Eating disorder debut cases during COVID-19 lockdown in adults. Exploring differences in treatment outcome contrasting with pre-pandemic onset cases.

OBJECTIVE: Despite an increase in eating disorder (ED) cases during the COVID-19 pandemic, there are limited longitudinal studies exploring treatment outcomes. The aims of the present study were: (1) to compare the clinical features of patients with EDs whose onset was during the COVID-19 lockdown (pandemic cohort) against patients with EDs whose onset was prior to the pandemic (pre-pandemic cohort) and, (2) to compare therapy responses between the cohorts. METHOD: The sample consisted of 115 adult women with an ED. N = 37 new ED cases (pandemic cohort) were diagnosed and included in the study during the pandemic (May 2020-May 2021); these patients did not have any previous history of an ED. We also included N = 78 ED cases (pre-pandemic cohort) diagnosed prior to the COVID-19 pandemic breakout (prior to March 2020). All ED subtypes were considered in both groups and several clinical variables were assessed. RESULTS: At baseline, pandemic cohort reported lower levels of impulsivity and higher emotional regulation capacities than the pre-pandemic cohort; however, no differences were found in aspects of general psychopathology and ED related severity. Following treatment, the pandemic cohort showed higher rates of good outcome and lower rates of dropouts than the pre-pandemic cohort. CONCLUSIONS: Although both cohorts showed similar ED-related symptoms and general psychopathology scores, treatment outcomes were more favourable in the pandemic cohort.

Emotion Regulation, Eating Psychopathology, and Putative Transdiagnostic Psychological Processes: Findings from an Exploratory Network Analysis in a College Sample.

OBJECTIVE: Considering the prevalence of ED-related prodromal symptoms among higher education students (making them a population at risk for developing EDs), the main goals of this study were to conduct a network analysis in a college sample and to explore multivariate dependencies between a selection of empirically informed variables of interest to eating psychopathology, namely difficulties in emotion regulation and psychological processes (e.g., interoceptive awareness, self-compassion, self-criticism, mindfulness, and experiential avoidance). METHODS: The sample included 294 college students (Mage = 21.4, SD = 5.0; MBMI = 22.4, SD = 3.7). A Gaussian graphical network model was estimated to visualize interactions among the studied variables and to assess their centrality in terms of betweenness, closeness, strength, and expected influence. RESULTS: A network system with 21 nodes was estimated (sparsity = 0.52). Nodes assessing disordered eating symptoms displayed the strongest correlation coefficients with nodes assessing dimensions of interoceptive awareness: eating concerns and not-distracting (r = -0.11), shape concerns and trusting (r = -0.16), and weight concerns and trusting (r = -0.10). Self-compassion was the node with the highest betweenness (SELFCS = 2.27) and closeness centrality (SELFCS = 1.70). The nodes with the highest strength centrality were strategies (DERS = 1.91) and shape concerns (EDE-Q = 1.51). DISCUSSION: In this network model conducted in a college sample, eating-related symptoms were mainly associated with dimensions of interoceptive awareness. Also, the lack of effective strategies to regulate emotions, shape concerns, and self-compassion stood out as central nodes in the network model. The results suggest that addressing these variables may be promising in disrupting network systems marked by the presence of prodromal eating psychopathology symptoms in at-risk populations (e.g., college students).

Treatment Targets and Strategies for Eating Disorders Recovery: A Delphi Consensus With Lived Experience, Carers, Researchers, and Clinicians.

OBJECTIVE: Long-term recovery rates following eating disorders (EDs) treatment remain low. This might be partly due to a lack of agreement between key stakeholder groups, including people with lived experience, carers, clinicians, and researchers, regarding optimal therapeutic targets and strategies. We aimed to reach a consensus across these diverse groups on the most valued treatment targets and strategies for fostering ED recovery. METHOD: We used the Delphi method with two phases: (i) Survey development and (ii) Expert rating. The survey development phase included the design of an initial set of items through scoping review and feedback from a committee of 14 experts. During the survey rating, we engaged a larger panel of 185 experts who comprised the stakeholder groups: Individuals with lived ED experience (n = 49), carers (n = 44), researchers (n = 46), and clinicians (n = 46). RESULTS: Thirty-one targets and 29 strategies reached consensus (> 70% agreement over three rounds). Psychological-emotional-social targets including quality of life, sense of purpose, and emotion regulation, along with ED behaviors, reached the highest agreement (> 90%). Strategies reflecting an individualized approach to treatment (i.e., considering diversity, assessing comorbidities, and enhancing rapport) achieved the highest agreement (> 90%). Responses across groups were similar, except researchers leaning more towards consideration of weight- and eating-related targets. DISCUSSION: Holistic targets and individualized therapeutic strategies have consistent support from the different stakeholder groups involved in ED treatment. The agreed set of targets/strategies may be used, in triangulation with other sources of evidence, to design and evaluate coproduced and personalized interventions.

