Cited by 65Gambling Behavior and TreatmentsNeurotransmitter Receptor Influence on BehaviorSubstance Abuse Treatment and Outcomes

The DOI matches its Crossref record; 286 of the 288 references it cites were found in a registry or an index; none of the 303 sources its claims cite is checked for support yet.

Cued for risk: Evidence for an incentive sensitization framework to explain the interplay between stress and anxiety, substance abuse, and reward uncertainty in disordered gambling behavior

Open access
Hellberg, Samantha N., Russell, Trinity I., Robinson, Mike J. F.·2019·Cognitive, Affective, & Behavioral Neuroscience

Abstract

Gambling disorder is an impairing condition confounded by psychiatric co-morbidity, particularly with substance use and anxiety disorders. Yet, our knowledge of the mechanisms that cause these disorders to coalesce remains limited. The Incentive Sensitization Theory suggests that sensitization of neural “wanting” pathways, which attribute incentive salience to rewards and their cues, is responsible for the excessive desire for drugs and cue-triggered craving. The resulting hyper-reactivity of the “wanting’ system is believed to heavily influence compulsive drug use and relapse. Notably, evidence for sensitization of the mesolimbic dopamine pathway has been seen across gambling and substance use, as well as anxiety and stress-related pathology, with stress playing a major role in relapse. Together, this evidence highlights a phenomenon known as cross-sensitization, whereby sensitization to stress, drugs, or gambling behaviors enhance the sensitivity and dopaminergic response to any of those stimuli. Here, we review the literature on how cue attraction and reward uncertainty may underlie gambling pathology, and examine how this framework may advance our understanding of co-mordidity with substance-use disorders (e.g., alcohol, nicotine) and anxiety disorders. We argue that reward uncertainty, as seen in slot machines and games of chance, increases dopaminergic activity in the mesolimbic pathway and enhances the incentive value of reward cues. We propose that incentive sensitization by reward uncertainty may interact with and predispose individuals to drug abuse and stress, creating a mechanism through which co-mordidity of these disorders may emerge.

Overview

AI snapshot

Written from the paper’s full text.

TL;DR

This review proposes an incentive sensitization/cross-sensitization framework in which reward uncertainty, drugs of abuse, and stress/anxiety each sensitize mesolimbic dopamine “wanting” pathways, helping explain comorbidity among disordered gambling, substance use, and anxiety. It argues that gambling cues and uncertain rewards become motivational magnets that can bidirectionally exacerbate drug use and stress-related pathology.

Key findings

  • Gambling disorder is common and impairing: gambling affects nearly 1.8 billion individuals worldwide, 85% of U.S. adults gamble in their lifetime, and average GD prevalence is approximately 2.3%, with subclinical gambling estimated at approximately 12%.
  • Comorbidity is high: meta-analytic estimates in subthreshold/clinical gamblers are 28.1% for alcohol use disorders (range 9.9%–73.2%) and 60.1% for nicotine dependence (range 34.9%–76.3%), versus general-population rates of 8.5% and 12.8%, respectively; approximately 37% of subthreshold/clinical gamblers have an anxiety disorder (range 14.0%–60.3%) versus 11.10% 12-month prevalence for any anxiety disorder in the general U.S. population.
  • Reward uncertainty is proposed to sensitize dopaminergic systems and enhance incentive salience: uncertain reward cues can become more “wanted” even when they predict reward only 50% of the time, and animal studies show uncertainty exposure increases amphetamine response, amphetamine self-administration, and risky decision-making.
  • Cross-sensitization is central: sensitization to stress, drugs, or gambling is argued to amplify dopaminergic and motivational responses to the others, with long-lasting neuroadaptations that may explain persistent craving and relapse; treatment outcomes are poor, with only 50% abstinent at 6 months, 29% at 1 year, and 15% at 2 years, and only 8% abstinent after 1 year in Gamblers Anonymous.

Methods

  • Narrative literature review synthesizing human and animal studies on incentive sensitization, cue reactivity, reward uncertainty, stress/anxiety, substance use, and gambling disorder.
  • The paper integrates evidence across dopaminergic, behavioral, and clinical domains to propose a conceptual cross-sensitization framework for comorbidity.
  • No primary data collection, systematic search strategy, or meta-analysis is reported.

Limitations

  • The paper states that reported comorbidity prevalence ranges vary considerably due to differences in sample size, diagnostic assessment method, gambling/problem-gambling diagnostic criteria, and geographic location.
  • The paper states that little research has examined comorbidity between gambling, substance use, and anxiety/stress-related disorders through this framework, and that further studies are needed to test acute stress effects on dopaminergic responses in gambling disorder and to clarify the direction of the gambling–stress relationship.
  • Evident from the text: this is a narrative review without a systematic search or quantitative synthesis, and it relies heavily on animal models and cross-sectional or indirect human evidence for several proposed mechanisms.

