Addictive Behaviors 126 (2022) 107176 Contents lists available at ScienceDirect Addictive Behaviors journal homepage: www.elsevier.com/locate/addictbeh Do emotion regulation and impulsivity differ according to gambling preferences in clinical samples of gamblers? Cristina Vintró-Alcaraz a, b, c, 1, Gemma Mestre-Bach d, 1, Roser Granero c, e, Mónica Gómez-Peña a, Laura Moragas a, Fernando Fernández-Aranda a, b, c, f, Susana Jiménez-Murcia a, b, c, f, * a Department of Psychiatry. Bellvitge University Hospital-IDIBELL, Barcelona, Spain b Psychiatry and Mental Health Group, Neuroscience Program, Institut d’Investigació Biomèdica de Bellvitge-IDIBELL, L’Hospitalet de Llobregat, Barcelona, Spain c Ciber Fisiopatología Obesidad y Nutrición (CIBERObn), Instituto de Salud Carlos III, Madrid, Spain d Universidad Internacional de La Rioja, La Rioja, Spain e Departament de Psicobiologia i Metodologia de les Ciències de la Salut, Universitat Autònoma de Barcelona, Barcelona, Spain f Department of Clinical Sciences, School of Medicine and Health Sciences, University of Barcelona, Barcelona, Spain A R T I C L E I N F O A B S T R A C T Keywords: Background and aims: Emotion regulation (ER) and impulsivity impairments have been reported in patients with Gambling disorder gambling disorder (GD). However, both constructs have not been studied in depth jointly in clinical samples. Emotion regulation Therefore, the aim of this study was to analyze ER and impulsive tendencies/traits in a sample of n = 321 Impulsivity treatment-seeking individuals with GD by differentiating them according to their gambling preference (n = 100 Gambling preferences Strategic strategic; n = 221 non-strategic). Non-strategic Methods: Our sample was assessed through the DERS (ER), the UPPS-P (impulsivity), and the DSM-5 (GD severity). Results: The non-strategic group included a higher proportion of women and reported greater ER impairments, and more impulsive traits/tendencies compared to strategic gamblers. GD severity was associated with all DERS subscale (except for awareness) and with urgency dimensions of the UPPS-P. Discussion and conclusions: Our findings confirm that strategic and non-strategic gamblers differ in their ER processes and impulsive tendencies, showing the first clinical group a more adaptive profile. These results suggest the relevance of assessing these ER and impulsivity in order to tailor better treatment approaches. 1. Introduction strategic and non-strategic gambling. In strategic gambling (e.g. poker, blackjack, sports betting, stock market investment, and animal racing), According to the Diagnostic and Statistical Manual of Mental Dis­ gamblers have to use their individual skills and knowledge about the orders Fifth Edition, Gambling disorder (GD) is the only behavioral game (Moragas et al., 2015; Odlaug, Marsh, Kim, & Grant, 2011). Non- addiction (DSM-5; American Psychiatric Association, 2013). It is char­ strategic gambling, also named chance or passive gambling (e.g. lot­ acterized by recurrent gambling behaviors that persist over time despite teries, slot machines, and bingo) (Barrault, Mathieu, Brunault, & Var­ their negative consequences and lead to social impairments (American escon, 2019; Navas et al., 2017), is characterized by a lack of influence Psychiatric Association, 2013). It has been described as a heterogeneous on the outcome (Grant, Odlaug, Chamberlain, & Schreiber, 2012; condition resulting in different gambler profiles. A widely used Odlaug et al., 2011). GD has been associated with multiple clinical approach for the classification of gamblers is based on gambling pref­ factors, including emotion regulation (ER) difficulties (Mestre-Bach, erences. Gambling activities have been classified into two modalities: Fernández-Aranda, Jiménez-Murcia, & Potenza, 2020) and impulsive * Corresponding author at: Department of Psychiatry, Bellvitge University Hospital-IDIBELL and CIBERObn, C/Feixa Llarga s/n, 08907, L’Hospitalet de Llobregat, Barcelona, Spain. E-mail addresses: cvintro@bellvitgehospital.cat (C. Vintró-Alcaraz), gemma.mestre@unir.net (G. Mestre-Bach), Roser.Granero@uab.cat (R. Granero), monicagomez@bellvitgehospital.cat (M. Gómez-Peña), lmoragas@bellvitgehospital.cat (L. Moragas), ffernandez@bellvitgehospital.cat (F. Fernández-Aranda), sjimenez@bellvitgehospital.cat (S. Jiménez-Murcia). 1 Shared first authorship. https://doi.org/10.1016/j.addbeh.2021.107176 Received 3 August 2021; Received in revised form 18 October 2021; Accepted 3 November 2021 Available online 8 November 2021 0306-4603/© 2021 The Author(s). Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). C. Vintró-Alcaraz et al. Addictive Behaviors 126 (2022) 107176 tendencies/traits (Mallorquí-Bagué et al., 2019; Nower & Blaszczynski, suggested, it has not been studied in depth in GD. In other disorders, 2006). such as alcohol use disorder, it has been observed that high levels of Emotion regulation (ER) is defined as the process by which in­ impulsivity and difficulties in ER were factors derived from the disorder dividuals try to influence the experience and expression of their emo­ and predicted relapse rates in individuals with this pathology (Jakubc­ tions (Gross, 1998). Emotion regulation skills are associated with good zyk et al., 2018). In other studies, negative urgency and ER difficulties school performance and good social relationships in children and ado­ have been found to be predictors of problematic behaviors (Hasking & lescents (Rawana, Flett, McPhie, Nguyen, & Norwood, 2014) and with Claes, 2020). It is essential, therefore, to delve deeper into how the two greater well-being in adults (Hu et al., 2014). On the other hand, transdiagnostic factors work together. impaired ER is related to the development and maintenance of several To address this limitation, the purpose of this study was two-fold. mental disorders (Sheppes, Suri, & Gross, 2015), including GD (Elmas, Our first aim was to examine whether ER and impulsive tendencies/ Cesur, & Oral, 2017; Velotti, Rogier, Beomonte Zobel, & Billieux, 2021; traits varied between strategic and non-strategic treatment-seeking Williams, Grisham, Erskine, & Cassedy, 2012). More specifically, pre­ adults with GD. Our second aim was to explore the association between vious studies found high levels of experiential avoidance of emotions in ER, impulsive tendencies/traits, and GD severity. Based on previous GD populations (Riley, 2014), as well as impaired abilities identifying studies (Mallorquí-Bagué et al., 2019; Sancho et al., 2019), we hy­ (Rogier & Velotti, 2018) and accepting emotions (Jauregui, Estévez, & pothesized that strategic and non-strategic gamblers will present similar Urbiola, 2016). It has also been found that suppression, described as the ER skills, whereas higher impulsive traits will be reported by those pa­ attempt to eliminate emotional thoughts and expressions (Gross, 1998), tients with a preference for strategic gambling. In addition, we consider was affected in these individuals (Navas et al., 2017; Rogier, Beomonte that especially positive and negative urgency will be linked to the Zobel, & Velotti, 2020). A recent systematic review upholds that sup­ different facets of ER. pression, understood as a maladaptive strategy, is more commonly used in strategic gamblers in comparison to mixed gamblers (who use both 2. Methods strategic and non-strategic modalities) (Marchica, Mills, Derevensky, & Montreuil, 2019). Moreover, alexithymia, defined as difficulties in 2.1. Participants and procedure identifying and describing feelings (Preece et al., 2020) has been related to strategic gambling (Bonnaire et al., 2017). Previous studies reported The sample included n = 321 consecutive treatment-seeking adults that some individuals with GD may use gambling as a way to regulate or with a GD diagnosis recruited from the Behavioral Addictions Unit escape from unpleasant emotions (Rogier & Velotti, 2018; Wood & within the Department of Psychiatry of Bellvitge University Hospital Griffiths, 2007). In this sense, higher ER deficits have been associated (Barcelona) between March 2016 and February 2021. This public hos­ with a higher GD severity (Elmas et al., 2017; Mestre-Bach et al., 2021; pital is certified as a tertiary care center (high specialization) for the Rogier & Velotti, 2018; Williams et al., 2012). treatment of psychological addictive behaviors and oversees the treat­ Impulsive tendencies/traits have also been described as a hallmark of ment of very complex cases. The catchment area of the hospital includes GD (Aragay et al., 2018; Canale, Vieno, Bowden-Jones, & Billieux, 2017; over two million people in the south of the metropolitan area of Savvidou et al., 2017). In general terms, impulsive tendencies/traits Barcelona. allow quick decisions to be made in situations that require it and tend to Diagnoses were determined by psychologists and psychiatrists be more accentuated in the young population and in the male gender with>20 years of clinical experience in both the assessment and treat­ (Chamorro et al., 2012). The UPPS-P theoretical model proposes five ment of GD. Only patients who sought treatment for GD as their primary dimensions of impulsivity: lack of premeditation (the tendency to act mental health concern were included in our sample. without considering the consequences of behavior), lack of perseverance Two different groups were made according to gambling preferences: (the disposition to fail to maintain focus on difficult or boring tasks), strategic vs. non-strategic. Those patients who gambled more than one positive and negative urgency (the tendency to perform impulsive be­ typology were classified based on the main gambling problem, i.e., that haviors when experiencing highly pleasant or unpleasant emotions, gambling activity that caused them the most distress and in which they respectively), and sensation seeking (the disposition to engage in spent the greatest amount of time. Inclusion criteria were: (1) being exciting and new experiences) (Whiteside, Lynam, Miller, & Reynolds, older than 18 years old; (2) both genders; and (3) having GD as their 2005). Among them, it has been observed that especially the urgency primary health concern. Exclusion criteria were: (1) having a history of levels are associated with GD severity (Billieux et al., 2012; Grall- brain injury or neurological disease; and (2) reporting an organic Bronnec et al., 2012; Yan, Zhang, Lan, Li, & Sui, 2016). Urgency has medical illness or neurodegenerative condition. also been associated with affective and executive mechanisms, both relevant factors in GD (Amlung, Vedelago, Acker, Balodis, & MacKillop, 2.2. Measures 2017; Lannoy et al., 2014; Wilbertz et al., 2014). Therefore, it has been suggested that urgency and high lack of perseverance are the dimensions 2.2.1. South oaks gambling screen (SOGS; Lesieur & Blume, 1987) that best distinguish individuals with GD from controls (Billieux et al., This is a self-reported screening questionnaire structured in 20 items. 