Rethinking cutoff values for the South Oaks Gambling Screen: Sex-specific insights and DSM-5 severity adjustments in Gambling Disorder assessment.

Background and aims: The South Oaks Gambling Screen (SOGS) is a commonly used tool for screening potential gambling problems. The SOGS score has been found to be correlated with the DSM-5 criteria for Gambling Disorder (GD). However, one of its main limitations is the high rate of false positives. The objective of this study was to establish more accurate cutoff points for the SOGS based on the DSM-5 criteria and severity levels, taking into account sex-specific samples. Additionally, we aimed to validate these cutoff points using external measures. Methods: The study sample comprised 4.516 patients (398 women and 4,118 men) who sought treatment for GD. Of these patients, 4.203 met the DSM-5 criteria for GD, while 313 did not meet the threshold for GD diagnosis. Results: The recommended cutoff value for the SOGS is eight for men (Sensitivity (Se): 82.9%, Specificity (Sp): 86.2%) and seven for women (Se: 85.6%, Sp: 77.4%). For moderate severity of GD, the cutoff points are nine for men (Se: 82.1%, Sp: 82.0%) and eight for women (Se: 86.3%, Sp: 73.3%), while for severe cases of GD, the cutoff point is ten for both sexes (Se: 83.0%, Sp: 56.7% for men; Se: 80.0%, Sp: 77.4% for women). These cutoff values are validated by evidence of worse psychopathological states, more dysfunctional personality traits, and risky behaviours commonly associated with GD. Discussion and Conclusions: These findings support adjusting the reference values for the SOGS to eight in males and seven in females to enhance the classification of individuals potentially experiencing GD. The use of higher cutoff values has significant implications for clinical and research purposes, enabling a more precise assessment of the diagnosis and severity of GD.

Maladaptive eating behaviors and health-related quality of life in Spanish children.

In children, assessing health-related quality of life (HRQoL) and identifying the factors that can influence it are essential to understanding their overall health and well-being. Although eating disorders in children have been associated with reduced HRQoL, the impact of maladaptive eating behaviors, such as external eating, emotional eating and restrained eating, on children's HRQoL has not yet been prospectively explored. Therefore, the aim of this study was to determine whether external, emotional and restrained eating at baseline was associated with HRQoL in children after 14.65 months (95% CI: 14.57-14.73) of follow-up. The study involved 690 boys and 681 girls aged between 8 and 10 years, recruited from primary schools in Catalonia (Spain). To assess the relationship between external, emotional and restrained eating behaviors at baseline and HRQoL at follow-up, the Dutch Eating Behavior and KIDSCREEN-10 questionnaires were used, respectively. After adjusting for sex, age, intervention allocation group, school, maternal education, zBMI and physical activity, external and emotional eating behaviors at baseline were negatively associated with HRQoL at follow-up (p < 0.01). These associations were attenuated after final adjustment for HRQoL at baseline. Furthermore, a composite score of maladaptive eating behaviors at baseline was created by summing the individual scores for emotional, restrained and external eating behaviors. This composite score showed a significant inverse association with HRQoL at follow-up, even after adjusting for baseline HRQoL (p = 0.024). In conclusion, external and emotional eating behaviors seems to negatively affect HRQoL prospectively in Spanish children. The composite score of maladaptive eating behaviors showed a stronger inverse association with HRQoL than each eating behavior individually. TRIAL REGISTRATION NUMBER: ISRCTN registry: ISRCTN68403446; Date of registration, August 01, 2014 'Retrospectively registered'.

Spanish Validation of the Brief Pornography Screen Within a Clinical Sample of Individuals with Gambling Disorder.

