Prefrontal activity during IOWA Gambling Task in young adult women.

This study aims to investigate the relationships between personality traits of impulsivity, using the UPPS-P Impulsive Behaviour Scales shortened version, and prefrontal cortex (PFC) activity during the IOWA Gambling Task (IGT) in young adult women. The study included a sample of 83 young, healthy females (19.8 ± 1.4 years), who voluntarily took part in the study. Repeated measures analysis during the IGT revealed a significant increase in HbO (all p <.001; ηp2 >.31) and a decrease in Hbr (all p <.003; ηp2 >.08) in all prefrontal quadrants. This increase in oxygenation occurs primarily during the choice period under ambiguity (r =.23; p =.039). Additionally, there was a significant linear decrease in selecting the decks associated with a high frequency of losses (p <.001), while the favorable deck with low losses showed a linear increase (F = 12.96; p <.001). Notably, discrepancies were found between UPPS-P and IGT impulsivity ratings. The Lack of Perseverance and Lack of Premeditation scales from the UPPS-P were identified as significant predictors of HbO levels, mainly in the two quadrants of the left hemisphere's, lateral (adjusted R2 =.23; p <.001; f2 =.34) and rostral (adjusted R2 =.13; p <.002; f2 =.17). These findings suggest that young adult women predominantly adopt a punishment-avoidance strategy during IGT, exhibiting increased activation in the left hemisphere, especially during the task's initial phase characterized by ambiguity.

Explicit and Implicit Emotional Expression in Gambling Disorder Measured by a Serious Game: A Pilot Study.

Behavioral addictions have been related with biased emotional reactions to risky choices. However, few studies have analyzed the role of both explicit and implicit emotional expression in gambling disorder (GD). This pilot study aims to examine emotion regulation in treatment-seeking patients with GD. The sample included n = 35 participants classified into three groups: patients with current GD, patients with GD in remission, and a control group without GD. Implicit emotional expressions were evaluated through a serious videogame (Playmancer) and explicit emotions were measured through self-reports. Patients in the current GD group had, compared to the remission and control groups, lower levels of implicit emotion expression and higher levels of explicit emotion expression. The patients in GD remission group endorsed better emotion regulation capacity in comparison to patients with current GD. We conclude that differences in emotion expression profiles (such as anger and anxiety) should be considered both in the development of screening and diagnostic measures and in the planning of prevention and treatment programs.

The influence of chronological age on cognitive biases and impulsivity levels in male patients with gambling disorder.

BACKGROUND AND AIMS: Due to the contribution of age to the etiology of gambling disorder (GD), there is a need to assess the moderator effect of the aging process with other features that are highly related with the clinical profile. The objective of this study is to examine the role of the chronological age into the relationships between cognitive biases, impulsivity levels and gambling preference with the GD profile during adulthood. METHODS: Sample included n = 209 patients aged 18-77 years-old recruited from a Pathological Gambling Outpatients Unit. Orthogonal contrasts explored polynomial patterns in data, and path analysis implemented through structural equation modeling assessed the underlying mechanisms between the study variables. RESULTS: Compared to middle-age patients, younger and older age groups reported more impairing irrational beliefs (P = 0.005 for interpretative control and P = 0.043 for interpretative bias). A linear trend showed that as people get older sensation seeking (P = 0.006) and inability to stop gambling (P = 0.018) increase. Path analysis showed a direct effect between the cognitive bias and measures of gambling severity (standardized effects [SE] between 0.12 and 0.17) and a direct effect between impulsivity levels and cumulated debts due to gambling (SE = 0.22). CONCLUSION: Screening tools and intervention plans should consider the aging process. Specific programs should be developed for younger and older age groups, since these are highly vulnerable to the consequences of gambling activities and impairment levels of impulsivity and cognitive biases.

Presence of problematic and disordered gambling in older age and validation of the South Oaks Gambling Scale.