2012; Michalczuk, Bowden-Jones, Verdejo-Garcia, & Clark, 2011). It discriminates between non-problem, probable pathological, and Finally, the dimension of lack of premeditation may be associated with problem gamblers. In this work, the Spanish validation (Echeburúa, poor decision making processes, another typical clinical feature of GD Báez, Fernández-Montalvo, & Páez, 1994) was used which showed (Mallorquí-Bagué et al., 2016; Navas, Verdejo-García, López-Gómez, excellent internal consistency (α = 0.94) and test–retest reliability (r = Maldonado, & Perales, 2016). 0.98). In the present sample, internal consistency was adequate (α = Although both ER and impulsivity have been proposed as two in­ 0.78). dependent constructs associated with GD, there is a possible link be­ tween them (Navas et al., 2017). In fact, it is well known that emotion 2.2.2. DSM-5 criteria (American Psychiatric Association, 2013) facilitates action and, consequently, experiencing intense emotions may Patients were diagnosed with GD if they met four or more criteria for be associated with the tendency to focus on immediate situations (Cy­ this disorder according to the DSM-5 (American Psychiatric Association, ders & Smith, 2008). On this basis, some authors have defined the di­ 2013). The internal consistency in this study was good (α = 0.812). mensions of positive and negative urgency as “emotional impulsivity” (Whiteside et al., 2005). That is, in the face of intense emotions, in­ 2.2.3. Difficulties in emotion regulation scale (DERS; Gratz & Roemer, dividuals with GD would present a greater tendency to act impulsively. 2004) However, although an association between ER and impulsivity has been This self-report questionnaire includes 36 items divided into six 2 C. Vintró-Alcaraz et al. Addictive Behaviors 126 (2022) 107176 subscales that measure emotional dysregulation: (1) lack of emotional DSM-5 criteria and SOGS-total). Two estimation methods were awareness (difficulties attending to emotional states), (2) lack of employed: enter procedure and stepwise procedure. emotional clarity (impairments related to recognizing emotional expe­ riences), (3) non-acceptance of emotional responses (the tendency to 2.4. Ethics experience negative secondary emotional responses), (4) difficulties engaging in goal-directed behavior (difficulties accomplishing tasks in The study procedures were carried out in accordance with the the presence of intense emotional states) (5) limited access to ER stra­ Declaration of Helsinki. The University Hospital Clinical Research Ethics tegies (this dimension reflects the belief that there is little that can be Committee approved the study. All subjects were informed about the done to effectively regulate emotions when experiencing upset) and (6) study and all provided informed consent. impulse control difficulties (meaning an impairment in remaining in control of one’s behavior under negative emotional states). This work 3. Results used the Spanish version of the questionnaire (Hervás & Jódar, 2008; Wolz et al., 2015). The internal consistency of our sample ranged from α 3.1. Characteristics of the sample = 0.76 to α = 0.93. The first block of Table 1 contains the descriptive for the complete 2.2.4. Impulsive behavior scale (UPPS-P; Whiteside et al., 2005) sample. Most participants were male (90.0%), achieved primary The UPPS-P is a 59-item self-report questionnaire developed for (48.0%) or secondary education levels (41.1%), were single (49.2%) or assessing five impulsive traits: (1) lack of perseverance, (2) lack of married (41.1%), were employed (63.2%) and pertained to social in­ premeditation, (3) sensation seeking, (4) negative urgency, and (5) dexes mean-low to low (79.1%). The mean age was 40.0 years (SD = positive urgency. The Spanish adaptation of this instrument, which was 13.8), the average age of onset of gambling problems was 28.8 years (SD used in the present study, showed adequate psychometric properties = 12.1) and the average duration of the gambling problems was 5.6 (Verdejo-García, Lozano, Moya, Alcázar, & Pérez-García, 2010). In our years (SD = 5.8). sample, internal consistency ranged from adequate (α = 0.75 for lack of The second block of Table 1 contains the comparison for the vari­ perseverance) to excellent (α = 0.92 or the negative urgency subscale). ables based on the gambling preference (non-strategic versus strategic). Non-strategic gambling was associated with female gender, lower edu­ 2.2.5. Other clinical and Sociodemographic variables cation levels, higher likelihood of being single, higher probability of A semi-structured face-to-face clinical interview was used