J Gambl Stud (2016) 32:157169

DOI 10.1007/s10899-015-9543-0

ORIGINAL PAPER

Brain Emotion Systems, Personality, Hopelessness,

Self/Other Perception, and Gambling Cognition:
A Structural Equation Model

Paolo Iliceto1 Laura DAntuono2

Henrietta Bowden-Jones3,4,5 Eleni Giovani6

Teodosio Giacolini7 Gabriella Candilera8

Ugo Sabatello7 Jaak Panksepp9

Published online: 18 April 2015

Springer Science+Business Media New York 2015

Abstract The aim of this study was to explore the relations between gambling, brain
emotion systems, personality, self/other perception, and hopelessness in an Italian com-
munity. Dimensions of gambling, positive and negative emotions, self/other perception,
personality and hopelessness were assessed in a community sample of 235 adults aged
1959 years. Two structural models were tested. We found a significant correlation be-
tween problem gambling and impulsivity, which in association with aggressivity and
negative personality dimensions may help explain the psychopathology factor, i.e. a latent
variable involving neurotic personality, hopelessness, high sensation seeking, low
metacognitive responsiveness, and disorganized patterns of interpersonal relationships.
These results contribute to develop a theoretical framework of gambling in relation with

& Paolo Iliceto

paolo.iliceto@statpsyc.com
1
S&P Statistics and Psychometrics Ltd, Via Tuscolana, 458, 00181 Rome, Italy
2
ARPCI, School of Cognitive-Interpersonal, Attachment Theory-Based Psychotherapy,
Circonvallazione Appia, 50, 00179 Rome, Italy
3
Division of Brain Science, Department of Medicine, Imperial College London, South Kensington
Campus, London SW7 2AZ, UK
4
National Problem Gambling Clinic, Soho Centre for Health and Care, 1 Frith Street,
London W1D 3HZ, UK
5
Central North West London NHS Foundation Trust, 20 Eastbourne Terrace, London W2 6LE, UK
6
Private Practice, Via dei Melograni, 13, Spello, Italy
7
Department of Pediatrics and Child Neuropsychiatry, Sapienza University of Rome, Via dei
Sabelli, 108, 00185 Rome, Italy
8
Private Practice, Via Fucino, 4b, 00199 Rome, Italy
9
Department of Integrative Physiology and Neuroscience, College of Veterinary Medicine,
Washington State University, Pullman, WA 99163, USA

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personality factors and provide a new approach for clinical intervention of problem
gambling that relies on a solid multidimensional perspective.

Keywords Brain emotion systems  Personality  Hopelessness  Self/other perception 

Gambling cognition

Introduction

Over the last two decades the incidence of gambling has increased dramatically, partly
because of increased accessibility (Derevensky 2009; Volberg 2001), with an estimated
13 % of general population developing pathological gambling (Beconia 1996; Ladouceur
et al. 2005; Shaffer et al. 1999). In Italy, pathological and problem gambling are rapidly
growing phenomena in both adult and adolescent populations (Bastiani et al. 2013; Donati
et al. 2013; Villella et al. 2011). Moreover they correlate with major addictive behaviours
that has also been increasing in the Italian populatione.g. especially cigarette smoking
and alcohol use and abuse (Bastiani et al. 2013; Ministero della salute 2011). The eco-
nomic burden of different forms of gambling in Italy increased up to 54 billion in 2009,
growing by 13 % in 1 year (20082009) and by 40 % in 6 years (20032009) (Ministero
della salute 2011), while the elevation was 8 billion in 1993 and 35 billion in 2006
(Croce et al. 2009).
Several studies reporting the occurrence of psychiatric disorders as depression and
social complications in adult problem gamblers are consistent with the current conceptu-
alization of problem gambling as a progressive and chronic disorder (American Psychiatric
Association 2013), which share significant features with other addictive syndromes, and
shows comorbidity with other psychiatric conditions (Abdollahnejad et al. 2014). Also it is
very well known the role of psychopathology as a framework involving the established
relationships between different severe psychiatric disorders and the impulse-control
problem of gambling (Knezevic and Ledgerwood 2012; Seguin et al. 2010; Toneatto
1999).
The neurobiology and neurobehavioural research on drug addictionby extending its
results to other strictly behavioural forms of compulsive activitieshas highlighted that
pathological gambling is an addictive behaviour like hypersexuality, obsessive shopping,
and excessive Internet-use compulsions, all of which appear to share the primal mam-
malian appetitive motivational system (Alcaro and Panksepp 2011; Ikemoto and Panksepp
1999), that has been give an official primary-process namethe SEEKING System
(Panksepp 1998; Panksepp and Biven 2012, 2014; Zellner et al. 2011). According to
Panksepp (1998), many types of drug addiction are primarily connected to the attachment
motivational system, named PANIC/GRIEF separation-distress system which during such
feelings of chronic distress provides a motivational push, psychologically instantiated as
craving, from dopaminergic SEEKING system. Both addictive substances and gambling
are substitutes of the well-being derived from experiencing attachment objects, whether
living or inanimate (e.g. via opioids) and from the positive enthusiasm derived from
various psychostimulants (e.g. via amphetamines and cocaine) (Zellner et al. 2011). The
dysphoria activated by the loss of the attachment object is analogous to craving in the
various kinds of addictions, including the need for gambling. According to the neuro-
biological model of mammalian emotions by Panksepp (1998), the SEEKING system and

