involved in strategic gambling, which sample, older patients showed higher scores in three first- induces elevated arousal though a high excitatory potential, order scales of DERS (limited access to effective ER strategies, suggesting possible alexithymia. lack of emotional clarity, and non-acceptance of emotions) In the present study, gambling severity was higher for as well as in DERS total scores. Based on the available data, younger patients. So, GD severity was higher in patients with we would expect worse performance in ER for younger higher levels across several ER domains (e.g., non-acceptance patients (32–34). One possible explanation accounting for our of emotions and impulse control), as well as ER global measure. results could come from GD itself: patients’ involvement in Greater GD severity in younger individuals could be explained persistent, uncontrollable, and unwanted gambling behavior by a preference of strategic gambling in this population. In generates significant emotional discomfort (distress), which addition, this subtype of gambling causes a higher level of could increase maladaptive ER strategies even at older ages. gambling-related biases, such as illusion of control (66, 67), This hypothesis requires further empirical research, however. increasing the severity of the disorder. In line with this, In line with this, some pioneering studies suggest that some previous studies showed that strategic gambling is associated strategies, such as emotional suppression, may be a useful with increased severity and with young gamblers, while non- form of ER for managing stressors in older age, which entails strategic gamblers tend to be older and less severe (26, 68–71). a possible decoupling of the psychological distress with age Likewise, an early onset of GD is generally related to a severe (65). However, these results must be evaluated with caution, presentation, as well as dysfunctional personality traits and since they have not assessed the specific contribution of ER greater psychopathology (46, 72). Other studies have shown domains in clinical samples of GD patients. less severity with advancing age, although medical problems Frontiers in Psychiatry | www.frontiersin.org 6 September 2019 | Volume 10 | Article 625 Sancho et al. ER in Gambling Disorder and depression increase (68, 69). In accordance with other explaining the relationships and the underlying mechanisms studies (25, 26, 73), in which ER-related constructs, such as between ER and gambling severity. Future research based alexithymia, were positively correlated with gambling severity, on alternative and complementary statistical procedures our results also indicated higher levels of ER deficits when such as person-centered approaches (e.g., mixture models or gambling severity was higher. The severity of the disorder cluster analysis) should focus on identifying the dynamics was higher in the younger group, but older patients showed of emergent therapeutic needs based on the categorizing of greater levels of ER. Some studies have identified associations individuals into common subgroups based on substantive between psychopathology and older age (72), suggesting that variables (such as ER domains) and on understanding the gambling could be a dysfunctional strategy to cope with or to pattern of relationships of these empirical latent clusters with regulate negative emotions in these cases (74, 75). predictors, correlates, and therapy outcomes. Our study has several limitations that need to be considered when interpreting the results. Firstly, the sample of this work includes mainly men with medium-low to low social position DATA AVAILABILITY levels and primary school education. Secondly, the number of women featured in the study is very small compared to men, All datasets generated for this study are included in the which could decrease statistical power (that is, increase in manuscript and the supplementary files. the likelihood of a type II error and therefore the ability to detect the real effect of gender on the relationship between ER and gambling). It must be argued, however, that this ETHICS STATEMENT study included all the patients consecutively arriving at the treatment unit, where the proportion of GD in men is higher. This study was carried out in accordance with the latest The number of women was enough to allow for statistical version of the Declaration of Helsinki. The Ethics Committee analyses. Thirdly, the size of the non-strategic gambler group of the University Hospital of Bellvitge approved the study and was greater than the strategic gambling group, and this could written informed consent was obtained and signed from all have interfered in our results. Further studies with larger final participants. sample sizes are needed to increase statistical power and external generalization validity. In spite of these limitations, the results of this study highlight AUTHOR CONTRIBUTIONS the importance of taking into account gender, age, and gambling type during treatment. The severity presented by the younger MS, SJ-M, IS, RG, and JMM were in charge of research project patients and those with a high level of ER could hinder cognitive– elaboration. MS, SJ-M, IS, and RG were in charge of organization. behavioral therapy. Although this treatment is effective for MS, SJ-M, IS, and RG were in charge of design. MS, MG, RG, GD, in these cases, other approaches could be considered NM-B, GM-B, AP-G, TM-M, CV-A, TS, NA, MG-P, and SJ-M (42, 76, 77). This subgroup could benefit from mindfulness- were in charge of execution. Writing of the first draft was done based interventions (MBI), such as mindfulness-based relapse by MS. Review and critique were done by MS, SJ-M, IS, JT, SG-S, prevention (MBRP; 78, 79). These types of treatment programs and FF-A. target the experiences of craving and negative affect. In addition, MBI is directly aimed at treating the experiential avoidance observed in these patients, improving their metacognitive FUNDING capacities (80–83). This manuscript and research were supported by grants from the Instituto de Salud Carlos III (ISCIII) and cofounded by CONCLUSIONS the FEDER funds/European Regional Development Fund (ERDF), a way to build Europe. CIBERobn and CIBERsam This study provides greater understanding about the role of are initiatives of ISCIII. This work was also supported by the ER in GD. On one hand, our results suggest greater severity of Ministerio de Economía y Competitividad (PSI2015-68701-R) GD among individuals with high ER deficits and in younger and by the Delegación del Gobierno para el Plan Nacional sobre individuals. On the other hand, ER deficits are higher in men Drogas(2017I067). and older individuals. No differences in ER strategies based on gambling preference (strategic vs. non-strategic) were found. Future research should focus on exploring ER and other SUPPLEMENTARY MATERIAL related constructs such as alexithymia, as well as on developing treatments that target difficulties in these aspects. 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