Trauma as a risk factor in gambling and alcohol-use disorders

■ INTRODUCTION

Gambling and alcohol-use disorders

The popularity of gambling has been growing steadily both in Poland and globally since the mid-1980s. The rise has been attributed to, among other things, the popularisation of games via the internet and mobile devices. The issue involves a number of different terms, with gambling supplemented by problem/harmful/pathological gambling, or gambling addiction. Silczuk and Habrat [1] propose using the term gambling disorder as an equivalent of the term introduced by American Psychiatric Association (APA)¹ [2].
A recent meta-analysis of studies from 68 countries estimates the prevalence of gambling to be 46.2% [3]. Available data suggest that up to 10% of young adults are at risk of developing gambling disorders [4] with the problem also affecting younger people. A recent review of studies found between 1.1% and 48.4% of adolescents showed signs of problematic online gambling [5]. The prevalence of gambling addiction in the general population is estimated to range from 0.2% to 5.3% [6]. Similarly, data from Spain indicates a low prevalence of gambling disorders (0.5%) with these related to online gaming [7].
According to a CBOS report, 37% of Poles over 15 years of age admitted to gambling, which was 0.3% more than in 2015. However, only 0.4% considered themselves compulsive gamblers [8].
Gambling addiction, previously referred to as pathological gambling, is the first disorder officially classified in the DSM-5 as a behavioural addiction. According to this classification [2], gambling disorders are evidenced by the inability to control oneself while playing, leading to various harmful professional, financial and legal consequences, as well as those associated with personal and family matters. The ICD-11 classification [9] covers gambling addiction as a persistent pattern of constant or recurrent gambling.
Gambling is a type of behavioural addiction; unlike alcohol or drugs, it is not characterised by any physical symptoms that affect the functioning of the body from a biological perspective. However, both substantial and behavioural addictions share a common mechanism. In the case of gambling, it manifests itself in an internal constant or recurrent compulsion, resulting in the behaviour being repeated, despite the harm suffered by the player. The individual is increasingly absorbed in playing and the prospect of playing, and displays increasing tolerance not indicated by the amount of the substance taken but by the level of risk or the amount wagered. People with a gambling problem also indicate that they experience a higher level of excitement during the game (a kind of euphoria) than those who play occasionally. When attempting to stop playing, people with gambling addiction also manifest withdrawal symptoms, although they are weaker than in the case of substance dependence [10].
Alcohol use can take many forms, ranging from occasional consumption to binge drinking i.e., heavy drinking for a limited time or extended periods of daily drinking that can last multiple years aimed at regulating emotions or preventing withdrawal symptoms. In addition, drinkers can indulge in risky drinking, which should not directly cause long-term consequences for the drinker, and harmful drinking, which is associated with harm [11, 12].
Alcohol addiction is defined as a chronic, recurrent disorder caused by excessive and compulsive alcohol drinking, loss of control over the amount consumed, and the occurrence of negative emotional states when access to alcohol is lost [9]. The DSM-5 classification [2] suggested abandoning the term addiction in favour of the term “substance-use disorder”, including alcohol.
One of the many factors that may lead to the development of addictions, including gambling and alcohol, is exposure to trauma and its consequences in the form of post-traumatic stress disorder (PTSD) symptoms [13].