The use of instruments originally developed for measuring gambling activity in younger populations may not be appropriate in older age individuals. The aim of this study was to examine the presence of problematic and disordered gambling in seniors aged 50 or over, and study the reliability and validity properties of the SOGS (a screening measure to identify gambling related problems). Two independent samples were recruited: a clinical group of n = 47 patients seeking treatment at a Pathological Gambling Outpatient Unit, and a population-based group of n = 361 participants recruited from the same geographical area. Confirmatory factor analysis verified the bifactor structure for the SOGS with two correlated underlying dimensions [measuring the impact of gambling on the self primarily (Cronbach's alpha α = 0.87) or on both the self and others also (α = 0.82)], and a global dimension of gambling severity (also with excellent internal consistency, α = 0.90). The SOG obtained excellent accuracy/validity for identifying gambling severity based on the DSM-5 criteria (area under the ROC curve AUC = 0.97 for discriminating disordered gambling and AUC = 0.91 for discriminating problem gambling), and good convergent validity with external measures of gambling (Pearson's correlation R = 0.91 with the total number of DSM-5 criteria for gambling disorder, and R = 0.55 with the debts accumulated due to gambling) and psychopathology (R = 0.50, 0.43 and 0.44 with the SCL-90R depression, anxiety and GSI scales). The optimal cutoff point for identifying gambling disorder was 4 (sensitivity Se = 92.3% and specificity Sp = 98.6%) and 2 for identifying problem gambling (Se = 78.8% and Sp = 96.7%). This study provides empirical support for the reliability and validity of the SOGS for assessing problem gambling in elders, and identifies two specific factors that could help both research and clinical decision-making, based on the severity and consequences of the gambling activity.

Clustering Gambling Disorder Patients with Lotteries as a Preferred Form of Gambling.

Few studies have focused on the specific subtype of gamblers who present lotteries as their main gambling problem. This study aimed to explore empirical subgroups of treatment-seeking patients who endorsed lotteries as their preferred form of gambling. The sample included n = 342 patients who were included in two-step cluster analysis procedures using sociodemographic and clinical measures as indicator variables. Three clusters were identified: (a) Cluster 1 (labeled as "severely impaired young men", n = 108, 31.6%) included mainly single young men that were employed, with short disorder duration, high gambling severity and high levels of comorbid psychopathology; (b) Cluster 2 (labeled as "moderate severity and highly functional", n = 120, 35.1%) included patients that were middle-aged, highly educated, married, employed, with high socioeconomic position indexes and functional personality traits; and (c) Cluster 3 (labeled as "older, moderately impaired patients", n = 114, 33.3%) included older patients, the highest percentage of separated or divorced subjects, high unemployment, low socioeconomic status and low levels of education. This study indicates that gambling disorder profiles characterized by lotteries as a preferred form of gambling constitute a heterogeneous group in which distinct, empirically based phenotypes can be identified. These factors should be taken into account for the development of reliable assessment instruments and for the design of effective prevention and treatment programs.

Gambling Phenotypes in Older Adults.

Participation in gambling is rising in older adults. Indeed, in the coming years, engagement in gambling as a social activity is expected to increase more sharply in the elderly than in any other age group. Due to their exposure to powerful age-specific risk factors such as isolation, inactivity and failing health, older people are highly vulnerable to gambling-related problems. This study aimed to explore the existence of empirical clusters related to gambling habits in a sample of elderly participants from the general population. The sample included n = 361 participants, age range 50-90 years (mean 73.8, SD 8.4). Empirical clusters were identified through a two-step clustering analysis based on a broad set of indicators, including sociodemographic features, psychopathological state, substance use, life events, gambling preferences and scores on screening measures of gambling severity. The prevalence of GD in the study was 1.4%. Two clusters were identified: (a) cluster 1 (labeled as "low risk of gambling problems", n = 265, 73.4%), which included the higher proportion of non-gamblers or individuals who engage only in non-strategic gambling, women, widowed, and lower levels of education (no individual into this group met criteria for GD); and (b) cluster 2 (labeled as "higher risk of gambling problems", n = 96, 26.6%), which included the higher proportion of men, who reported both non-strategic and strategic gambling preferences (all participants diagnosed of GD were grouped into this cluster), older age, longer history of gambling, higher gambling severity, higher use of substances and worse psychopathological state. The elderly constitute a heterogeneous group with regard to gambling phenotypes. The results of this study may prove particularly useful for developing reliable screening tools able to identify older patients at a high risk of gambling problems, and for designing effective prevention and intervention programs.

Differences in Emotion Regulation Considering Gender, Age, and Gambling Preferences in a Sample of Gambling Disorder Patients.