in the being unemployed, and lower education levels. Non-strategic gambling present study to analyze additional data such as age, gender, education was also characterized by older age, later onset of the gambling prob­ level, civil status, employment status, and social status. This last variable lems, and longer duration of the gambling problems. No differences was defined with Hollingshead’s algorithm, which provides a global between the groups were obtained for the GD severity (number of DSM- measurement based on the patients’ education level, the profession and 5 criteria and SOGS total). the employment status (Hollingshead, 2011). Other gambling-related variables [the age of onset of the GD and the duration of this disorder, 3.2. Association between gambling preferences and ER and impulsive as well as the main gambling activity (strategic versus non-strategic)] tendencies/traits were also analyzed in this work. Table 2 contains the results of the ANCOVA (adjusted by age, gender, 2.3. Statistical analysis and social position), comparing the DERS and the UPPS-P scores be­ tween the groups defined by the gambling preference. Non-strategic The statistical analysis was performed with Stata17 for Windows gambling was associated with higher impairments in ER in all the do­ (Stata-Corp., 2021). First, the comparison between the groups defined mains assessed using the DERS (except in the difficulties in engaging in by the gambling preference was done with chi-square tests (|2) for cat­ goal-directed behavior/goals subscale), as well as higher levels in the egorical variables and T-TEST for quantitative measures. The compari­ impulsivity domains positive urgency, negative urgency, and total. son between the groups for the ER and the impulsive tendencies/traits Fig. 1 contains the radar chart displaying the standardized z-scores in scores was adjusted by the covariates’ age, gender and social position, the DERS and the UPPS-P registered in each group. Fig. 2 contains the through analysis of covariance (ANCOVA). All these comparisons graph-lines with the prevalence of participants within the clinical range included Cohen’s-h and Cohen’s-d coefficients for estimating the effect for each gambling preference (Table S1, supplementary material). It size of the proportion differences and the mean differences (null effect includes the statistical comparison for the proportions of the graphs. size was considered for values |h|<0.20 or |d|<0.20, low-poor for |h|> 0.20 or |d|>0.20, moderate-medium for |h|>0.50 or |d|>0.50, and 3.3. Correlations between ER, impulsive tendencies/traits and GD severity large-high for |h|>0.80 or |d|>0.80) (Cohen, 1988). In addition, the Finner’s-method (a family-wise error rate stepwise procedure which has Table 3 displays the matrix with the partial correlations (adjusted by proved more powerful results than the classical Bonferroni correction) age, gender, and social position) between the DERS scores, the UPPS-P was used to control Type-I error due to the application of multiple sta­ scores, the number of DSM-5 criteria for GD and the SOGS total score. tistical comparisons (Finner & Roters, 2001). The results of this table have been obtained separately for the non- Second, the partial correlation matrix for ER (DERS scores) and strategic preference group (correlation coefficients displayed in the impulsive tendencies/traits (UPPS-P scores) was obtained (correlations upper-diagonal part) and the strategic preference group (correlations in estimates were adjusted by gender, age, and social position). Due to the the lower-diagonal part). As a whole, high correlations were obtained strong association between the result of the significance test for the for the variables contained in each questionnaire, with the following correlation coefficient and the sample size, the next cut-off points were exceptions: a) DERS-awareness did not achieve correlation with other considered for interpreting the effect size: null for |R|<0.10, low-poor measures of ER; b) the UPPS-P sensation seeking did not correlate with for |R|>0.10, moderate-medium for |R|>0.24 and large-high for |R|> the UPPS-P lack of premeditation and lack of perseverance (within non- 0.30 (these values correspond to Cohen’s-d equal to 0.20, 0.50 and 0.80) strategic group, the positive and negative urgency subscales did not (Kelley & Preacher, 2012). converge with lack of premeditation and sensation seeking). Finally, regression models were obtained to assess the specific For patients with a non-strategic gambling preference, the following contribution of each ER dimension (DERS scores) and each impulsivity associations were observed: a) high correlations between the DERS dimension (UPPS-P scores) on the GD severity (defined as the number of subscales lack of emotional awareness and lack of emotional clarity with 3 C. Vintró-Alcaraz et al. Addictive Behaviors 126 (2022) 107176 Table 1 Descriptive for the sample. Total n = 321 Non-strategic n = 221 Strategic n = 100 Sociodemographics n % n % n % p |h| Gender Female 32 10.0% 31 14.0% 1 1.0% 0.001* 0.57y Male 289 90.0% 190 86.0% 99 99.0% Education Primary 154 48.0% 120 54.3% 34 34.0% 0.001* 0.41 Secondary 132 41.1% 85 38.5% 47 47.0% 0.17 University 35 