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the PANIC/GRIEF system are two of the six primary process subcortical brain emotion-
al/motivational systems, together with RAGE, FEAR, CARE and PLAY. (Please note,
capitalizations are used as a specialized nomenclature to highlight the primary-process
nature of such brain systems). These systems are foundational for human personality
development, therefore a test to study their function in Humans, named the Affective
Neuroscience Personality Scales (ANPS), was developed. The ANPS operationalizes six of
the basic emotional/motivational personality tendencies with six subscales (Davis et al.
2003; Davis and Panksepp 2011), and the Italian version of the ANPS has recently been
validated (Bembich et al. 2015).
The research investigating the personality dimensions related to the gambling behaviour
has been primarily based on the Five-Factor Model (McCrae and Costa 2003), which is
based on a biological and temperamental approach. According to the model, the five
personality dimensions are Neuroticism, Extraversion, Openness to Experience, Agree-
ableness and Conscientiousness. They are described as Neuroticism, Extraversion, Ag-
gressiveness, Sensation Seeking and Activity in the Alternative Five-Factor Model (Aluja
et al. 2010). Bagby et al. (2007) found that pathological gamblers scored higher in Neu-
roticism compared to non-pathological players. Also, Iliceto et al. (2015) found positive
correlations between Gambling and Neuroticism. Moreover they observed high positive
correlations between Gambling and depression, and hopelessness, supporting previous
findings.
Interestingly, Myrseth et al. (2009), while confirming the positive correlation between
Neuroticism and susceptibility to gambling in a sample of Norwegian pathological gam-
blers, also observed that pathological gamblers showed higher Sensation Seeking com-
pared to non-pathological gamblers. The Sensation Seeking factor has been often
associated with impulse control, and has been for long considered a major determinant of
the gambling behaviour.
However, to date a comprehensive and detailed theoretical framework on the relations
between personality and gambling behaviour is lacking. Also, the literature investigating
the relation between problem gambling and the Attachment construct is limited (see
Magoon and Ingersoll 2006).
The Attachment Theory claims that early attachment experiences are enclosed in im-
plicit memory structures named Internal Working Models, which reveal specific repre-
sentations of the self and others (Bowlby 1969, 1973, 1980).
In theoretical and clinical research, the connection between Attachment disorganization
with a deficit in the development and exercise of meta-cognitive functions, particularly in
adulthood, is a matter of interest (Fino et al. 2014). A severe deficit in metacognitive
monitoringi.e. the ability to observe the mental operations of thought and affectivity as
they unfold, and the ability to check their coursesis typical of disorganized relationships.
Similarly, the inability of the self to reflect on mental states (thoughts, emotions, beliefs,
memories) in terms of discrete entities, is often associated with disorganized attachment
relationships (Dimaggio et al. 2013).
The metacognitive monitoring and the ability to reflect on self/other mental represen-
tations are necessary pre-conditions in order to regulate emotional experiences in inter-
personal relationships. An effective metacognitive monitoring supports the cognitive-
emotional development, since it allows us: (1) to understand the nature of contextual,
relational and transient emotions and impulses; (2) to build an efficient theory which
accounts of emotions, impulses and environmental events; (3) to name each emotion
properly. Metacognitive skills represent mental tools that contribute to define a system of
emotional regulation during the human development (Lorenzini et al. 2008).