Introduction: Impairments in emotion regulation are understood to be a transdiagnostic risk factor of suffering from compulsive and addictive behaviors. The aim of this study was to investigate the role of emotion regulation deficits in gambling disorder and to analyze these differences taking gender, age, and gambling activity preferences into account. METHODS: The sample included n = 484 patients seeking treatment for gambling disorder at a specialized outpatient service. Main outcomes were sociodemographic variables, emotion regulation, and gambling severity. RESULTS: Differences between sexes were found in non-acceptance of emotions. Older patients obtained higher levels in non-acceptance of emotions, lack of emotion regulation strategies, emotional clarity, and global emotion regulation scores. No differences were found in emotion scores considering gambling preferences (non-strategic versus strategic). Path analysis showed that emotion regulation scores and age had a direct effect on gambling disorder severity, while emotion regulation and gambling preference were not mediational variables in the relationships of gender and age with gambling severity. CONCLUSIONS: Emotion regulation impairments differ in patients seeking treatment for gambling problems. Early prevention and intervention programs should incorporate the different dimensions of this process, taking into account clinical phenotypes.

Impulsivity and cognitive distortions in different clinical phenotypes of gambling disorder: Profiles and longitudinal prediction of treatment outcomes.

BACKGROUND: Impulsivity and cognitive distortions are hallmarks of gambling disorder (GD) but it remains unclear how they contribute to clinical phenotypes. This study aimed to (1) compare impulsive traits and gambling-related distortions in strategic versus non-strategic gamblers and online versus offline gamblers; (2) examine the longitudinal association between impulsivity/cognitive distortions and treatment retention and relapse. METHODS: Participants seeking treatment for GD (n = 245) were assessed for gambling modality (clinical interview), impulsive traits (Urgency, Premeditation, Perseverance and Sensation Seeking [UPPS] scale) and cognitive distortions (Gambling Related Cognitions Scale) at treatment onset, and for retention and relapse (as indicated by the clinical team) at the end of treatment. Treatment consisted of 12-week standardized cognitive behavioral therapy, conducted in a public specialized clinic within a general public hospital. RESULTS: Strategic gamblers had higher lack of perseverance and gambling-related expectancies and illusion of control than non-strategic gamblers, and online gamblers had generally higher distortions but similar impulsivity to offline gamblers. Lack of perseverance predicted treatment dropout, whereas negative urgency and distortions of inability to stop gambling and interpretative bias predicted number of relapses during treatment. CONCLUSIONS: Individuals with online and strategic GD phenotypes have heightened gambling related biases associated with premature treatment cessation and relapse. Findings suggest that these GD phenotypes may need tailored treatment approaches to reduce specific distortions and impulsive facets.

Corrigendum: Phenotypes in Gambling Disorder Using Sociodemographic and Clinical Clustering Analysis: An Unidentified New Subtype?

[This corrects the article DOI: 10.3389/fpsyt.2019.00173.].

A Comparison of DSM-IV-TR and DSM-5 Diagnostic Criteria for Gambling Disorder in a Large Clinical Sample.

Background and Aims: Gambling-related crimes are known to be associated with gambling disorder (GD). Due to a lack of consensus in the scientific community regarding the relevance of this diagnostic criterion, it was removed from the DSM-5. The primary aim of this study was to investigate through structural equation modeling (SEM) whether higher GD severity in treatment-seeking GD patients with a criminal record is mediated through the illegal acts criterion itself, or whether it can be better explained by other related clinical factors. Methods: An initial sample of 2,081 patients seeking treatment for gambling problems was included in the sample. SEM was used to evaluate the mediational role of the illegal acts criterion between the sex, age and personality traits, gambling severity, and comorbid depression levels. Comparisons between patients with coinciding and divergent DSM criterion for GD diagnosis were carried out. Results: Illegal acts mediated the relationship between personality traits and GD severity: younger age, high levels of novelty seeking, and low levels of self-transcendence increased the risk of endorsing the illegal acts criterion. No differences between coincident-divergent groups in terms of DSM-IV and DSM-5 diagnosis were found with regards to sex (p = 0.878), education level (p = 0.387), or civil status (p = 0.792). Discussion and Conclusion: The results obtained in the present study offer new insights into the utility of using a history of illegal acts, their different personality characteristics, and psychopathology to categorize GD patients. Our findings suggest that patients who engage in criminal behavior may require a more comprehensive intervention.