The relationship between trauma and gambling and alcohol-use disorders

The understanding of trauma has changed over the years and is still understood differently by various authors. It is worth emphasising that the term trauma can be identified both with the traumatic event itself and the reaction to events like it [14]. The DSM-5 classification includes traumatic events both experienced directly and indirectly [2].
Among the negative consequences of experienced traumatic events, the most frequently mentioned is Post-traumatic Stress Disorder (PTSD). According to the DSM-5 classification, PTSD consists of symptoms falling within the scope of four criteria i.e., intrusion or re-experiencing the traumatic event (recurrence), avoidance, negative changes in cognition and emotions, increased arousal and reactivity [2]. Exposure to trauma and its negative consequences serves as a risk factor for the development of addictions in adulthood and, consequently, for failures in therapy. Leppink and Grant [15] showed that 22.6% of gamblers who revealed gambling disorders had experienced a traumatic life event. Also, Dragan and Lis-Turlejska [16] indicate that 80% of alcohol dependent patients reported at least one traumatic event. Similarly, Skotnicka [17] report that 70% of people diagnosed as alcohol dependent have experienced at least one traumatic event in their lives, compared to 31% within a control group of people without alcohol use problems.
Various forms of violence experienced during childhood seem to play a particularly adverse role in the development of addictions [18]. Analyses of data from twins differing in their degree of gambling behaviour indicated that neglect or being a victim of violence as well as witnessing a serious injury, death and physical assault on another person were associated with a higher risk of pathological gambling [19]. However, it is not only the type of traumatic events experienced that matters, but also their number and the time of their occurrence. It was found that, among other things, people addicted to gambling experienced an average of four different types of traumatic events [20, 21].
A positive relationship was also noted between traumatic experiences and the intensity of gambling in a group of adolescents and young adults [13].
It has also been shown that alcohol dependent people reported traumatic events earlier in life that they were more frequent and were more numerous, compared to people who do not have a problem with alcohol [17]. Sex also plays a certain role in the relationship between the experience of trauma and the risk of addiction, with women reporting experiences of early trauma being more predisposed to the development of alcohol dependence than those without experiences of this kind [22].
In the development of addictions, however, a greater role is attributed to PTSD symptoms. However, while the most popular self-medication model suggests that excessive involvement in substance use or undertaking other problematic activities are treated as secondary to PTSD, it is not possible to clearly determine which occurs earlier [23-25]. For people experiencing trauma, alcohol use or gambling may be a form of escape from the traumatic situation intended to relieve pain and alleviate anxiety related to the traumatic situation [26].
Among addicts who had experienced childhood trauma and showed more intense PTSD symptoms abusing psychoactive substances started earlier compared to those who did not, and those who had not experienced traumatic situations [27]. Moreover, they are also characterised by greater severity of depression, anxiety states, more frequent suicidal thoughts and suicide attempts, a tendency to overdose on medications or drugs, the occurrence of dual addictions mainly to alcohol and illegal drugs and the co-occurrence of other psychopathologies [27].
PTSD symptoms have been recorded in approximately 17% of gambling addicts and in 29% of gambling addicts seeking help from specialists. Moreover, those with a dual diagnosis i.e., gambling addicts who were simultaneously diagnosed with PTSD, also had a greater intensity of dissociative symptoms than people with a single diagnosis [20, 21].
Many studies also found PTSD to co-occur with alcohol dependence and other psychoactive substances although alcohol is believed to be the most commonly used substance by people suffering from PTSD [22]. Chilcoat and Breslau [28] showed that people with PTSD are four times more likely to abuse psychoactive substances than those without post-traumatic disorders.
Among patients treated for disorders related to the use of various psychoactive substances (alcohol, heroin, cocaine, marijuana, abuse/mixed dependence), the prevalence of PTSD ranges from 30 to 58% for lifetime PTSD and from 20 to 38% for a current diagnosis [24]. Other studies indicate that 25% of alcohol dependent patients meet the criteria for a current diagnosis of PTSD [29].
Most studies to date have focused on searching for connections between trauma and a specific type of addiction, mainly alcohol. Moreover, in the field of trauma, studies have examined either traumatic experiences, particularly their type, or the occurrence of PTSD. Few studies have explored the relationship between trauma and its various indicators, and the risk of addiction, just as few of them refer to the risk of different types of addiction simultaneously.
The aim of the study was to determine the relationship between previously experienced trauma and the severity of problems resulting from gambling and alcohol use among adults. The study also aimed to verify whether trauma plays a role as a predictor of gambling and alcohol dependence. The study includes two trauma indicators: the number of traumatic events (experienced directly and indirectly) and PTSD symptoms. The following questions were sought:
1. What is the severity of problems resulting from gambling and alcohol use in the study group and how many people show a risk of developing disorders?
2. Are the age, sex, education and income level of the respondents associated with the severity of problems with gambling and alcohol use?
3. How many traumatic events (directly and indirectly) did the respondents experience and what is the severity of PTSD symptoms?
4. Are the number of traumatic events and PTSD symptoms associated with the severity of problems with gambling and alcohol use?
5. Which of the trauma indicators (number of traumatic events, PTSD symptoms) is a predictor of gambling and alcohol dependence?
6. Is the severity of alcohol use problems associated with the severity of gambling problems?
It was assumed that trauma indicators i.e., the number of experienced traumatic events and the presence of PTSD symptoms will be positively associated with the severity of gambling and alcohol use problems while the main predictor of the risk of gambling and alcohol dependence will be PTSD symptoms.