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Recently, some empirical contributions have shown the validity of the metacognitive
approach to the study of gambling (pathological gambling: Dowling et al. 2007; problem
gambling: Toneatto and Millar 2004; non pathological gambling: Weatherly and Flannery-
Woehl 2009). The metacognitive approach focuses specifically on the control of stimuli
and cognitions associated with gambling, aiming at restructuring and/or strengthening
coping skills, emotions and cognitions challenging the addictive behaviour, and preventing
recurrence. Specifically, it adopts the thinking aloud method (Raylu and Oei 2004), a
technique where gamblers are required to provide self-report of their thoughts, intentions,
ideas, images and impulses that may come to their mind during the game. Following this
methodology, Raylu and Oei (2004) have developed the Gambling Related Cognitions
Scale (GRCS), a self-report questionnaire for the assessment of gambling-related cog-
nitions. In the final version of the scale, validated with an exploratory factor analysis on
data collected from a non-clinical Australian sample, a five-factor structure has emerged,
which includes the dimensions of interpretative control/bias, illusion of control, predictive
control, gambling-related expectancies, and perceived inability to stop gambling. Inter-
estingly, the GRCS can be used to assess knowledge issues among non-clinical players,
and provide an initial screening between problematic and not problematic gamblers (Grall-
Bronnec et al. 2012; Iliceto et al. 2015; Oei et al. 2007).
Nevertheless, to date no study has investigated the interrelation between the mentioned
dimensions in a comprehensive framework. The description of the relations between these
dimensions would be crucial to understand how they mediate and affect each other, and
eventually predict problem gambling behaviour, outlining opportunities for a multidi-
mensional intervention and more effective prevention policies.
Accordingly, on the basis of the cited research findings, we have chosen the five latent
variables Aggressivity, Impulsivity, Positive Personality, Negative Emotions and Psy-
chopathology, in order to explore the relations between gambling, brain emotion systems,
personality, self-other perception, and hopelessness in a sample of adults from the Italian
community.

Method

Participants

Two hundred thirty-five respondents aged 1959 years (mean age = 40.9, SD = 10.4)
voluntarily participated to the study after providing their informed consent: males were
43 % of the sample (N = 101) and females 57 % (N = 134). No differences were found
between the age of males (M = 41.3 9.7) versus females (M = 40.7 10.9)
(t(233)) = .40; p = .68). They have been recruited at Universities, banks, offices, industries,
markets, public parks and shops within two non-randomly selected Italian regions, which
are highly representative of the demographic background of Italy: Friuli Venezia-Giulia,
located in the north-east Italy, and Lazio located in the central Italy. All participants were
from lower to upper-middle classes, having various educational and socio-economic
backgrounds, which well represent the Italian population. They were housewives (7.7 %),
college students (12.3 %), unemployed (10.9 %), industry workers (6.4 %), employers
(29.8 %), retailers (7.7 %), professionals (16.2 %), entrepreneurs (4.3 %), and teachers
(5.5 %). Two groups of subjects based on the working status were considered: (1) non-
occupied: housewives, college students, and unemployed, and (2) occupied: industry

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workers, employers, retailers, professionals, entrepreneurs and teachers. No sex differences

in the two groups concerning the working status (v21 1:68; p = .19), and the years of
education (v23 2:62; p = .45) were found.

Instruments

Affective Neuroscience Personality Scales (ANPS: Davis et al. 2003; Davis

and Panksepp 2011)

The ANPS is a 112 items self-report questionnaire based on the neurobiological research
on emotions. The items are rated on a four-point scale from 0 (strongly disagree) to 3
(strongly agree) to measure six sub-scales: three sub-scales assess SEEKING, PLAY and
CARE as positive emotions, while other three sub-scales assess FEAR, ANGER (RAGE)
and SADNESS (PANIC/GRIEF) as negative emotions.