Developmental trajectories of gambling severity after cognitive-behavioral therapy.

AIMS: To estimate trajectories of the gambling disorder (GD) severity for 12 months following a manualized cognitive-behavior-therapy (CBT) program, and to identify the main variables associated with each trajectory. METHODS: Latent Class Growth Analysis examined the longitudinal changes of n = 603 treatment-seeking patients with GD. RESULTS: Five separate empirical trajectories were identified: T1 (n = 383, 63.5%) was characterized by the most highest baseline gambling severity levels and positive progress to recovery during the follow-up period; T2 (n = 154, 25.5%) featured participants with high baseline gambling severity and good progress to recovery; T3 (n = 30, 5.0%) was made up of patients with high gambling baseline severity and slow progress to recovery; T4 (n = 13, 2.2%) and T5 (n = 23, 3.8%) contained participants with high baseline gambling severity and moderate (T4) and poor (T5) progress in GD severity during the follow-up. Psychopathological state and personality traits discriminated between trajectories. Poor compliance with the therapy guidelines and the presence of relapses also differed between the trajectories. CONCLUSIONS: Our findings show that patients seeking treatment for GD are heterogeneous and that trends in progress following treatment can be identified considering sociodemographic features, psychopathological state and personality traits. These results could be useful in developing more efficient interventions for GD patients.

Spanish validation of the pathological buying screener in patients with eating disorder and gambling disorder.

BACKGROUND AND AIMS: Pathological buying (PB) is a behavioral addiction that presents comorbidity with several psychiatric disorders. Despite the increase in the prevalence estimates of PB, relatively few PB instruments have been developed. Our aim was to assess the psychometric properties of the Spanish version of the pathological buying screener (PBS) and to explore the associations between PB, psychopathology, and personality traits. METHODS: A total of 511 participants, including gambling disorder (GD) and eating disorder (ED) patients diagnosed according to DSM-5 criteria, as well as healthy controls (HCs), took part in the study. RESULTS: Higher PB prevalence was obtained in ED patients than in the other two study groups (ED 12.5% vs. 1.3% HC and 2.7% GD). Confirmatory factor analysis (CFA) verified the 13-item structure of the PBS, and indexes of convergent and discriminant capacity were estimated. CFA confirmed the structure in two factors (excessive buying behavior and loss of control) with excellent internal consistency (α = .92 and .86, respectively). Good convergent capacity was obtained with external psychopathology and personality measures (positive correlations with novelty seeking and negative associations with self-directedness and harm avoidance were found). Good discriminative capacity to differentiate between the study groups was obtained. DISCUSSION AND CONCLUSIONS: This study provides support for the reliability and validity of the Spanish adaptation of the PBS. Female sex, higher impulsivity, and higher psychopathology were associated with PB.

Phenotypes in Gambling Disorder Using Sociodemographic and Clinical Clustering Analysis: An Unidentified New Subtype?

Background: Gambling disorder (GD) is a heterogeneous disorder which has clinical manifestations that vary according to variables in each individual. Considering the importance of the application of specific therapeutic interventions, it is essential to obtain clinical classifications based on differentiated phenotypes for patients diagnosed with GD. Objectives: To identify gambling profiles in a large clinical sample of n = 2,570 patients seeking treatment for GD. Methods: An agglomerative hierarchical clustering method defining a combination of the Schwarz Bayesian Information Criterion and log-likelihood was used, considering a large set of variables including sociodemographic, gambling, psychopathological, and personality measures as indicators. Results: Three-mutually-exclusive groups were obtained. Cluster 1 (n = 908 participants, 35.5%), labeled as "high emotional distress," included the oldest patients with the longest illness duration, the highest GD severity, and the most severe levels of psychopathology. Cluster 2 (n = 1,555, 60.5%), labeled as "mild emotional distress," included patients with the lowest levels of GD severity and the lowest levels of psychopathology. Cluster 3 (n = 107, 4.2%), labeled as "moderate emotional distress," included the youngest patients with the shortest illness duration, the highest level of education and moderate levels of psychopathology. Conclusion: In this study, the general psychopathological state obtained the highest importance for clustering.

The predictive capacity of DSM-5 symptom severity and impulsivity on response to cognitive-behavioral therapy for gambling disorder: A 2-year longitudinal study.