■ MATERIAL AND METHODS

The study was conducted online using Microsoft Forms. In total, 190 people representing a non-clinical group were recruited. The inclusion criteria for the analyses were 1. playing some gambling games in the last year (at least once), 2. alcohol use (drinking at least one drink in the last year) and 3. experiencing at least one previous traumatic event. After applying the inclusion criteria and completing the questionnaires, the results obtained from 120 respondents were qualified for analysis. Those who did not meet the inclusion criteria or did not complete the submitted questionnaires in full were excluded.
None of the respondents were in treatment for gambling or alcohol use disorders. The age range was from 18 to 72 years (M = 35.75; SD = 14.85) and the majority were women (58.3%). The largest group i.e., 50%, completed secondary education, 37.9% higher education and 12.1% primary education. The monthly income in the range of PLN 3,001-4,500 was reported by 38.7% while 4% reported incomes exceeding PLN 7,500 per month.
The most popular types of gambling (the respondents could make more than one choice) were scratch cards used by 48% of respondents, followed by number games like Lotto and lotteries indicated by 39%. Betting in bookmakers was chosen by 19%, card games by 10% and slot machines by 9%.
The most frequently mentioned traumatic events (respondents could indicate more than one event) included a road accident, a life-threatening illness and severe human suffering. The least common were captivity, exposure to warfare and exposure to toxic substances. The respondents reported experiencing different numbers of traumatic events.
The respondents completed a questionnaire developed for the study containing questions about sex, age, education, monthly earnings, type of gambling games used and treatment for gambling or alcohol dependence. In addition, the study used four standard measurement tools.
The Problem Gambling Severity Index/Canadian Problem Gambling Index – PGSI was developed by Ferris and Wynne, and the Polish adaptation was prepared by Wieczorek, Dąbrowska and Sierosławski [30]. The tool is designed to assess the prevalence of problem gambling in the general population. It includes nine questions about control over gambling, funds spent on gambling, winning money back, borrowing money, stress and anxiety caused by gambling, financial problems and guilt due to gambling. The respondent provides answers on a scale from 0 (never) to 3 (almost always). A score of seven points or above may indicate problem gambling.
The Alcohol Use Disorders Identification Test – AUDIT, was created by the World Health Organization as a screening method and aid in the diagnosis of excessive alcohol consumption as well as in the assessment of the occurrence of negative consequences associated with drinking. The Polish version of the tool was developed by the State Agency for the Prevention of Alcohol Related Problems (PARPA) [31]. The test allows for determining the level of harmfulness of alcohol consumption and suspicion of alcohol dependence. The test consists of ten items, scored from 0 to 4: a score below eight points indicates low risk drinking, 8-15 for risky alcohol drinking, 16-19 for harmful alcohol drinking and 20 points and more for suspicion of alcohol dependence.
The Life Events Checklist for DSM-V-LEC-5 is a tool for assessing exposure to potentially traumatic events in the respondent’s whole life. Its authors are Weathers, Blake, Schnurr, Kaloupek, Marx, and the Polish adaptation was carried out by Rzeszutek, Lis-Turlejska, Palich and Szumiał [32]. The LEC-5 contains 17 items referring to personally-experienced or directly witnessed traumatic events as well as events experienced indirectly (that the person has heard about and that concerned their close ones). The tool has satisfactory psychometric properties and is suitable for screening measurement of trauma exposure.
The PTSD Checklist for DSM-V-PCL-5, authored by Weathers, Litz, Keane, Palmieri, Marx and Schnurr, was designed to monitor PTSD symptoms in people experienced by trauma, to conduct screening tests and support diagnosis. The authors of the Polish adaptation are Ogińska-Bulik, Juczyński, Lis-Turlejska and Merecz-Kot [33]. The tool consists of 20 statements describing PTSD symptoms according to the DSM-5 classification, providing an overall score on four criteria consistent with the DSM-5: intrusion, avoidance, negative changes in cognition and mood and changes in arousal and reactivity. The respondent assesses each item on a five-point scale, ranging from 0 (not at all) to 4 points (very much). The cut-off point was 33 points, indicating a high risk of post-traumatic stress disorders. The tool has very good psychometric properties: Cronbach’s  coefficient is 0.96 [34].

