The Role of Acupuncture in Treating a Patient with a Gambling Disorder

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The Role of Acupuncture in Treating a Patient with a Gambling Disorder

Yolanda Teja, MD, Irma Nareswari, MD, and Christina L. Simadibrata, MD

ABSTRACT

Background: Addiction is a chronic/relapsing disorder characterized by compulsive seeking and continuous involvement despite dangerous consequences. It causes long-term changes in the brain. Gambling disorder is a nonsubstance behavioral addiction. An important feature of gambling disorder is maladaptive gambling be- havior that is persistent and repetitive, and interferes with patients’ personal lives, families, and/or activities.

Acupuncture is a nonpharmacologic therapeutic modality for managing addiction, with good results.

Case: A 32-year-old man with a gambling disorder was referred from a psychiatry department. The patient had a history of gambling since high school. He began to gamble in larger amounts in 2019. The patient got antiseizure, antidepressant, and antipsychotic medications, and cognitive behavioral therapy in the psychiatry department. Manual acupuncture therapy was performed at GV 20, Ex-HN 1, Ex-HN 3, PC 6, ST 40, and LR 3.

Electroacupuncture was performed at LI 4, LI 11, ST 36, SP 6, and ST 25. Laser acupuncture was performed at NADA protocol bilateral ear points. The patient also received scalp acupuncture for extrapyramidal symptoms After this combination of acupuncture therapy for 8 sessions, with pharmacotherapy and psychotherapy, the patient’s condition improved.

Conclusions: Acupuncture produces positive results in patient with gambling disorders. It helps regulate the reward system; stimulates release of neurotransmitters in the brain; produces neuroprotective effects; and activates certain brain areas to suppress impulsivity and craving and to balance emotions. Acupuncture is thought to be related to increased blood flow in the frontal lobe, thereby increasing nerve metabolism, as well as regulating dopamine in the basal ganglia. A combination of acupuncture, pharmacologic agents, and psycho- therapy has a positive synergistic effect in patients with gambling disorder.

Keywords:acupuncture, craving, NADA protocol, gambling disorder, addiction, psychiatric disorders

INTRODUCTION

A

ddiction is a chronic or relapse disordercharac- terized by compulsive seeking, continuous involvement despite dangerous consequences, and long-term changes in the brain. Addiction includes both substance and nonsubstance (behavioral) issues.¹ In 2013, the Di- agnostic and Statistical Manual of Mental Disorders V

(DSM-5) classified behavior addiction, with gambling disorder as the first nonsubstance behavioral addiction.

Behavioral addiction refers to impulsive or inappropriate behavior, or even risky or thoughtless behavior, that often results in bad consequences.^2,3

The prevalence of gambling disorder in women is *0.2%, whereas, in men, the prevalence is *0.6%.⁴The etiology of gambling disorder involves a variety of complex multifactorial

Department of Medical Acupuncture, RSUPN, Dr. Cipto Mangunkusumo, and Medical Acupuncture Specialist Program, Faculty of Medicine, Universitas Indonesia, both in Jakarta, Indonesia.

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DOI: 10.1089/acu.2021.0013

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processes involving neurobiologic, psychologic, and social issues. The risk factors for someone experiencing gambling disorder include male gender, temperamental personality, gambling beginning at a young age, low level of educa- tional attainment, a history of psychopathology and high impulsivity, minority ethnicity, presence of problems, presence of close family members with gambling disorders, and genetic factors. Support structures, religion, motivation, self- defense, and the skills to overcome problems are known as protection factors.^2,5

The reward system is very important and supports basic processes such as drinking, eating, and reproduction.⁶Additives cause changes in brain dopamine levels associated with feelings of well-being and pleasure, and provide positive reinforcement that leads to the use of further additives. Conversely, discon- tinuation of chronic drug administration results in decreased dopamine flow in the nucleus accumbens, leading to withdrawal (dysphoria, anhedonia, etc.). This is related to negative reinforcement.⁷ Dopamine plays an important role in the learning and memory processes. The dopamine system includes both mesolimbic and mesocortical pathways.⁶In the reward pathway, activation of serotonin neurons in the hypothalamus induces the release of meth-enkephalin in the ventral tegmental area (VTA) of the brain, and, as a result, c-aminobutyric acid (GABA) neurons in VTA are inhibited, thereby increasing dopamine release in the nucleus accumbens.⁷