Gambling-Related Cognitions ScaleItalian Version (GRCS: Raylu and Oei 2004;

GRCS-I: Iliceto et al. 2015)

The GRCS is a 23-item self-report questionnaire designed to assess gambling-related

cognitions (GRC) and to screen for individuals with high levels of GRC. It relies on a
seven-point Likert scale ranging from 1 (strongly disagree) to 7 (strongly agree) to measure
five sub-scales: gambling-related expectancies (GE), illusion of control (IC), predictive
control (PC); perceived inability to stop gambling (IS); interpretative bias (IB). The total
score is the sum of the values obtained from each item. The Italian version of GRCS
(GRCS-I) of the test has shown excellent reliability (Cronbachs Alpha = .85) (Iliceto
et al. (2015)).

Beck Hopelessness Scale (BHS: Beck and Steer 1989; Beck et al. 1974; Pompili et al.
2009)

The BHS is a 20-item true or false self-report scale developed to operationalize the con-
struct of hopelessness. When individuals respond to the items on the BHS, they can either
endorse a pessimistic statement or deny an optimistic statement. Research consistently
supports a positive relation between BHS scores and measures of depression, suicidal
intent and current SI. In the present study we used a Likert-type scale with five-point
format, yielding three composite scores, i.e. Affective, Motivational and Cognitive re-
spectively, and then summing up these three subscales to obtain the measure of Hope-
lessness (Cronbachs Alpha = .83) (Iliceto and Fino 2015).

Attachment Profile (9AP: Candilera 2007)

The 9AP is a semi-projective test for assessing the quality of the interpersonal relationships
based on Self/Other Perception and Internal Working Models of adult Attachment.
Bowlbys construct of Attachment representation involves ideas regarding both the self and
others, whereas a persons representation of the self and the other could be characterized
by one of two orientations, i.e. positive or negative. The test includes seven basic pictures,
with each picture showing one black silhouette and one or more white silhouettes in
different scenarios. For each picture, two identical semantic differential 9-point scales (i.e.

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lists of bipolar pairs of semantically opposite terms), of nine items are presented. For the
first list, participants are asked to rate for each item their self-perception, while for the
second list they rate their perception of the others. The nine items of 9AP explore the
following psychological and emotional constructs (that are both self-related and other-
related): AcceptanceRejection, FriendlinessHostility, PowerSubmission, Security
Insecurity, AvailabilityUnavailability, CalmAgitation, SatisfactionDissatisfaction, In-
dependenceDependence, Lack of competitionCompetition. Higher scores correspond to
the first term of each bipolar item (positive representation), while lower scores to the
second term (negative representation). The two general indicators Self-perception (Cron-
bachs Alpha = .91) and Other-perception (Cronbachs Alpha = .89) that we used, are the
sum of the scores of the nine self-related and the nine other-related items, respectively.

ZuckermanKuhlmanAluja Personality Questionnaire (ZKAPQ: Aluja et al. 2010)

The ZKA-PQ is a 200-item questionnaire based on the theoretical constructs of the al-
ternative Five-factor model of personality. The instrument measures Aggressiveness
(physical aggression, verbal aggression, anger, hostility), Activity (work compulsion,
general activity, restlessness, work energy), Extraversion (positive emotions, social
warmth, exhibitionism, sociability), Neuroticism (anxiety, depression, dependency, low
self-esteem), and Sensation Seeking (thrill and adventure seeking, experience seeking,
disinhibition, boredom susceptibility/impulsivity). The authors reported that Alphas for
Aggressiveness, Activity, Extraversion, Neuroticism, and Sensation Seeking were .78.81,
.76.73, .75.75, .74.79, and .70.72 for the Spanish and American samples, respectively.