■ RESULTS

The results of the Shapiro-Wilk test were statistically significant for all analysed variables: intensity of gambling problems, alcohol use, the number of events experienced directly and indirectly and PTSD symptoms (p < 0.05). This indicates that the distributions of these variables deviate from normal. Therefore, nonparametric tests were used in the analyses. The Mann-Whitney U-test was applied to show differences between the two studied subgroups, and the relationships between variables were established based on Spearman’s rho correlation coefficients. Regression analysis (stepwise forward version) was used to determine the predictors of gambling and alcohol dependence. The mean values, standard deviations, and correlation coefficients (Spearman’s rho) between trauma and problems resulting from gambling and alcohol use are presented in Table I.
In the case of the Problem Severity Gambling Index (PGSI), the scores obtained by the respondents ranged from 0 to 15. The obtained mean from all participants indicates moderate intensity of gambling problems in the studied group. Eight people, which is 6.7% of the respondents, demonstrate a pattern of behaviour suggesting gambling addiction (i.e., a score of at least seven points). The remaining 112 (93.3%) do not demonstrate gambling problems although 49 (40.8% of the respondents) obtained scores in the range of 1-6 points and 63 (52.5%) scored 0.
The group obtained a mean score of 6.17 in the AUDIT, indicating moderate drinking. Three respondents scored 20 points or more (2.5%), five (4.2%) scored above 15 points, indicating harmful drinking and 27 (22.5%) obtained 8-15 points, indicating risky drinking. The remaining 85 respondents (70.8%) were characterised by low-risk alcohol use. It should be noted that the standard deviations are high, which indicates a large dispersion of results in the study group. Among the study participants, five (4.2%) showed problems with both gambling and alcohol use as indicated by scores of seven points or more in the PGSI and eight points or more in the AUDIT.
Although sex did not influence the intensity of gambling problems (Z = 1.02, p < 0.30), it weakly differentiated the intensity of problems resulting from alcohol use (Z = 2.44, p < 0.05), with a slightly higher intensity noted in men than women. Age is not associated with the intensity of problems resulting from gambling (rho = –0.13) or alcohol use (rho = –0.14). Similarly, gambling and alcohol use problems are not associated with education (rho = –0.12 and rho = 0.11) or income achieved by respondents (rho = 0.05 and rho = 0.06).
The data presented in Table I also shows that the mean numbers of traumatic events experienced by the respondents are 3.63 (directly) and 2.66 (indirectly). The mean PCL-5 score indicates a generally moderate intensity of PTSD symptoms among the group. A score above the cut-off point (33 points), indicating a high risk of developing PTSD, was achieved by 30 respondents (25%). The remaining 90 respondents (75%) demonstrated a lower intensity of PTSD symptoms, hence a lower risk of developing this disorder.
PTSD symptoms are positively associated with both the severity of gambling problems and alcohol use. However, the number of traumatic events, experienced both directly and indirectly, are not associated with the severity of gambling problems or alcohol use. In addition, the severity of gambling problems is positively associated, albeit weakly, with the severity of problems resulting from alcohol use.
The severity of problems related to gambling and alcohol use in the group with lower (below 33 points in the PCL-5) and higher (equal to or higher than 33 points) PTSD severity was also verified. The results are presented in Table II.
It was found that individuals with higher PTSD symptom intensity, indicating a high probability of developing post-traumatic stress disorders, tend to show significantly higher intensity of gambling problems. On the other hand, PTSD intensity does not significantly differentiate the degree of problems related to alcohol use although the higher values reported were associated with individuals with a high probability of developing post-traumatic stress disorders.
Next, the predictors of gambling and alcohol dependence were established using regression analysis (stepwise forward version). The explanatory variables included all trauma indicators i.e., the number of traumatic events experienced directly, indirectly and PTSD symptoms. The results are presented in Table III.
PTSD symptoms and the number of traumatic events experienced indirectly were found to be predictors of gambling addiction. Both variables explain 15% of the variance of the dependent variable, with PTSD symptoms displaying a greater share in predicting gambling addiction at 10%. PTSD symp
toms turned out to be the only predictor of alcohol dependence and were weak, explaining only 5% of the variance of the dependent variable.
Additional analyses were also conducted. These also considered the intensity of problems resulting from alcohol use as an explanatory variable, in addition to trauma indicators, for gambling addiction (explained variable); similarly, the intensity of gambling problems was used as the explanatory variable for alcohol dependence (explained variable). The results of the regression analysis are presented in Table IV.
Three factors were found to play a predictive role for gambling addiction, explaining together 18% of the variance of the dependent variable. The largest contribution was made by PTSD symptoms (10%), followed by the number of directly experienced traumatic events (5%) and problems resulting from alcohol consumption (3%). In turn, the risk of alcohol dependence is predicted by a high intensity of gambling problems; however, this variable explains only 6% of the variance in alcohol dependence.