Activation of the l-opioid receptor (MOR) and j-opioid receptor (KOR) is known to involve the opposite modulation of dopamine neurons in the mesolimbic dopamine system. Activation of MORs causes hyperpolarization of GABAergic neurons, which causes increased release of accumbal dopamine and triggers euphoria. In contrast, KOR agonists inhibit dopaminergic neurons directly, triggering an antireward effect that results in decrease of accumbal dopamine and, thus, causing dysphoria. In the development of the addiction process, increased stress may improve KOR function, contributing to dysphoric mood during withdrawal and abstinence, and leading to relapse.^7,8

Gambling behavior activates a reward system similar to that activated by drug abuse and produces several behavioral symptoms that appear comparable to those produced by substance-use disorders.² Addiction includes 3 stages: (1) preoccupation/anticipation; (2) binge/intoxication; and (3) withdrawal/negative effects. These 3 stages mutually rein- force each other and become more intense over time. With- drawal symptoms in behavioral addiction are usually described as emotional states (irritability, restlessness, anger, moodiness, sadness, guilt, anxiety, feelings of tension).^9,10

The diagnostic criteria for gambling disorder have been established in the DSM V.² The differential diagnosis of gambling disorder includes nondisordered gambling, mania, personality disorders, and other medical conditions.²One of the assessment instruments that can be used to evaluate gambling disorders is the Gambling Symptom Assessment Scale (G-SAS).¹¹

Management of gambling disorder includes pharmacologic and nonpharmacologic therapies. Methods of pharmacologic management include opioid antagonists, antidepressants, mood stabilizers, antiseizure agents, and antipsychotics. The use of pharmacologic therapy can cause a variety of side- effects, such as nausea, headaches, anxiety, insomnia, impo- tence, tremors, impaired organ function, and seizures.^12–14 Nonpharmacologic methods of management for gambling disorder include cognitive–behavioral therapy (CBT), motivational interviewing (MI) therapy, and motivational en- hancement therapy (MET). The goal of these therapies is to help patients stop gambling behavior by forming inner motivation, forming commitments, and finding solutions to possible future relapses.^15–17 Acupuncture is a non- pharmacological therapeutic method that uses fine needles on acupuncture points. Acupuncture has been widely used to manage substance and behavioral addictions.^3,18,19

Acupuncture mechanisms consist of local, segmental, and central mechanisms. The insertion of acupuncture needles causes microtrauma, which causes degranulation of mast cells and release of various neuropeptides. These stimuli are transmitted to the spinal-cord segments and then carried to the cortex and the pituitary–hypothalamus to induce regulation of various hormones and neurotransmitters in the brain.^20,21

In treating addiction, acupuncture has a dualistic effect.

With positive reinforcement, acupuncture can activate the GABA receptor, which decreases dopamine in the nucleus accumbens. Acupuncture also activates KORs in the nucleus accumbens via dynorphin neurons, which also decreases dopamine release in the nucleus accumbens. With negative reinforcement, acupuncture stimulates encephalic neurons in the hypothalamus, causing release of methionine–

encephalin in the VTA, which, in turn, interacts with the MORs to inhibit the interneuron GABAergic VTA, thereby increasing dopamine release in the nucleus accumbens.⁷

There are various modalities of acupuncture therapy, such as electroacupuncture (EA) and laser acupuncture. Ear acupuncture is also widely used to treat addiction. EA is the stimulation of acupuncture points with an electric current that can activate various neurotransmitters in the brain,²² whereas laser acupuncture is the stimulation of photons at acupuncture points to induce a therapeutic effect similar to a needle, with a photo biomodulation effect.²³Laser acupuncture has both primary and secondary stimulatory effects.