Problematic pornography use (PPU) shares characteristics with behavioral addictions, such as gambling disorder (GD), and PPU and GD may frequently co-occur. In order to fill existing gaps in screening instruments for PPU validated in GD, the study examined the psychometric properties of the Spanish version of the Brief Pornography Screen (BPS) within a clinical sample of individuals with GD. A total of 200 individuals seeking treatment for GD were consecutively recruited. The psychometric properties of the BPS were examined by performing confirmatory factor analysis (CFA) and testing for evidence of convergent and discriminant validity. The CFA supported a one-factor solution showing high internal consistency (α = 0.81). The BPS showed convergent validity and correlated with psychological distress, general psychopathology, impulsive tendencies, and low self-directedness. The BPS demonstrated adequate psychometric properties and is therefore recommended as a brief screening tool for identifying probable PPU in individuals seeking treatment for GD.

Tumor slice culture system for ex vivo immunotherapy studies.

Personalized immunotherapy is emerging as a promising approach for cancer treatment, aiming to harness the patient's own immune system to target and eliminate tumor cells. One key aspect of developing effective personalized immunotherapies is the utilization of tumor slices derived from individual patient tumors. Tumor slice models retain the complexity and heterogeneity of the original tumor microenvironment, including interactions with immune cells, stromal elements, and vasculature. These ex vivo models serve as valuable tools for studying tumor-immune interactions and for testing the efficacy of immunotherapeutic agents tailored to the specific characteristics of each patient's tumor. In this chapter, we set up a protocol for immunotherapy strategies in mouse models highlighting their translational potential to guide treatment decisions and improve therapeutic outcomes in cancer patients.

Pornography Use and Associated Factors in Adolescents: A Cross-Jurisdictional Approach (Spain vs. Mexico).

Pornography use is common among adolescents. However, there has been limited in-depth examination of cross-country differences in adolescent pornography use. Therefore, the main aim of the present study was to understand cross-jurisdictional differences in problematic pornography use (PPU) in 1810 adolescents from Spain and Mexico. The relationship between sociodemographic variables, loneliness, sexual risk behaviors, and religiosity with PPU and cross-jurisdictional differences between the two Spanish-speaking populations was assessed. In the Spanish sample, pornography use was a mediator of risky sexual behaviors, with this association being greater in males, older individuals, and those with a non-heterosexual orientation. In the Mexican sample, non-use of condoms was directly statistically predicted by older age, poor familial relationships, low religiosity, and more frequent pornography use. Jurisdictional differences in relationships between variables were observed in the two samples (Spanish and Mexican). Clinical implications and potential sociocultural factors that may underlie observed differences in the two Spanish-speaking cultures are considered and warrant additional investigation.

The prognostic role of food addiction for weight loss treatment outcomes in individuals with overweight and obesity: A systematic review and meta-analysis.

Food addiction (FA) could be a potential prognostic factor of weight loss intervention outcomes. This systematic review with meta-analysis aimed to (1) estimate this prognostic effect of FA diagnosis and symptom count in individuals with overweight or obesity and (2) explore potential sources of heterogeneity based on properties of the weight loss intervention, study, and sample (e.g., age, gender, ethnicity). We searched PubMed, PsycINFO, and Web of Science for studies reporting on associations between pre-intervention FA (assessed with the Yale Food Addiction Scale) and weight outcomes after weight loss intervention in individuals with overweight or obesity without a medically diagnosed eating disorder. Twenty-five studies met inclusion criteria, including 4904 individuals (71% women, Mage = 41 years, BMI = 40.82 kg/m2), k = 18 correlations of weight loss with FA symptom count, and k = 21 mean differences between FA diagnosis groups. Pooled estimates of random-effects meta-analyses found limited support for a detrimental effect of FA symptom count and diagnosis on weight loss intervention outcomes. Negative associations with FA increased for behavioral weight loss interventions and among more ethnically diverse samples. More research on the interaction of FA with pre-existing mental health problems and environmental factors is needed.

Statistical predictors of the co-occurrence between gambling disorder and problematic pornography use.

Co-occurrence between gambling disorder (GD) and other mental disorders is common, but its association with problematic pornography use (PPU) remains unexplored. This study aimed to investigate relationships between sociodemographic variables, personality measures, psychopathology, emotional regulation, and impulsivity and the co-occurrence of GD and PPU using structural equation modeling (SEM). The sample consisted of 359 adults seeking treatment for GD. The short version of the Problematic Pornography Consumption Scale (PPCS-6) identified patients with GD + PPU. Psychopathology, impulsivity, emotional regulation, and personality were also assessed. Higher impulsivity levels statistically predicted co-occurrence between GD and PPU. Impulsivity mediated the relationship between younger age, maladaptive personality features, and emotional dysregulation and co-occurrence. Psychopathological distress did not directly associate with GD + PPU co-occurrence. Impulsivity relates importantly to the co-occurrence of GD and PPU. Younger age, maladaptive personality, and emotional dysregulation contribute to increased impulsivity levels and co-occurrence. The findings highlight the importance of addressing impulsivity in understanding and treating co-occurring GD and PPU.