■ DISCUSSION

The study group was characterised by a moderate intensity of gambling problems and a moderate intensity of alcohol-use related problems. Nevertheless, 6.7% of the respondents revealed a pattern of behaviour indicating gambling addiction, while 8.3% obtained a result indicating alcohol dependence with almost 26% reporting risky drinking.
The respondents had experienced various traumatic events in their lives, both directly and indirectly and many reported experiencing more than one. The most common types were a traffic accident, life-threatening illness and severe human suffering. Those who were exposed to trauma revealed PTSD symptoms to varying degrees; of these, 25% obtained PCL-5 results indicating a high probability of developing PTSD and the remaining 75% showed a lower probability.
The number of traumatic events, experienced both directly and indirectly, was not associated with the severity of gambling and alcohol use problems, although indirectly experienced events proved to be a predictor, albeit a very weak one, of the occurrence of gambling disorders. On the other hand, the presence of PTSD symptoms in those who experienced traumatic events turned out to be positively associated with the severity of both gambling problems and alcohol use. PTSD was also the main predictor of gambling and alcohol dependence. The obtained results indicate that it is not so much exposure to trauma, in the form of the number of experienced traumatic events, that constitutes the risk of developing addictions, as its consequences, revealed in the form of persistent PTSD symptoms.
The obtained results are partially consistent with those obtained by other researchers, although it should be noted that the data available in the literature on the links between experienced traumatic events and addictions is not unambiguous. For example, Green et al. [35] report no differences in the number of experienced traumatic events between a group of addicts and non-addicted controls, although it should be emphasised that only 35 people participated in the studies. In turn, a Spanish study identified a relationship between the type and number of experienced traumatic events and addictions [13], with the authors highlighting the role of inter alia rumination, positive reinterpretation and acceptance as mediators in the adaptive processing of difficult events. The authors indicate that these characteristics can protect people from developing addiction. According to Skotnicka [17], those alcohol dependent reported traumatic events that tended to occur earlier and in greater numbers than those who were not.
The results regarding the relationship between PTSD symptoms and addictions are consistent with most studies conducted in this area and seem to confirm the most commonly adopted self-medication model. The model indicates that persistent PTSD symptoms may lead to alcohol abuse, typically to cope with the occurring symptoms, and that this may promote the development of dependence, usually with the participation of other risk factors.
Although PTSD symptoms may play a similar role in increasing the risk of gambling, it is important to consider other models, a detailed review of which is presented by Dragan [24]. For example, an alternative to the self-medication model assumes that excessive alcohol consumption may increase the risk of PTSD, mainly due to the greater risk of people being exposed to traumatic situations while under the influence of alcohol. In addition, the use of psychoactive substances can prolong the duration of PTSD symptoms and make it difficult to process the trauma [24]. It cannot be ruled out that the symptoms of addiction, mainly withdrawal symptoms, together with the negative emotions that accompany these states can provoke an increase or recurrence of the experienced PTSD symptoms [11].
Surprisingly, PTSD symptoms appeared to show a stronger relationship with problems related to gambling than with those resulting from alcohol use. This suggests that the negative consequences of trauma, in the form of PTSD, have a greater influence on the development of behavioural addictions than substance dependence. Perhaps engaging in gambling is a more effective form of escape from problems resulting from experienced events for people who have experienced trauma than engaging in alcohol consumption. In addition, alcohol is often used as a recourse in response to stress and everyday problems, and not necessarily to the experienced trauma. It should be emphasised that the present study was conducted among people from the general population and not in a clinical group e.g., those addicted to gambling and alcohol.
It is worth noting the results obtained from the regression analysis, which also included the type of problem behaviour among the explanatory variables. While problems resulting from alcohol use were found to be of no major significance for gambling addiction, the severity of gambling problems turned out to be the main predictor of alcohol dependence. This indicates that gambling problems serve as a better predictor of alcohol dependence than experienced trauma.