BACKGROUND: DSM-5 proposed a new operational system by using the number of fulfilled criteria as an indicator of gambling disorder severity. This method has proven to be controversial among researchers and clinicians alike, due to the lack of studies indicating whether severity, as measured by these criteria, is clinically relevant in terms of treatment outcome. Additionally, numerous studies have highlighted the associations between gambling disorder and impulsivity, though few have examined the impact of impulsivity on long-term treatment outcomes. METHODS: In this study, we aimed to assess the predictive value of DSM-5 severity levels on response to cognitive-behavioral therapy (CBT) in a sample of male adults seeking treatment for gambling disorder (n = 398). Furthermore, we explored longitudinal predictors of CBT treatment response at a follow-up, considering UPPS-P impulsivity traits. RESULTS: Our study failed to identify differences in treatment outcomes between patients categorized by DSM-5 severity levels. Higher baseline scores in negative urgency predicted relapse during CBT treatment, and higher levels of sensation seeking were predictive of drop-out from short-term treatment, as well as of drop-out at 24-months. CONCLUSIONS: These noteworthy findings raise questions regarding the clinical utility of DSM-5 severity categories and lend support to the implementation of dimensional approaches for gambling disorder.

Underlying Mechanism of the Comorbid Presence of Buying Disorder with Gambling Disorder: A Pathways Analysis.

Buying disorder (BD) and gambling disorder (GD) are behavioral addictions that are increasingly being researched and treated by mental health professionals. This study analyzes the underlying mechanisms of the comorbidity between both conditions in a sample of treatment-seeking patients. The sample included n = 127 patients recruited from a specialized unit in addictive behaviors at a public university hospital who presented BD symptoms with and without GD. Structural equation models analyzed the mediational mechanisms that explained the presence of the comorbid condition BD + GD. Personality variables indirectly influence the concurrence of GD and BD, and the relationship patterns were modulated by the age of onset of these two conditions. A direct relationship between being male and an increase in the risk of GD + BD comorbidity was also found. Sex and the amount of disorder-related debts also were directly associated with psychopathology. These results provide evidence on the pathways of concurrent BD + GD, which could contribute to the development of evidence-based preventive and therapeutic interventions.

Suicidal ideation and history of suicide attempts in treatment-seeking patients with gambling disorder: The role of emotion dysregulation and high trait impulsivity.

BACKGROUND AND AIMS: Gambling disorder (GD) presents high rates of suicidality. The combined influences of emotion dysregulation and trait impulsivity are crucially important (albeit understudied) for developing strategies to treat GD and prevent suicide attempts. The aim of this study is to investigate the association between trait impulsivity, emotion dysregulation, and the dispositional use of emotion regulation (ER) strategies with suicidal ideation and psychopathological symptom severity in GD. METHODS: The sample composed of 249 patients with GD (166 with suicidal ideation) who underwent face-to-face clinical interviews and completed questionnaires to assess psychopathological symptoms, impulsive traits, and ER. RESULTS: Patients with GD who presented suicidal ideation were older and had a later age of GD onset and higher GD severity. Analyses of variance showed higher comorbid symptoms, emotion dysregulation, and trait impulsivity in patients with suicidal ideation. Still, no significant differences were found in the use of ER strategies. SEM analysis revealed that a worse psychopathological state directly predicted suicidal ideation and that both emotion dysregulation and GD severity indirectly increased the risk of suicidal ideation through this state. High trait impulsivity predicted GD severity. Finally, a history of suicide attempts was directly predicted by suicidal ideation. CONCLUSIONS: Patients with GD are at risk of presenting suicidal behaviors. The results of this study revealed the importance of comorbid psychopathology in the occurrence of suicidal ideation and the indirect effect of trait impulsivity and emotion dysregulation on suicidality. Thus, suicidal rates in GD could possibly be reduced by specifically targeting these domains during treatment.

The Contribution of Sex, Personality Traits, Age of Onset and Disorder Duration to Behavioral Addictions.