Resonant acupuncture laser therapy is based on the assump- tion that resonance increases photon absorption and increases the therapeutic effect.^24,25Auricular acupuncture (AA) is a method for diagnosing and treating physical and psychosomatic dysfunctions by stimulating specific points on the auricula.²⁶ The National Acupuncture Detoxification Asso- ciation (NADA) protocol involves stimulating 5 acupuncture points at a time in both ears. The points are Shenmen, Sympathetic, Kidney, Lung, and Liver.²⁷The NADA protocol may have neurophysiologic, biochemical, endocrine,

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emotional, and cognitive effects,²⁸ and reduce cravings and withdrawal symptoms associated with addiction.²⁹

Acupuncture balances the reward cascade, thereby reducing dysphoria, depression, craving, and withdrawal.

Acupuncture can modulate the reward signal to its balance state.³⁰

CASE

A 32-year-old man with gambling disorder was referred from a psychiatry department. This patient had a history of gambling since high school. He began to gamble in larger amounts initially to support his close friend financially in 2019. His loss triggered him to gamble more. He borrowed money, lied, and sold his family’s goods to obtain money for his gambling. The family also reported that he spent most of his time with his cell phone and that he tended to hide his phone many times. Knowing the patient’s condition, the family took him for psychiatric treatment in 2020. A physical examination showed his body was within normal limits. His G-SAS score was 27. The patient also had a history of misusing alcohol and methamphetamines in 2017, which had stopped by 2020.

This patient was given antiseizure, antidepressant, and antipsychotic medications. Admitting that he wanted re- venge for his losses, when he felt stressed, he tended to gamble. While taking the medications, he repeated his gambling behavior for 4 consecutive months.

The patient was given manual acupuncture therapy at GV 20, Ex-HN 1, Ex-HN 3, PC 6, and ST 40; a 10/50-Hz Dense Disperse (DD) wave EA at LI 4, LI 11, ST 36, SP 6, and ST 25; and Nogier G laser acupuncture NADA protocol, 2 times per week. EA therapy at the first to fourth meeting was given in a DD frequency 10/50 Hz, while, at the fifth to eighth meeting the therapy was given in low-frequency (LF) continuous waves).

In the fifth treatment, the patient developed tremor in both hands, which was diagnosed by the psychiatry department as extrapyramidal syndrome according to an extrapyramidal symptom rating scale (ESRS) as 1/1. This patient’s antipsychotic dose was reduced by the psychiatry department, and he was given additional scalp acupuncture therapy in areas that affected the tremor.

After 8 sessions of therapy, the patient’s G-SAS score decreased from 27 to 0, and the ESRS ratings for both hands were 0/0. At a 2-month follow-up post-therapy, the patient’s family said that there were no signs that he had resumed gambling. This can be monitored from the absence of negative changes in the patient’s saving account held by his family. In addition, the duration of the patient’s cell phone use was significantly reduced, compared to before therapy, and he no longer tried to hide his cell phone. The patient’s family also said that, after acupuncture therapy, the patient was calm and less emotional.

DISCUSSION

EA LF and high frequency (HF) DD waves in a study by Yang et al., published in 2017, were applied to patients with behavioral addictions and produced a significant decreases in the patients’ impulsivity.³ Impulsiveness is a result of impaired inhibitory function. If the response inhibition function is damaged, impulse control will also be damaged leading to unplanned short-term seemingly benefit-oriented impulsive behavior. The frontal and temporal lobes are areas of the brain associated with impulse control; the temporal lobe is associated with emotions and the prefrontal cortex plays an important role in processing emotional information and impulsive behavior. Decreased inhibitory function of the frontal lobe plays an important role in the development of addiction.

The prefrontal lobe and anterior cingulate cortex neural cir- cuitry are essential for monitoring and inhibiting inappropriate behavior, suggesting that effective impulse control is dependent on normal functioning of the circuit.