Model-written summary. Check it against the paper before relying on it.

Integrity signals

Registry

Crossref · 10.3758/s13415-018-00662-3

Cites

286 of 286 references verified0 citation errors · 0 not checkable

Statistics

Nothing to recompute.

Verification

Claims the paper makes

0 of 303 cited sources checked · 0 supported · 0 flagged

Show all 177 claims

  • Probably not a substantial claim. 32
  • It may state two separate claims as one. 57
  • The quote only partly states this claim. 1
87 of 87
  • The paper relies on this without support.

    Knowledge of the mechanisms that cause gambling disorder, substance use, and anxiety disorders to coalesce remains limited.

    “Yet, our knowledge of the mechanisms that cause these disorders to coalesce remains limited.”
  • The paper relies on this without support.

    Little research has examined the comorbidity between gambling, substance use, and anxiety or stress-related disorders through the incentive sensitization framework.

    “However, little research has examined the comorbidity that exists between gambling, substance use, and anxiety or stress-related disorders through this framework.”
  • The paper relies on this without support.

    The complex biopsychosocial mechanisms through which childhood adversity and stressful life events confer risk for these disorders remain largely unknown.

    “Though this pathway has been highlighted as a potential shared diathesis, the complex biopsychosocial mechanisms through which childhood adversity and stressful life events confer risk for these disorders remain largely unknown.”
  • The paper relies on this without support.

    Neural and biological pathways through which anxiety disorders may actively increase risk for addictive spectrum disorders remain largely unknown.

    “However, neural and biological pathways through which anxiety disorders may actively increase risk for addictive spectrum disorders remain largely unknown.”
  • The paper relies on this without support.

    There is no standard intervention for gambling disorder.

    “there is no standard intervention for gambling disorder”
  • The paper relies on this without support.

    Gambling disorder treatments fail to successfully address comorbidity, cultural influences, and socio-demographic differences within the gambling population.

    “gambling disorder treatments fail to successfully address comorbidity, cultural influences, and socio-demographic differences within the gambling population”
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Claims other papers make about this one

Each is checked against this paper’s own text: does it say what the citing paper says it does?

Self-check

Percentages, sums and reported differences re-computed from the paper’s own numbers.

Each contradiction between two passages listed here was confirmed by an independent check.

  • Gaming study cited as evidence about gambling cues

    Minor

    The text cites Thalemann et al. as evidence of heightened gambling-cue reactivity, but the paper's reference describes a study of computer-game cues in excessive gamers.

  • Problem-gaming study cited for problem gamblers' gambling-cue responses

    Minor

    The sentence cites van Holst et al. for findings about problem gamblers and gambling cues, whereas the listed study concerns gaming cues and problem gaming in adolescents.

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Citations

Cites

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2 of the 288 references couldn’t be matched to a known paper.

Research works printed but not linked: 2

  1. American Psychiatric Association. (2013). American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5®). (A. P. Association, Ed.). Arlington: American Psychiatric Association.
  2. Balfour, D. J. K. (2015b). The role of mesoaccumbens dopamine in nicotine dependence. Current Topics in Behavioral Neurosciences, 24(Chapter 3), 55–98. https://doi.org/10.1007/978-3-319-13482-6_3 · DOI

Cited by

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Metadata

Authors
Hellberg, S. N., Russell, T. I., & Robinson, M. J. F.
Affiliations
Wesleyan University (US)
Corresponding author
Robinson, Mike J. F.
Venue
Cognitive, Affective, & Behavioral Neuroscience
Published
2018-10-24
Volume
19
Issue
3
Pages
737-758
ISSN
  • 1530-7026 (ISSN-L)
  • 1531-135X
OpenAlex
W2898505690
Cited by
65
References
288
Citations by year
2026: 6 · 2025: 3 · 2024: 9 · 2023: 12 · 2022: 4 · 2021: 13 · 2020: 8 · 2019: 10
FWCI
1.31
Type
journal article
Language
en
Open access
Locations
  • Cognitive Affective & Behavioral Neuroscience (publishedVersion)
  • PubMed (publishedVersion)
  • PubMed Central (acceptedVersion)
Funders
National Institute on Drug Abuse (R03DA045281)
Topics
  • Social Sciences › Psychology › Clinical Psychology › Gambling Behavior and Treatments
  • Life Sciences › Neuroscience › Cellular and Molecular Neuroscience › Neurotransmitter Receptor Influence on Behavior
  • Health Sciences › Medicine › Epidemiology › Substance Abuse Treatment and Outcomes
Keywords
gambling addiction, incentive-sensitization theory, reward uncertainty, stress, anxiety disorders, substance use disorders, mesolimbic dopamine system, cross-sensitization, incentive salience, relapse, comorbidities, slot machines
MeSH terms
Anxiety Disorders, Cues, Gambling, Humans, Motivation, Reward, Substance-Related Disorders, Uncertainty

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