Background and aims: Increases in the prevalence of behavioral addictions worldwide have led to a growth in the etiological research of the specific contribution of risk/protective factors to these disorders. The objective of this study was to assess the relative role of patients' sex, age of disorder onset and disorder duration on the clinical profile of behavioral addictions. Methods: Our sample included treatment-seeking patients diagnosed with gambling disorder (GD, n = 3,174), internet gambling disorder (IGD, n = 45), compulsive buying (CB, n = 113), and sex addiction (SA, n = 34). Results: The pattern of associations between the independent variables and the outcomes were strongly related to the behavioral addiction subtype: (a) for GD-men early onset of the disorder was related to GD severity, while for GD-women early onset was linked to novelty seeking; (b) for IGD-men, late onset correlated with addiction severity, worse psychopathological state, and high harm avoidance and self-transcendence levels; (c) for CB-women, early onset was related to higher reward-dependence scores and lower self-transcendence levels, and longer duration predicted higher cumulate debts; for CB-men, early onset and long duration correlated with high scores in harm-avoidance, self-directedness, self-transcendence, and cooperativeness; and (d) for SA-men, late onset and longer duration correlated with high disorder severity. Discussion and Conclusions: These findings are relevant for developing prevention and treatment programs specific to different behavioral addictions.

Clustering of treatment-seeking women with gambling disorder.

BACKGROUND: The prevalence of gambling disorder (GD) in women has increased, but, to date, few studies have explored the features of clinical GD subtypes in female samples. AIMS: The aim of this study is to identify empirical clusters based on clinical/sociodemographic variables in a sample of treatment-seeking women with GD. METHODS: Agglomerative hierarchical clustering was applied to a sample of n = 280 patients, using sociodemographic variables, psychopathology, and personality traits as indicators for the grouping procedure. RESULTS: Three mutually exclusive groups were obtained: (a) Cluster 1 (highly dysfunctional; n = 82, 29.3%) endorsed the highest levels in gambling severity, comorbid psychopathology, novelty seeking, harm avoidance, and self-transcendence, and the lowest scores in self-directedness and cooperativeness; (b) Cluster 2 (dysfunctional; n = 142, 50.7%) achieved medium mean scores in gambling severity and psychopathological symptoms; and (c) Cluster 3 (functional; n = 56, 20.0%) obtained the lowest mean scores in gambling severity and in psychopathology, and a personality profile characterized by low levels in novelty seeking, harm avoidance, and self-transcendence, and the highest levels in self-directedness and cooperativeness. DISCUSSION AND CONCLUSIONS: This study sheds light on the clinical heterogeneity of women suffering from GD. Identifying the differing features of women with GD is vital to developing prevention programs and personalized treatment protocols for this overlooked population.

Corrigendum: Validation of the Spanish Version of the Yale Food Addiction Scale 2.0 (YFAS 2.0) and Clinical Correlates in a Sample of Eating Disorder, Gambling Disorder and Healthy Control Participants.

[This corrects the article DOI: 10.3389/fpsyt.2018.00208.].

Trait impulsivity and cognitive domains involving impulsivity and compulsivity as predictors of gambling disorder treatment response.

BACKGROUND AND AIMS: Gambling disorder (GD) is a highly heterogeneous condition with high rates of chronicity, relapses and treatment dropout. The aim of this study was to longitudinally explore the associations between trait impulsivity, impulsivity-compulsivity related cognitive domains, and treatment outcome in an outpatient sample of adult patients with GD. METHODS: 144 adult male participants diagnosed with GD undergoing cognitive-behavioural treatment (CBT) at a specialized outpatient service completed a series of neuropsychological tests to assess executive functioning (including cognitive flexibility, inhibition control and decision making) and psychometric questionnaires. RESULTS: Trait impulsivity predicted low compliance [UPPS-P negative urgency (B = 0.113; p = 0.019)] and relapse [UPPS-P negative urgency (B = 0.140; p = 0.015)] at 5 weeks of treatment and dropout at the end of treatment [(UPPS-P sensation seeking B = 0.056; p = 0.045)]. Cognitive flexibility performance predicted: dropout rates at the end of treatment [WCST perseverative errors (B = 0.043; p = 0.042)]; dropout [WCST categories completed (B = -1.827; p = 0.020)] and low compliance or relapses at follow-up [WCST perseverative errors (B = 0.128; p = 0.020)]; and time to first relapse [WCST failure to maintain set (B = -0.374; p = 0.048)] and time to dropout [WCST perseverative errors (B = 0.0198; p = 0.019)]. CONCLUSIONS: Our findings indicate impulsivity-compulsivity levels may influence response to GD treatment (i.e.: low compliance and dropout or relapse rates) thus representing a potential target for improving treatment outcomes.