COVID-19 and Cognitive Decline in Older Adults with High-Cardiovascular Risk: A Post Hoc Analysis.

Cognitive decline has been reported as a short-term sequela in patients hospitalized for coronavirus disease-19 (COVID-19). Whether COVID-19 is associated with late cognitive impairment in older free-living individuals with high cardiovascular risk, a group at greater risk of cognitive decline, is unknown. We determined this association of COVID-19 through a longitudinal evaluation of post-COVID-19 cognitive performance and impairment as post hoc analysis in 5,179 older adults (48% female) with mean (SD) age 68.5 (5.0) years, body mass index 31.7 (3.7) kg/m2, harboring ≥ 3 criteria for metabolic syndrome (e.g., hypertension, hyperlipidemia, hyperglycemia etc.) enrolled in PREDIMED-Plus trial. Pre- and post-COVID-19 cognitive performance was ascertained from scheduled assessments conducted using a battery of neuropsychological tests, including 5 domains: Global Cognitive Function, General Cognitive Function, Execution Function, Verbal Fluency and Attention domains, which were standardized for the cohort. Cognitive impairment was defined as the bottom 10 percentile of the sample. Multivariable linear and logistic regression models assessed the association of COVID-19 with cognitive decline and impairment, respectively. After a mean 50-week follow-up, no significant associations were observed between COVID-19 status and post-COVID-19 scores of all tapped neuropsychological domains, except Global Cognitive Function (GCF). When fully adjusted, COVID-19 was marginally associated with higher (better) post-pandemic GCF score (ßadj (95% CI): 0.06 (0.00, 0.13) p=.05). However, the odds for post-COVID-19 cognitive impairment in GCF domain were not associated with the disease (ORadj (95% CI): 0.90 (0.53, 1.51) p=.68). In the PREDIMED-Plus cohort, COVID-19 status and cognitive impairment determined 50 weeks post-infection showed no association in older adults at high cardiovascular risk. This suggests that cognitive changes observed shortly after COVID-19 revert over time. However, cautious interpretation is warranted as these data were obtained within the framework of a clinical trial encouraging a healthy lifestyle.

Getting even: chasing behavior, decision-making, and craving in habitual gamblers.

BACKGROUND: Dysfunctional decision-making and intense craving represent pivotal aspects across all addictive behaviors, notably evident in gambling addiction where these factors significantly shape chasing behavior-continuing gambling to recoup losses-indicative of problematic gambling. This study explores the correlation between chasing behavior, craving, affective decision-making, decision-making styles, and gambling severity among habitual Italian gamblers. METHODS: One hundred and sixty-six participants from diverse gambling venues completed assessments including the South Oaks Gambling Screen (SOGS), the Iowa Gambling Task (IGT), the General Decision-Making Style (GDMS), the Gambling Craving Scale (GACS), and a computerized task to measure chasing behavior. Participants were randomly assigned to Control and Loss chasing conditions. RESULTS: Regression analyses revealed craving as a predictor of chasing behavior. Interestingly, individuals with a dependent decision-making style exhibited lower tendencies to chase. While IGT performance correlates with chasing frequency, it is not associated with the decision to continue or cease gambling. Intriguingly, gambling severity (SOGS total score) did not feature in the final models of both regression analyses. DISCUSSION: These findings emphasize the significant role of craving in driving chasing behavior. Additionally, this study introduces, for the first time, the idea that a dependent decision-making style could potentially serve as a safeguard against chasing proneness. CONCLUSIONS: The study suggests a fundamental dichotomy between chasers and nonchasers among gamblers, irrespective of gambling severity. This distinction could be instrumental in tailoring more effective intervention strategies for gambling disorder treatment.

Glycated hemoglobin, type 2 diabetes, and poor diabetes control are positively associated with impulsivity changes in aged individuals with overweight or obesity and metabolic syndrome.