N-acetyl aspartate (NAA) is a metabolic substance that is specifically found in nerve cells as a marker of neuron in- tactness. Brain injury, followed by neuron loss, correlates with a decrease in NAA, while the concentration of NAA in the brain increases with neuron recovery. A functional deficit of acetylcholine (ACh) can cause impaired brain function, resulting in disorders such as addiction and attention-deficit disorder. Ach is a precursor to Cho (cho- line) wherein a decrease in Cho levels in patients with addictions is related to decreased self-control, lack of attention, sleep disturbances, and unstable emotion.³

In that 2017 article, Yang et al. observed the impact of EA and psychologic interventions on impulsive behavior in adult patients with behavioral addictions. Magnetic resonance spectroscopy (MRS) showed that a treatment group who received EA therapy in LF and HF DD waves had a significant increase in brain NAA and Cho levels. This showed that the EA mechanism in addiction is related to the protection of brain nerves. In addition, functional magnetic resonance imaging scans showed that stimulation at the PC 6 point activated the patients’ bilateral temporal and frontal lobes. Stimulation at the SP 6 point activates the temporal lobes, whereas stimulation at the LI 4 and LR 3 points increased blood flow to the frontal and temporal lobes.³

HF EA causes release of dynorphin and serotonin. HF EA activates presynaptic KORs via dynorphin neurons, which contribute to decreased dopamine release in the nucleus accumbens. HF EA also triggers the release of serotonin. In regulation of impulsivity, deficits in serotonin function can lead to hyperactivity of the dopamine system, leading to impulsive behavior. Serotonin decreases dopamine activity, thereby reducing impulsive behavior.³¹HF EA also increases brain-derived neurotrophic factor levels in the VTA, which plays a role in maintaining neuron function, differentiation, and plasticity. Finally, HF EA also facilitates recovery of dopaminergic cells in a damaged VTA.²²

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LF EA stimulates release of ß-endorphins, which play a role in stress regulation.³²LF EA also stimulates release of encephalins. While starting abstinence, a patient with an addiction has a tendency to an increased sensitivity to addictive agents, which indicates increased mesolimbic dopaminergic sensitivity. Slow release of enkephalin can lead to desensitization of the dopaminergic mesolimbic system.³³

In the current patient’s initial therapy, a combination of LF and HF EA therapy was given with the aim of sup- pressing his impulsivity. Meanwhile, LF continuous wave EA was administered in the fourth session. In addition to stimulating release of ß-endorphins, which play a role in stress regulation,³² LF EA activates MORs, which will cause hyperpolarization of GABAergic neurons, which will then cause dopamine neuron disinhibition. This may prevent negative feelings and moods.^7,8 Combination therapy is given to reduce impulsivity and prevent withdrawals that can arise in the form of negative emotions. Thus, the therapy is given to prevent a patient from relapsing.

Studies have shown that stimulation at GV 20 regulates dopamine and serotonin, and also prevents apoptosis of brain cells.^34,35A 2015, study by Sun et al., showed that EA at ST 25 increased serotonin in the hypothalamus, pre- sumably through acupuncture’s potential to modulate the brain–gut axis.³⁶ Research about impulse-control disorder in adolescents showed that stimulation at this point also increased glucose metabolism and blood flow in the brain to help maintain nerve-cell function,³and protected nerve cells from injury.³⁷In healthy subjects, stimulation of Ll 4 and Ll 11 increased regional cerebral blood flow and glucose metabolism in the frontal region, limbic system, middle cin- gulum, and medial orbitofrontal gyrus.³⁸EA at ST 36 and SP 6 regulated dopamine neurons in the VTA.³⁷In addition, stimulation of GV 20, Ex-HN 1, Ex-HN 3, HT 7, ST 36, ST 40, LI 4, LI 11, and LR 3 was used to manage psychiatric disorders, especially for balancing emotions.³⁹

Stimulation at HT 7 results in modulation of the central dopaminergic system and regulation of neuronal activation in the nucleus accumbens, and regulates activity in brain regions associated with craving (the prefrontal cortex and amygdala) in withdrawal. In addition, stimulation of ST 36 or HT 7 can reduce anxietylike behavior after nicotine withdrawal by modulating corticotropin-releasing factor in the amygdala.³⁷ Acupuncture can also modulate the autonomic nervous system and increase parasympathetic stimulation, thereby exerting relaxing effect on a patient.⁴⁰