10.9% 16 7.2% 19 19.0% 0.36 Civil status Single 158 49.2% 98 44.3% 60 60.0% 0.010* 0.31 Married 132 41.1% 96 43.4% 36 36.0% 0.15 Divorced 31 9.7% 27 12.2% 4 4.0% 0.31 Employment Unemployed 118 36.8% 91 41.2% 27 27.0% 0.015* 0.30 Employed 203 63.2% 130 58.8% 73 73.0% SocialMean/high - high 30 9.3% 15 6.8% 15 15.0% 0.002* 0.27 Mean 37 11.5% 25 11.3% 12 12.0% 0.02 Mean-low 124 38.6% 77 34.8% 47 47.0% 0.25 Low 130 40.5% 104 47.1% 26 26.0% 0.44 Age, onset, duration Mean SD Mean SD Mean SD p |d| Age (yrs-old) 40.04 13.79 44.20 13.58 30.84 8.95 0.001* 1.16y Onset of GD (yrs-old) 28.83 12.10 30.56 13.33 24.99 7.52 0.001* 0.51y Duration of GD (yrs) 5.61 5.79 6.55 6.34 3.55 3.59 0.001* 0.58y GD severity Mean SD Mean SD Mean SD p |d| DSM-5 criteria 7.10 1.83 7.10 1.95 7.09 1.56 0.996 0.12 SOGS total score 10.93 3.21 10.77 3.11 11.28 3.42 0.192 0.29 Note. SD: standard deviation. *Bold: significant comparison. †Bold: effect size within the ranges moderate to large. Within the strategic group, the next associations were also found: a) Table 2 the UPPS-P positive urgency and negative urgency subscales correlated Comparison between the groups: analysis of covariance (adjusted by age, sex with all the DERS subscales, except with the lack of emotional awareness; and social position). b) the UPPS-P sensation seeking only correlated with the DERS limited Non-strategic n Strategic n = access to emotion regulation; c) the UPPS-P lack of premeditation correlated = 221 100 with the DERS difficulties engaging goal-directed behaviors, the impulse Mean SD Mean SD p |d| control difficulties, the lack of emotional clarity and the total score; and d) Emotional (dys) the UPPS-P lack of perseverance was related to the DERS difficulties regulation (DERS engaging goal-directed behaviors, the limited access to emotion regulation, scales) the lack of emotional clarity and the total score. Non-acceptance of 16.84 6.92 14.17 6.42 0.004* 0.40 emotional responses Table S2 (estimate-methods material) displays the correlation matrix Difficulties engaging 14.05 4.86 13.37 4.82 0.294 0.14 within the total sample (partial correlations adjusted by age, gender and goal directed social position). behaviors Impulse control 14.34 6.04 11.40 4.69 0.001* 0.55y difficulties 3.4. Regression models between ER, impulsive tendencies/traits and GD Lack of emotional 17.43 5.29 15.88 3.87 0.022* 0.33 severity awareness Limited access to 19.60 7.84 17.01 6.60 0.010* 0.36 emotion regulation Table S3 (supplementary material) displays the results of the mul­ Lack of emotional 12.55 4.56 10.71 4.16 0.002* 0.42 tiple regressions assessing the specific contribution of the ER and the clarity impulsivity dimensions on the GD severity (ENTER method). Within the Total score 94.81 25.95 82.54 22.95 0.001* 0.50y non-strategic preference subsample, the number of DSM-5 criteria was Impulsivity (UPPS-P scales) significantly related to the higher scores in the DERS difficulties engaging Lack of premeditation 25.01 6.28 25.05 5.49 0.967 0.01 goal-directed behaviors, the DERS lack of emotional awareness and the Lack of perseverance 22.53 5.79 21.49 5.41 0.179 0.19 UPPS-P negative urgency, while the SOGS total score was significantly Sensation seeking 27.32 8.50 27.12 7.52 0.848 0.03 related to the DERS lack of emotional awareness and the UPPS-P negative Positive urgency 33.12 10.32 28.26 8.72 0.001* 0.51y Negative urgency 33.57 7.44 30.69 6.90 0.004* 0.40 urgency. Within the strategic preference subsample, the number of DSM- Total score 141.56 24.51 132.60 23.94 0.006* 0.37 5 criteria was significantly associated with the UPPS-P positive urgency and negative urgency, while no significant contributors were observed for Note. SD: standard deviation. *Bold: significant comparison. †Bold: effect size the SOGS-total score. within the ranges moderate to large. Table 4 contains the results of the regressions obtained with the stepwise method, which automatically selected the variables with sig­ the UPPS-P subscale lack of premeditation; b) high correlations between nificant contribution to GD severity. The same predictors were retained the DERS scores with the trait impulsivity domains included in the in the final model obtained within the non-strategic group for the cri­ UPPS-P lack of perseverance subscale (except for the DERS scales non- terion number of DSM-5 criteria for GD (DERS difficulties engaging goal- acceptance of emotional responses and lack of emotional awareness); c) high directed behaviors, the DERS lack of emotional awareness and the UPPS-P correlations between all the ER subscales with the impulsivity levels negative urgency). For the criterion SOGS-total score, the DERS impulse registered in positive urgency, negative urgency and total scale (with the control difficulties was selected also with the DERS lack of emotional exception of the DERS subscale lack of emotional awareness); d) high awareness and the UPPS-P negative urgency. Within the strategic prefer­ correlations between all the DERS subscales with the GD severity mea­ ence subsample, the following significant contributors were selected: a) sures; and e) high correlations between the impulsivity subscales positive for the criterion number of DSM-5 criteria for GD, the