Impulsivity has been proposed to have an impact on glycemic dysregulation. However, it remains uncertain whether an unfavorable glycemic status could also contribute to an increase in impulsivity levels. This study aims to analyze associations of baseline and time-varying glycemic status with 3-year time-varying impulsivity in older adults at high risk of cardiovascular disease. A 3-year prospective cohort design was conducted within the PREDIMED-Plus-Cognition substudy. The total population includes 487 participants (mean age = 65.2 years; female = 50.5%) with overweight or obesity and metabolic syndrome. Insulin resistance (HOMA-IR), glycated hemoglobin (HbA1c), presence of type 2 diabetes mellitus, and type 2 diabetes control were evaluated. Impulsivity was measured using the Impulsive Behavior Scale questionnaire and various cognitive measurements. Impulsivity z-scores were generated to obtain Global, Trait, and Behavioral Impulsivity domains. Linear mixed models were used to study the longitudinal associations across baseline, 1-year, and 3-year follow-up visits. HOMA-IR was not significantly related to impulsivity. Participants with higher HbA1c levels, type 2 diabetes, and poor control of diabetes showed positive associations with the Global Impulsivity domain over time, and those with higher HbA1c levels were further related to increases in the Trait and Behavioral Impulsivity domains over the follow-up visits. These results suggest a potential positive feedback loop between impulsivity and glycemic-related dysregulation.

The Impact of High Levels of Compensatory Exercise on Treatment Outcomes in Threshold and Subthreshold Bulimia Nervosa.

Bulimia nervosa (BN) and other specific feeding or eating disorders with subthreshold BN symptoms (OSFED-BN) are characterized by recurrent binge eating episodes accompanied by compensatory behaviors, including excessive exercise. We aimed to examine the role of compensatory exercise on several clinical disorder-related variables and the treatment outcomes. The sample included 478 patients diagnosed with either BN or OSFED-BN admitted for a 16-week eating disorder-specific treatment program. A battery of questionnaires was administered to evaluate eating and general psychopathology, and personality traits. Other clinical disorder-related data, including levels of compensatory exercise, were assessed through a semi-structured clinical interview. Between-group comparisons of compensatory exercise levels were analyzed, as a predictive model of risk of poor treatment outcomes. Path analysis was conducted using structural equation models to estimate the direct and indirect effects between the main variables. Higher levels of self-reported compensatory exercise were associated with greater eating psychopathology, general psychopathology, and more dysfunctional personality traits and were a predictor of poor treatment outcomes. Additionally, these levels achieved a mediating role in several paths contributing to a higher likelihood of a poor outcome. Further research is required to determine how psychotherapeutic approaches can be optimized to adequately include adaptive exercise for these patients.

Perceived Impact of Gambling Advertising can Predict Gambling Severity among Patients with Gambling Disorder.

There is growing evidence that gambling advertising disproportionately affects those experiencing more severe gambling harm. Such association has been studied by recruiting gamblers using online panels, by analysing registered users' data from gambling websites, and through surveys and focus group interviews. However, it is thought that these methods tend to overestimate gambling severity. The present study employed a sample of gamblers with a verified gambling disorder diagnosis (N = 210, 7.1% females, Mage = 39.4 years) recruited for a period of under two years at a large public hospital. It examined the relationship between self-reported impact of gambling advertising, gambling preference (strategic versus non-strategic) and gambling modality (online versus in-person). The results indicated that higher perceived impact of gambling advertising predicted higher gambling severity, which supports previous findings obtained from non-clinical settings. However, contrary to what was expected, strategic gambling and online gambling were not associated with higher perceived impact of gambling advertising, even though these groups are believed to be exposed to more gambling marketing and advertising from gambling operators. The study aligns well with available scientific evidence proposing further restrictions on gambling advertising regulation due to their disproportionate impact on those already experiencing gambling harm.

Relationship between sex, APOE genotype, endocannabinoids and cognitive change in older adults with metabolic syndrome during a 3-year Mediterranean diet intervention.