Laser acupuncture—stimulation of photons at acupuncture points and areas—induces a therapeutic effect similar to that of needling, along with a photobiomodulating effect.²³ The current patient was given laser acupuncture at the bilateral NADA points of the ears. These were Nogier G points associated with psychosomatic problems and related to the cortex.²⁴

Ear innervation arises from the cranial nerves that origi- nate in the brain. This means that any effect of acupuncture

can have an effect on areas of the brain itself, such as the brainstem and limbic system. The cranial nerves that supply the ears have a nucleus in the brainstem—the reticular formation (RF). The points used in the NADA protocol are located in the part of the ear that is innervated by the trigeminal and vagus nerves, so that stimulation of these nerves affects the brainstem directly. The brainstem controls autonomic functions and transmits information between the brain and spinal cord. Acupuncture stimulation causes information to be conveyed to the RF, inducing changes in levels of neurotransmitters, including serotonin and dopamine, which alter nervous-system activity. Ear acupuncture also activates the periaqueductal gray (PAG), which is part of the RF, causing release of endorphins (especially meth- encephalins), providing analgesic effects, and reducing fear and anxiety.³⁰

Shenmen ear point stimulation can modulate monoam- inergic activity in the brainstem nucleus, and induce c-Fos expression in the trigeminal sensory nucleus, thalamus, somatosensory cortex, nucleus solitarius tract, locus coer- uleus, nucleus dorsal raphe, and forebrain. This stimulation which is thought to induce an anxiolytic effect.⁴¹ Sympa- thetic ear points can modulate sympathetic innervation.⁴² Lung ear points can induce serotonin release and activation of methionine encephalin, which inhibits GABA release and can lead to an increased dopamine level.⁴³ Kidney, Lung, and Liver ear points are innervated by the auricular branch of the vagus nerves (ABVN). The ABVN delivers its fibers to the solitary tract nucleus (NTS). Input to the NTS includes cranial-nerve fibers and internal afferent nerves. Meanwhile, output of the NTS includes the RF, parasympathetic preganglionic neurons to the viscera, the hypothalamus paraventricular nucleus, the thalamus (visceromotor cen- ter), and the amygdala. The NTS mediates various reflexes that regulate organ function, for example, carotid sinus reflexes (chemoreceptors and mechanoreceptors), aortic reflexes (chemoreceptors and mechanoreceptors), and re- spiratory and gastrointestinal reflexes. Based on the complex connections in the NTS between the brain and internal organs, ABVN stimulation can regulate the ANS.⁴⁴ This plays a role in ameliorating the physical symptoms of withdrawal. Stimulation of this area also modulates sympathetic–parasympathetic innervation.^29,30,45

The current patient complained about tremors in both hands at the fifth session. He was given scalp acupuncture in the area involved with tremors. The scalp acupuncture mechanism for managing tremors is thought to be related to increased blood flow in the frontal lobe, thereby increasing nerve metabolism, as well as dopamine regulation in the basal ganglia.⁴⁶The patient’s complaints of tremor in both hands were relieved after acupuncture therapy.

To the current authors’ knowledge, there has not been any case illustration of the role of acupuncture for treating gambling addiction. This article may serve as a reference and can be used to manage similar cases.

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CONCLUSIONS

Acupuncture helps regulate the reward system, stimulates release of various neurotransmitters in the brain, induces neuroprotective effects, and activates certain brain areas to suppress impulsivity and craving, and to balance emotions in patients with gambling disorders. Acupuncture also plays a role in managing tremors that occur during treatment.

These effects are in line with pharmacologic therapeutic targets. Psychotherapy is needed to form motivation and a better mindset, and to prepare anticipatory actions for patients to prevent relapses. In this case report, combination therapy of acupuncture, pharmacologic agents, and psychotherapy had a positive synergistic effect in a patient with a gambling disorder.

AUTHOR DISCLOSURE STATEMENT

No financial conflicts of interest exist.

FUNDING INFORMATION

The funding of this present work was wholly provided by the first author.

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Address correspondence to:

Yolanda Teja, MD Medical Acupuncture Specialist Program Faculty of Medicine Universitas Indonesia Salemba Raya Number 6 Jakarta 10440 Indonesia E-mail: yolandateja90@gmail.com