contributors were urgency, negative urgency and total scale with the GD severity measures. the UPPS-P positive urgency and negative urgency, as well as the DERS non- 4 C. Vintró-Alcaraz et al. Addictive Behaviors 126 (2022) 107176 Fig. 1. Radar charts. Fig. 2. Prevalence of participants within the clinical range. acceptance of emotional responses; and b) for the criterion SOGS total, the 2010). Regarding GD severity, as in previous studies (Odlaug et al., selected contributors were the UPPS-P positive urgency and the DERS 2011), we did not find significant differences between strategic and non- non-acceptance of emotional responses. strategic groups. Non-strategic gambling was more prevalent in women and, contrary 4. Discussion to our hypotheses, it was associated with higher impairments in ER, as well as with higher levels of positive and negative urgency. This finding The present study aimed to compare ER and impulsive tendencies/ supports the proposal to distinguish between so-called action-seekers traits between strategic and non-strategic gambling patients. It also and so-called over-stimulated gamblers (Blaszczynski & Nower, 2002). pretended to analyze the relationship between these two variables. In this case, our results would support the latter group, formed by in­ Sociodemographic data indicated a higher education level as well as dividuals with a greater emotional vulnerability. This vulnerability may a greater rate of employment and social status in strategic gamblers make them experience dysphoric emotional states more frequently, compared to non-strategic ones. Furthermore, in the present study, which they may try to reduce or avoid by using the gambling behavior strategic gamblers were the youngest group, which also explains the (Blaszczynski & Nower, 2002). This is also in line with the results of the higher number of singles and lower frequency of married and divorced present study stating that negative urgency contributes to the severity of compared to non-strategic gamblers. These findings are consistent with GD in non-strategic gamblers. In fact, other authors have highlighted the earlier studies describing the profile of the strategic gambler as young relationship between negative urgency and GD severity (Michalczuk and with a high level of education (Jiménez-Murcia, Granero, Fernán­ et al., 2011; Rogier et al., 2020), and in samples composed of non- dez-Aranda, & Menchón, 2020; Moragas et al., 2015; Stevens & Young, strategic gamblers only as well (Haw, 2017). Furthermore, the greater 5 C. Vintró-Alcaraz et al. Addictive Behaviors 126 (2022) 107176 presence of women in this group is consistent with previous studies, 0.271y 0.289y 0.276y 0.316y 0.267y 0.431y 0.306y 0.611y which observed that women have a greater tendency to use gambling as 0.195 0.141 0.188 0.027 0.189 0.008 a maladaptive coping strategy to deal with anxiety, boredom, or feelings 15 — of loneliness and social isolation, primarily (Holdsworth, Hing, & Breen, 2012; McCormack, Shorter, & Griffiths, 2014; Toneatto & Wang, 2009). 0.338y 0.417y 0.296y 0.384y 0.277y 0.433y 0.349y 0.416y 0.344y 0.600y -0.012 When analyzing gambling modalities according to gender, previous 0.147 0.046 0.227 14 — studies had already observed a greater preference of women for non- strategic games (chance-based games such as lotteries, electronic gambling machines, or bingo), compared to men, who would prefer 0.353y 0.454y 0.524y 0.441y 0.503y 0.569y 0.500y 0.567y 0.423y 0.820y 0.752y 0.625y 0.476y 0.224 skill-based games (Castrén et al., 2013; Svensson & Romild, 2014). 13 — Finally, the fact that urgency dimensions are specifically those that stand out in the non-strategic group with greater ER impairments may confirm the emotional component of both dimensions of impulsivity, as sug­ 0.397y 0.439y 0.503y 0.459y 0.392y 0.532y 0.340y 0.665y 0.851y 0.652y 0.461y 0.090 0.146 0.092 gested by other authors (Whiteside et al., 2005) and hypothesized in this 12 — study. It should be noted, however, that Barrault et al. (2019) observed that strategic gamblers showed higher use of suppression, a non- 0.384y 0.367y 0.464y 0.422y 0.419y 0.497y 0.246y 0.729y 0.872y 0.657y 0.464y adaptive regulatory strategy, in comparison to mixed gamblers. These 0.081 0.154 0.234 differences between studies may be due to the fact that different in­ 11 — struments have been used to measure ER difficulties in each of the re­ searches. Whereas Barrault et al. (2019) just evaluated suppression and 0.439y 0.266y 0.529y 0.316y -0.043 -0.124 reappraisal strategies, we used the DERS scores which are not focused on 0.023 0.058 0.156 0.041 0.005 0.129 0.086 0.214 10 — specific strategies but on several ER deficits. Our data also indicated that between one third and one half of the patients evaluated are within the clinical range regarding emotional 0.424y 0.358y 0.361y 0.373y 0.444y 0.582y 0.356y 0.488y 0.592y 0.266y 0.282y -0.070 0.221 0.227 dysregulation. This finding dovetails with several studies that demon­ — strate an impaired ER in patients with GD (Elmas et al., 2017; Navas 9 et al., 2017; Rogier et al., 2020; Toneatto, Lecce, & Bagby, 2009; Wood & Griffiths, 2007). Besides, high correlations between almost all the 0.354y 0.247y 0.496y 0.332y 0.433y 0.587y -0.010 0.004 0.133 0.101 0.097 0.195 0.155 0.180 DERS subscales and GD severity were found in both strategic and non- — 8 strategic groups, highlighting the relation between ER impairments and GD severity, also observed in previous studies (Mestre-Bach et al., 0.783y 0.823y 0.847y 0.906y 0.794y 0.339y 0.378y 0.567y 0.531y 0.599y 0.505y 0.415y 2019). 