Statistical Analyses

We used SPSS 17.0 (Chicago, IL, USA) to calculate descriptive statistics, two-tailed t-tests
for continuous variables and Chi square tests with Yatess correction where appropriate for
categorical variables, while we examined the hypothesized relations in the model by using
LISREL 8.30 (Skokie, IL, USA).
Structural equation modelling (SEM) relies on several statistical tests to determine the
adequacy of model fit to the empirical data, taking into account the modelling of multiple
latent independents, each measured by multiple indicators, and one or more latent de-
pendents, each with multiple indicators. The process includes two steps: (1) to validate the
measurement model and (2) to fit the structural model. At first, a model is specified on the
basis of theory and previous empirical research, and two or more alternative models are
then compared in terms of model fit, that measures the extent to which the covariances
predicted by the model correspond to the observed covariances in the data, by means of the
statistical fitting of the factor model to the observed data (variances and covariances or
correlations), the assessment of fit, and the interpretation of the results if the model is
consistent with the data (Bollen 1989).
We used the following criteria to evaluate the overall goodness of fit. The v2 value close
to zero indicates a small difference between expected versus observed covariance matrices,
with the probability level [.05, evidencing the absence of meaningful unexplained vari-
ance. Moreover, we utilized the Goodness of Fit Index (GFI; Joreskog and Sorbom 1996),
the Comparative Fit Index (CFI; Bentler 1990), the Root Mean Square Error of Ap-
proximation (RMSEA; Steiger 1990) and the Standardized Root Mean Square Residual
(SRMR; Joreskog and Sorbom 1996). Indicators of a well-fitting model are evidenced by

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GFI than .90 and CFI greater than .95, RMSEA smaller than .06 and SRMR smaller than
.08 (Browne and Cudeck 1993; Hu and Bentler 1998, 1999).

Results

In order to proceed with the use of SEMs, we tested for the normality of the scales. Given
that in normal distribution, skewness and kurtosis should be comprised within -2 and ?2
range, we assumed the data as normally distributed. Moreover we conducted a preliminary
study taking in account sex, i.e. we compared males and females on all the scales, but we
did not find any statistically significant differences. The descriptive statistics for all the
scales, and the comparisons between males and females are listed in Table 1.
A model was specified using the Sample Covariance Matrix and the estimated pa-
rameters using Maximum Likelihood, with 15 observed variables and 5 latent variables. In
the first model, we tested Positive Personality (Self, Other, Extraversion, Activity, Care) as
inverse indicator of Negative Emotions (FEAR and SADNESS), Aggressivity (Aggres-
siveness and ANGER), Impulsivity (Gambling, Sensation Seeking, SEEK, and PLAY).
Moreover we assumed Negative Personality, Impulsivity, and Aggressivity as indicators of
Psychopathology (Neuroticism and Hopelessness). All of the factors were allowed to inter-
correlate and all indicator cross-loadings were pre-specified to equal zero. When we tested
the first model the fit indices were as follows: v283 214:26 (p \ .000); GFI = .89;
CFI = .84; RMSEA = .08; SRMR = .08. The results were statistically insignificant and
unsatisfactory, with all fitted indices outside the accepted values. The hypothesis that this
model represented a good fit to the data was easily rejected. The loadings of Activity (.18)
and PLAY (.39) were extremely low, thus we excluded these two variables from the model.
The second model produced fit indices as follows: v258 59:42 (p = .42); GFI = .96;
CFI = .99; RMSEA = .01; SRMR = .04. Therefore, we considered this model as more
appropriate to describe the relations between the observed variables and the latent vari-
ables, with good fit with the data.
In the measurement model (Fig. 1), the factor loadings that are showed on each arrow,
represent the strength of the relation between the variables; all of them were high and
statistical significant, and the squared multiple correlations (indicate the amount of vari-
ance in the observed variables which is accounted for by the common factors) ranged from
19 % (Aggressiveness) to 78 % (ANGER). Impulsivity involved Sensation Seeking (.57)
and SEEK (.55), and consistently Gambling was also a good indicator of such latent
variable (.56). As expected, Aggressiveness (.44) and ANGER (.88) were associated with
the Aggressivity factor. Positive Personality resulted as an inverse indicator of Negative
Emotions, including Extraversion (.70) and CARE (.58), as well as Self/Other perception
(.48 and .47, respectively). As expected, SADNESS (.75) and FEAR (.50) were positively
associated with Negative Emotions, while Psychopathology was strongly correlated with
Hopelessness (.66) and Neuroticism (.49). The structural equations indicated that the latent
predictor variable Positive Personality, as an inverse indicator, explained about 33 % of
Negative Emotions (structural regression coefficient = -.57), while Positive Personality,
Aggressivity, and Impulsivity (structural regression coefficients = -.72, .27, .22, re-
spectively,) significantly explained Psychopathology with about 83 % of variance.