Our data also indicates that both types of problem behaviours are positively related with each other; however, this suggests the relationship is not strong. Also, the problems resulting from gambling and alcohol use may go hand in hand, which is in accordance with reports from other authors [36]. However, it is difficult to determine the direction of this relationship.
It is also worth noting that the development of both forms of addiction and PTSD is based on previously formed cognitive schemas. Negative cognitive schemas may cause an individual to turn to alcohol abuse or gambling in later stages of life to distract themselves and escape from the problems they are experiencing, including trauma. It is also important to consider other factors that contribute to the development of addictions, including the influence of the family environment as well as the importance of various types of personality predispositions.
The conducted studies are associated with certain limitations. Firstly, they were cross-sectional, which does not allow for conclusions about cause-and-effect relationships. Moreover, the study group was not very large. Furthermore, the analyses did not specify the type of preferred gambling games or experienced traumatic events because the respondents could indicate several; it was also not analysed whether the respondents played on the internet or “in real life”. Additionally, a certain problem is the very diverse terminology, especially in relation to gambling, as Silczuk and Habrat [1] point out, as well as the changing classifications of disorders, which also applies to PTSD.
Despite the limitations presented, the study contributes new content in the field of the relationship between trauma and gambling and alcohol use disorders. It is worth emphasising the inclusion of various trauma indicators i.e., both the number of experienced traumatic events (directly and indirectly) and PTSD symptoms, and the fact that it examines the relationship between trauma and the risk of two types of addictions i.e., substance (alcohol) and activity (gambling) in the same group. It is also worth noting that it uses relatively new measurement tools (LEC-5 and PCL-5), developed in accordance with the DSM-5 classification, to assess traumatic events and PTSD symptoms.
Our findings also are of value for therapeutic practice, especially since Poland has been found to present a higher percentage of people with PTSD symptoms than other countries [37]. Furthermore, the number of people engaging in gambling and excessive drinking continues to increase. Our data may facilitate a greater awareness of the significance of problems resulting from traumatic experiences among clinicians working with addicted people and support the implementation of appropriate therapeutic programmes aimed at increasing the effectiveness of treatment. In cases of this kind, comprehensive therapy that takes into account both types of disorders is recommended. The most desirable is cognitive-behavioural therapy, but exposure therapy with the inclusion of pharmacotherapy may also be valuable [11]. The obtained results may also be useful in developing preventive programmes for people with traumatic experiences who do not demonstrate any addiction; these would aim to equip those with post-traumatic experiences with the skills to cope with the consequences of experienced events and could contribute to reducing the risk of developing both substance dependence and behavioural addictions.

■ CONCLUSIONS

The obtained results suggest the following conclusions:
• PTSD symptoms appear to play a greater role in the development of gambling addiction and alcohol dependence than the number of experienced traumatic events.
• PTSD symptoms are a stronger risk factor for the development of gambling addiction than alcohol dependence.
• Prevention programmes to promote skills to cope with experienced traumatic events may be of use in reducing the risk of substance and behavioural addictions.

Conflict of interest/Konflikt interesów

None declared./Nie występuje.

Financial support/Finansowanie

None declared./Nie zadeklarowano.

Ethics/Etyka

The work described in this article has been carried out in accordance with the Code of Ethics of the World Medical Association (Declaration of Helsinki) on medical research involving human subjects, Uniform Requirements for manuscripts submitted to biomedical journals and the ethical principles defined in the Farmington Consensus of 1997.
Treści przedstawione w pracy są zgodne z zasadami Deklaracji Helsińskiej odnoszącymi się do badań z udziałem ludzi, ujednoliconymi wymaganiami dla czasopism biomedycznych oraz z zasadami etycznymi określonymi w Porozumieniu z Farmington w 1997 roku.

References/Piśmiennictwo