0.122 0.234 Finally, significant correlations between GD severity and positive — 7 and negative urgency were observed. On the one hand, in the case of negative urgency, this study was partially in line with previous findings. 0.474y 0.573y 0.564y 0.321y 0.611y 0.746y 0.379y 0.531y 0.501y 0.516y 0.590y 0.384y 0.318y For example, Quintero, Navas, and Perales (2020) observed that nega­ 0.158 — tive urgency predicted higher craving scores which, in turn, were pre­ 6 dictive of greater severity of GD symptomatology. These authors concluded, as previously stated by Navas, Billieux, Verdejo-García, and 0.745y 0.775y 0.789y 0.498y 0.880y 0.264y 0.266y 0.468y 0.427y 0.485y 0.480y 0.340y -0.153 0.205 Perales (2019), that negative urgency, although it does not seem to play — an essential role in the etiology of GD, complicates the symptomatology 5 Upper diagonal-part: results obtained within the non-strategic subsample (n = 221). of the disorder since it enhances its externalizing component. In this line, Lower diagonal-part: results obtained within the strategic subsample (n = 100). other authors have suggested that negative urgency is essential espe­ 0.328y -0.223 -0.106 -0.073 -0.107 -0.045 0.166 0.214 0.157 0.043 0.035 0.097 0.017 0.112 cially in escape-oriented gambling modalities, such as electronic — 4 gambling machines (Lutri et al., 2018). On the other hand, the present study observed that positive urgency contributes to greater severity of Partial correlation matrix (adjusted by age, sex and social position). the disorder in the group of strategic gamblers. Previous literature had 0.601y 0.704y 0.616y 0.482y 0.769y 0.293y 0.533y 0.479y 0.515y 0.359y 0.283y 0.019 0.192 0.223 already reported the association between positive urgency and severity — 3 Note. †Bold: effect size within the ranges moderate to large. of the disorder (Kim, Poole, Hodgins, McGrath, & Dobson, 2019; Sav­ vidou et al., 2017). Furthermore, an association between positive ur­ 0.594y 0.597y 0.768y 0.590y 0.842y 0.307y 0.416y 0.432y 0.455y 0.518y 0.385y 0.354y -0.098 gency and one of the essential components of GD, gambling-related 0.200 cognitions, has been identified in previous studies (Ruiz de Lara, Navas, — 2 Perales, & Rodda, 2019). This link, however, was not evident in the case of negative urgency. Consequently, the authors suggested that although 0.683y 0.581y 0.807y 0.493y 0.861y 0.463y 0.397y 0.418y 0.488y 0.375y -0.064 0.170 0.181 0.169 both positive and negative urgency contribute significantly to the — symptomatology of GD and, therefore, to the severity of the disorder, 1 both dimensions of impulsivity are theoretically different and would influence different gambling pathways. DSM-5 total criteria UPPS-P Total score UPPS-P Persevera. DERS Non-accept. UPPS-P Premedit. UPPS-P Sensation DERS Total score UPPS-P Negative DERS Awareness SOGS total score UPPS-P Positive DERS Strategy DERS Impulse 4.1. Clinical implications DERS Clarity DERS Goals The results obtained in the present study confirm the need to jointly assess ER difficulties and impulsivity levels in clinical contexts. Knowing the presence or absence of these factors in each patient, as well as the Table 3 specific interaction between them, would allow us to understand in 10. 11. 12. 13. 14. 15. 1. 2. 3. 4. 5. 6. 7. 8. 9. greater depth and address these possible factors that maintain gambling 6 C. Vintró-Alcaraz et al. Addictive Behaviors 126 (2022) 107176 Table 4 Regression models assessing the specific contribution of the emotion dysregulation (DERS) and the impulsivity (UPPS-P) on the GD severity (adjusted by age, sex and social position). Subsample Criterion B SE Beta p 95%CI (B) Non-strategic (n = 221) # DSM-5 crit. DERS Goal directed behavior 0.127 0.027 0.316 <0.001 0.074 0.179 UPPS-P Negative urgency 0.067 0.017 0.255 <0.001 0.032 0.101 DERS Emotional awareness 0.059 0.022 0.162 0.007 0.016 0.103 Non-strategic (n = 221) SOGS total UPPS-P Negative urgency 0.134 0.029 0.320 <0.001 0.076 0.192 DERS Impulse control diff. 0.101 0.036 0.197 0.006 0.030 0.173 DERS Emotional awareness 0.074 0.035 0.127 0.037 0.004 0.144 Strategic (n = 100) # DSM-5 crit. UPPS-P Positive urgency 0.059 0.019 0.332 0.002 0.022 0.097 UPPS-P Negative urgency 0.070 0.023 0.310 0.003 0.025 0.115 DERS Non acceptance 0.056 0.019 0.231 0.005 0.018 0.094 Strategic (n = 100) SOGS total UPPS-P Positive urgency 0.140 0.039 0.357 0.001 0.062 0.218 DERS Non acceptance 0.114 0.053 0.214 0.034 0.009 0.220 Note. B: un-standardized coefficient. SE: standard error. Beta: standardized coefficient. behavior, as well as to design personalized and effective treatment plans. impulsivity is essential in GD and both variables, although independent, It has been observed that both factors (impulsivity and ER) may be could be highly interrelated. considered as transdiagnostic treatment targets and have