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Table 1 Descriptive statistics of the scales and comparisons between males and females
Scales Sample Skewness Kurtosis Males Females t(233) p

Gambling (GRCS-I) 46.03 11.4a .453 -.297 44.27 10.6a 47.36 11.8a 2.06 .04
a a
Hopelessness (BHS) 16.86 3.3 .608 1.460 16.62 3.4 17.04 3.2a .95 .34
Self perception (9AP) 332.50 42.6a .465 .233 333.99 43.4a 331.38 42.1a .46 .64
Other perception (9AP) 317.30 44.0a .731 .697 321.65 45.0a 314.01 43.0a 1.32 .18
Aggressiveness (ZKA-PQ) 99.39 20.2a -1.613 1.164 101.51 17.3a 97.78 22.1a 1.40 .16
a a
Activity (ZKA-PQ) 108.70 11.6 -.842 -.295 108.77 11.9 108.65 11.4a .08 .93
Extraversion (ZKA-PQ) 120.81 15.1a -.642 .258 121.07 15.0a 120.61 15.2a .22 .81
Neuroticism (ZKA-PQ) 91.73 19.3a -.445 -.885 94.88 18.6a 89.36 19.6a 2.18 .03
Sensation seeking (ZKA-PQ) 101.00 18.9a -.570 -.644 103.40 17.4a 99.19 19.8a 1.69 .09
a a
SEEK (ANPS) 24.21 6.5 -.080 -.248 24.36 6.6 24.10 6.6a .28 .77
FEAR (ANPS) 21.67 4.7a .386 1.868 21.25 5.0a 21.99 4.4a 1.18 .23
CARE (ANPS) 23.80 6.4a .276 -.152 24.23 6.1a 23.48 6.7a .87 .38
a a
ANGER (ANPS) 18.79 5.2 -.209 -.859 18.78 5.3 18.80 5.2a .02 .98
PLAY (ANPS) 26.51 6.5a -.258 -.164 26.05 6.3a 26.86 6.5a .95 .63
SADNESS (ANPS) 19.35 4.3a .017 -.564 19.23 4.5a 19.44 4.3a .36 .71
a
Values shown as mean SD
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Fig. 1 Structural model. Latent variables. PSYCHOPA: Psychopathology; NEGEMO: Negative Emotions;
AGGRESSI: Aggressivity; IMPULSIV: Impulsivity; PERSONAL: Positive Personality. Observed vari-
ables. gambling: Gambling (GRCS-I); self: Self perception (9AP); other: Other perception (9AP); aggressi:
Aggressiveness (ZKA-PQ); sensatio: Sensation seeking (ZKA-PQ); extraver: Extraversion (ZKA-PQ); seek:
SEEK (ANPS); care: CARE (ANPS); anger: ANGER (ANPS); hopeless: Hopelessness (BHS); neurotic:
Neuroticism (ZKA-PQ); fear: FEAR (ANPS); sadness: SADNESS (ANPS)

Discussion

In the present study, we aimed to test two models for explaining the relations between
brain emotion systems, personality, hopelessness, Self/Other perception, and problem
gambling. The distribution of the observed variables indicated that the latent predictor
variable Positive Personality, as an inverse indicator, significantly explained Negative
Emotions, representing the traits of FEAR and SADNESS, while Negative Personality,
Aggressivity, and Impulsivity significantly explained Psychopathology, representing neu-
roticism and hopelessness. Positive Personality involved individuals characteristics of
sociability, assertiveness, emotional expressiveness, and positive model of the self and the
others, reflecting in efficient metacognitive monitoring and organized interpersonal pat-
terns. On the other hand, Negative Personality, Impulsivity, and Aggressivity resulted as
good indicators of Psychopathology. In particular, Impulsivity involved Sensation Seeking
and the ANPS SEEK dimension, i.e. personality traits related to the tendency to pursue
sensory pleasure and excitement with low ability to delay, frequently observed in problem
gambling.
The major finding of the study is the significant association we found between Gam-
bling and Impulsivity, and how directly Impulsivity and Aggressivity, and Negative Per-
sonality predict what it has been named Psychopathology factor, i.e. a latent variable

