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Clinical Atlas Prestige · Evidence-first

Psych VivasAddiction psychiatry — behavioural addictions

Psych Vivas · Addiction psychiatry — behavioural addictions

Gambling disorder — structured clinical viva

Fellowship viva on gambling disorder with dopamine-agonist ICD overlap, depression comorbidity, CBT first-line, and off-label naltrexone counselling.

clinical
On this page & tools

Target exams

FRANZCPMRCPsychABPNMD-DNB

Target exams

FRANZCPMRCPsychABPNMD-DNB
Prompt
You are the addiction psychiatry registrar. A 51-year-old woman with restless legs syndrome on pramipexole presents with 6 months of escalating electronic gaming machine use, maxed credit cards, marital crisis, and G-SAS scores in the severe range. She also meets criteria for major depression and smokes 20 cigarettes daily. She wants 'naltrexone like for alcohol' and refuses to involve her neurologist. Discuss diagnosis, iatrogenic contributors, risk, stepped care, and how you would counsel on medication.

Interpretation

Reveal interpretation

This viva tests whether the candidate can hold two formulations at once: (1) a behavioural addiction meeting DSM-5-TR gambling disorder criteria with depression and nicotine comorbidity; and (2) a probable dopamine-agonist-associated impulse-control disorder temporal to pramipexole. Refusing neurology liaison is a risk — candidates must explain why agonist review is medically necessary without bullying, and arrange safe contact pathways.[1][2][5]

Risk. Marital crisis plus severe financial harm demands suicide assessment, domestic conflict screening, and practical financial safeguarding (self-exclusion, banking controls). Depression treatment is not optional window-dressing.[1]

Treatment hierarchy. CBT and harm reduction remain core regardless of pharmacotherapy interest. Naltrexone may be discussed as off-label adjunct for urges with LFT monitoring, but it does not replace agonist review if the ICD pathway is active.[3][4]

Key points

Agonist first when temporal link is clear

Weintraub-level evidence links dopamine agonists to gambling ICDs — do not leave the dose untouched while only adding tablets.

CBT is still first-line behavioural care

Cowlishaw Cochrane and Petry-type RCTs anchor psychosocial treatment even when patients request medication.

Naltrexone is adjunctive and off-label for GD

Counsel evidence, LFTs, opioid interaction, and realistic expectations — not a licensed cure.
[2] [3] [4]

References

  1. [1]Potenza MN, et al. Gambling disorder Nat Rev Dis Primers, 2019.PMID 31346179
  2. [2]Weintraub D, et al. Impulse control disorders in Parkinson disease: a cross-sectional study of 3090 patients Arch Neurol, 2010.PMID 20457959
  3. [3]Grant JE, Kim SW, Hartman BK A double-blind, placebo-controlled study of the opiate antagonist naltrexone in the treatment of pathological gambling urges J Clin Psychiatry, 2008.PMID 18384246
  4. [4]Cowlishaw S, et al. Psychological therapies for pathological and problem gambling Cochrane Database Syst Rev, 2012.PMID 23152266
  5. [5]Weintraub D, et al. Association of dopamine agonist use with impulse control disorders in Parkinson disease Arch Neurol, 2006.PMID 16831966