an essential role in the treatment of multiple pathologies, including GD. In the spe­ 6. Funding sources cific case of ER, Sloan et al. (2017) highlighted that psychological in­ terventions seem to produce changes in the ER process, independently of CERCA Programme/Generalitat de Catalunya gave institutional the treatment protocol or the disorder addressed. Modifications in ER support. This work was additionally supported by a grant from the are associated with an improvement in clinical symptomatology, and Ministerio de Ciencia, Innovación y Universidades (grant RTI2018- therefore the ER approach would contribute to the reduction of psy­ 101837-B-100). The research was funded by the Delegación del chopathology, as proposed by the authors. Moreover, impulsivity could Gobierno para el Plan Nacional sobre Drogas (2017I067 and 2019I47), be considered as a key predictor of treatment outcomes, especially in the Instituto de Salud Carlos III (ISCIII) (PI20/132) and co-funded by FEDER case of addictions (Loree, Lundahl, & Ledgerwood, 2015). For those funds/European Regional Development Fund (ERDF), a way to build individuals with high levels of impulsivity, a promising effect of con­ Europe. CIBEROBN is an initiative of ISCIII. CVA is supported by a tingency management has been observed (Tomko, Bountress, & Gray, predoctoral grant awarded by the Ministerio de Educación, Cultura y 2016). However, more studies on both ER and impulsivity are needed to Deporte (FPU16/01453). GMB was supported by a postdoctoral grant by solidly determine their specific role in the development and mainte­ FUNCIVA. The funders had no role in the study design, data collection nance of GD, as well as their impact on the treatment of this disorder. and analysis, decision to publish or preparation of the manuscript. 4.2. Limitations 7. Author agreement Certain limitations of the present study should be considered. First, All the authors declare that this manuscript is original, has not been due to the cross-sectional nature of the study at hand, we could not draw published before and is not currently being considered for publication conclusions regarding causality or the direction of the effects analyzed. elsewhere. Longitudinal studies are needed to provide important data about the We confirm that the manuscript has been read and approved by all interactions between gambling modalities and ER and impulsive ten­ named authors and that there are no other persons who satisfied the dencies/traits and also to examine whether these variables may improve criteria for authorship but are not listed. We further confirm that the after treatment or could be predictors of low taxes of remission, dropout, order of authors listed in the manuscript has been approved by all of us. or relapses. Second, ER and impulsive tendencies/traits were assessed We understand that the Corresponding Author is the sole contact for using self-report measures that can hardly fully capture the complexity the Editorial process. She is responsible for communicating with the of both variables. In addition, only trait impulsivity was analyzed, but it other authors about progress, submissions of revisions and final should be noted that impulsivity is a multifactorial construct. Third, no approval of proofs. data on pharmacotherapy were recorded, although different drugs may alter particularly the levels of impulsivity and emotional states. Simi­ CRediT authorship contribution statement larly, comorbidity with other disorders that may also have an impact on impulsivity and emotional dysregulation levels (such as anxiety or Cristina Vintró-Alcaraz: Conceptualization, Writing – original depression, among others) has not been taken into account in the present draft. Gemma Mestre-Bach: Conceptualization, Writing – original study. Finally, our sample was mostly composed of male patients with draft. Roser Granero: Formal analysis, Methodology. Mónica Gómez- GD. Thus, the generalizability of the present findings to other pop­ Peña: Investigation. Laura Moragas: Investigation. Fernando ulations should be avoided. Fernández-Aranda: Writing – review & editing, Funding acquisition. Susana Jiménez-Murcia: Writing – review & editing, Project admin­ 5. Conclusions istration, Funding acquisition. This study provides a greater understanding of the specific role of ER Declaration of Competing Interest and trait impulsivity in GD, as well as their interaction. Our findings suggest that non-strategic gambling is associated with higher impair­ The authors declare that they have no known competing financial ments in ER, as well as with higher levels of positive and negative ur­ interests or personal relationships that could have appeared to influence gency. Therefore, gamblers with GD who prefer the non-strategic the work reported in this paper. FFA received consultancy honoraria modality could be using gambling as a maladaptive coping strategy in from Novo Nordisk and editorial honoraria as EIC from Wiley. The rest the face of intense emotions and, therefore, would present a more of the authors declare no conflict of interest. The funders had no role in altered clinical profile than strategic gamblers. 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