BACKGROUND: The Mediterranean diet (MedDiet) has demonstrated efficacy in preventing age-related cognitive decline and modulating plasma concentrations of endocannabinoids (eCBs) and N-acylethanolamines (NAEs, or eCB-like compounds), which are lipid mediators involved in multiple neurological disorders and metabolic processes. Hypothesizing that eCBs and NAEs will be biomarkers of a MedDiet intervention and will be related to the cognitive response, we investigated this relationship according to sex and apolipoprotein E (APOE) genotype, which may affect eCBs and cognitive performance. METHODS: This was a prospective cohort study of 102 participants (53.9% women, 18.8% APOE-ɛ4 carriers, aged 65.6 ± 4.5 years) from the PREDIMED-Plus-Cognition substudy, who were recruited at the Hospital del Mar Research Institute (Barcelona). All of them presented metabolic syndrome plus overweight/obesity (inclusion criteria of the PREDIMED-Plus) and normal cognitive performance at baseline (inclusion criteria of this substudy). A comprehensive battery of neuropsychological tests was administered at baseline and after 1 and 3 years. Plasma concentrations of eCBs and NAEs, including 2-arachidonoylglycerol (2-AG), anandamide (AEA), oleoylethanolamide (OEA), palmitoylethanolamide (PEA), and N-docosahexaenoylethanolamine (DHEA), were also monitored. Baseline cognition, cognitive changes, and the association between eCBs/NAEs and cognition were evaluated according to gender (crude models), sex (adjusted models), and APOE genotype. RESULTS: At baseline, men had better executive function and global cognition than women (the effect size of gender differences was - 0.49, p = 0.015; and - 0.42, p = 0.036); however, these differences became nonsignificant in models of sex differences. After 3 years of MedDiet intervention, participants exhibited modest improvements in memory and global cognition. However, greater memory changes were observed in men than in women (Cohen's d of 0.40 vs. 0.25; p = 0.017). In men and APOE-ε4 carriers, 2-AG concentrations were inversely associated with baseline cognition and cognitive changes, while in women, cognitive changes were positively linked to changes in DHEA and the DHEA/AEA ratio. In men, changes in the OEA/AEA and OEA/PEA ratios were positively associated with cognitive changes. CONCLUSIONS: The MedDiet improved participants' cognitive performance but the effect size was small and negatively influenced by female sex. Changes in 2-AG, DHEA, the OEA/AEA, the OEA/PEA and the DHEA/AEA ratios were associated with cognitive changes in a sex- and APOE-dependent fashion. These results support the modulation of the endocannabinoid system as a potential therapeutic approach to prevent cognitive decline in at-risk populations. TRIAL REGISTRATION: ISRCTN89898870.

Unveiling the multifaceted antitumor effects of interleukin 33.

Interleukin 33 (IL-33), once predominantly recognized for its pro-tumoral activities, has emerged as a multifunctional cytokine with antitumor properties. IL-33 pleiotropic activities include activation of Th1 CD4+ T cells, CD8+ T cells, NK cells, dendritic cells, eosinophils, as well as type 2 innate lymphoid cells. Regarding this immunomodulatory activity, IL-33 demonstrates synergistic interactions with various cancer therapies, including immune checkpoint blockade and chemotherapy. Combinatorial treatments leveraging IL-33 exhibit enhanced antitumor efficacy across different tumor models, promising novel avenues for cancer therapy. Despite its antitumor effects, the complex interplay of IL-33 within the tumor microenvironment underscores the need for further investigation. Understanding the mechanisms underlying IL-33's dual role as both a promoter and inhibitor of tumor progression is essential for refining therapeutic strategies and fully realizing its potential in cancer immunotherapy. This review delves into the intricate landscape of IL-33 effects within the tumor microenvironment, highlighting its pivotal role in orchestrating immune responses against cancer.

Network analysis of DSM-5 criteria for gambling disorder: considering sex differences in a large clinical sample.

BACKGROUND: The fifth version of the Diagnostic and Statistical Manual for Mental Disorders (DSM-5) and its revised version (DSM-5-TR) propose severity levels for gambling disorder (GD) based on the number of criteria met. However, this taxonomy has some limitations. We aimed to assess the centrality of each criterion and its relationship by conducting a network analysis while considering sex differences. METHODS: We performed a network analysis with the DSM-5 criteria for GD with data from 4,203 treatment-seeking patients (3,836 men and 367 women) diagnosed with GD who sought for treatment in a general tertiary hospital which has a unit specialized in behavioral addictions. RESULTS: The withdrawal criterion ("Restless or irritable when attempting to cut down or stop gambling") showed the highest centrality values in both sexes. In men, the second most central criterion was the tolerance criterion ("Needs to gamble with increasing amounts of money in order to achieve the desired excitement"); while among women, the second was the chasing losses criterion ("After losing money gambling, often returns another day to get even"). CONCLUSIONS: The most central criteria identified are associated with compulsivity-driven behaviors of the addictive process. Taking into account the high relevance and transitive capacity of withdrawal in both men and women, as well as tolerance in men, and chasing losses in women, the recognition and understanding of these symptoms are fundamental for the accurate diagnosis and severity assessment of GD.