Gambling disorder — criteria, risk, CBT, and naltrexone (MEQ)

(i) Diagnosis and severity. He meets multiple DSM-5-TR gambling disorder criteria within 12 months (preoccupation/daily play, unsuccessful cut-downs, restlessness when stopping, chasing losses, lying/concealment, financial jeopardy/bailout trajectory). Threshold is ≥4 of 9; with many criteria endorsed this is at least moderate (6–7) and possibly severe (8–9) pending full criterion count. Note DSM-5 reclassification under addictive disorders and removal of the illegal-acts criterion relative to DSM-IV.^[1]

(ii) Risk and dual diagnosis. Prioritise structured suicide risk assessment and safety planning after catastrophic disclosure and debt; assess intimate-partner conflict, child protection if dependents, and forensic exposure. Screen alcohol use disorder severity and withdrawal risk; mood, anxiety, ADHD, and personality pathology given NESARC-level comorbidity. Collateral from partner on true losses. Capacity around high-stakes financial decisions if relevant.^[1][5]

(iii) Psychosocial first-line plan. Engage with MI despite psychology refusal — roll with resistance, link tablet request to comprehensive care. Offer CBT for gambling: cognitive restructuring of chasing and control illusions, urge surfing, stimulus control (app deletion, self-exclusion, bank blockers), behavioural alternatives, and financial counselling/debt plan with agreed third-party money management if safe. GA as adjunct. Couple session if appropriate. Measurement (e.g. G-SAS concept) and early review.^[3][4]

(iv) Naltrexone counselling. Explain no formal GD monotherapy licence; evidence from placebo-controlled trials (Kim; Grant) supports urge reduction in selected patients as adjunct. Practical framing: oral naltrexone often discussed from about 50 mg daily after baseline labs, specialist titration if used, LFT monitoring — his ALT 62 warrants explanation, alcohol reduction plan, and caution rather than automatic high-dose starts. Contraindications include acute hepatitis/liver failure and current opioid use (precipitated withdrawal). Do not offer a tablet alone without psychosocial package.^[2][6]

(v) Differential traps. (1) Unrecognised mania/hypomania driving betting — need sleep, grandiosity, and episode timeline. (2) Dopamine-agonist ICD if Parkinson/RLS drugs present (not in this stem but classic exam trap). Also: pure willpower framing; missing alcohol withdrawal risk.^[1]