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involving neurotic personality, hopelessness and, remarkably, high sensation seeking, low
metacognitive responsiveness, and disorganized patterns of interpersonal relationships.
These results contribute to the development of a theoretical framework of Gambling in
relation with Personality and provide a new approach for clinical intervention of Problem
Gambling which relies on a solid multidimensional perspective. Currently the most widely
studied treatment for gambling disorders is cognitive-behavioural therapy (CBT), but
although multiple forms of CBT have shown their benefits in the treatment of problem
gambling, no shared vision exists on the diverse types of such a therapy (e.g., behavioural,
cognitive, cognitive-behavioural), partly, no doubt, due to the considerable variability of
the reported outcomes, and therapy settings (e.g., individual, group, self-directed) (Cow-
lishaw et al. 2012).
The interventions should cover several therapeutic approaches, such as Psychotherapy,
Cognitive Therapy, Cognitive-Behavioural Therapy, Cue-exposure, Brief Interventions
and Motivational Interviewing, Family Therapy, Gamblers Anonymous, while the im-
portance of the link between affectively driven cognitions and gambling should be em-
phasized, providing cognitive guidance and stimulations for problem gamblers by
identifying and increasing skills for coping with high-risk situations. As noted by Rash and
Petry (2014), Rather than attempting to develop new treatments, a more systematic
evaluation of existing therapies is likely to guide implementation of effective interventions
in clinical care (Rash and Petry 2014, p. 293).
The novelty of this study lay in considering dimensions of Attachment and metacog-
nitive responsiveness dimensions as observed variables, in addition to those already
identified in existing research, together with the introduction of evaluation of primary brain
emotion states in the model, yielded a variety of personality dimensions that may be
predictive of problem gambling.
Self/other perceptions are essential elements in this model. In fact, since they are related
to early attachment experiences, they are indicators of organized personality development
and stable interpersonal organizations that may differentially control impulse control
problems and thereby promote strategies to reduce addictive gambling behaviours.
Therefore, this research has helped delineate variables that need to be considered for a
comprehensive framework of psychologically meaningful dimensions that promote prob-
lem gambling. The improved comprehension of how personality, social-attachment,
metacognitive and psychopathological dimensions are mutually associated, highlights a
new perspective on the understanding of problem gambling that may facilitate develop-
ment of new interventions.
Nevertheless, the study has some limitations. First, it is not possible to confirm the
observed relations in terms of causal effects, given the cross-sectional nature of the data.
More research is needed to clarify the role of the observed variables in influencing the
development of problem gambling, and of other potential pathways involved, as well as
comorbidity with other kinds of addictions, anxiety, and mood disorders.
Furthermore, the size-limited, culturally-constrained sample of individuals studies does
not allow us to make any comprehensive generalization of results. Third, psychometric
assessment tools were administered in a general community sample, as opposed to a
targeted at-risk population, calls for more research along these lines with individuals
defined as problem gamblers, supplemented by longitudinal observations. However, the
relationships of variables found in our analysis may offer future investigators a robust
measurement model. We emphasize here the importance of improved future research
aimed at identifying risk factors for Problem Gambling and providing more comprehensive
theoretical frameworks for Problem Gambling. Further understanding of the structures of

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these underlying psychological relations may promote development and implementation of

more advanced prevention and intervention policies, especially for individuals from the
community who are at higher risk of developing Problem Gambling.

Acknowledgments The author(s) received no financial support for the research, authorship, and/or pub-
lication of this article.

Conflict of interest The authors declare no potential conflicts of interest with respect to the research,
authorship, and/or publication of this article.

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