Cognitive Distortions of Pathological Gamblers

Cognitive distortions of pathological gamblers

INTRODUCTION

Drawing from Erikson's cascade of human developmental needs, which are: basic trust, autonomy, initiative, industry, ego identity, intimacy, generativity, and ego integrity, it can be stated that their unfulfillment leads to various cognitive distortions that are transformed into the area of gambling in a depressed and frustrated individual. The addictologically risky personality development of an individual can thus be a key risk factor, a determinant for the emergence and deepening of gambling pathology as a consequence of the occurrence and variability of cognitive distortions and their reinforcement.

Predictors of gambling problems in adulthood in relation to the occurrence of cognitive distortions can also be found in early childhood. Winnicott considered "healthy" interaction with the mother to be a basic developmental need. This was later followed up by Bowlby, who emphasized the motivational need for attachment, i.e., the creation of a deep and lasting bond with the mother. Also applicable in this case is Maslow's hierarchy of needs (physiological needs, safety and security needs, belongingness and love needs, esteem needs, self-actualization). Another connection is found in the need to fulfill existential needs according to Frankl (creation, experiences, attitudes). The failure to fulfill these basic and secondary needs leads to stagnation and even regression of the personality and to gambling pathology. The attempt to fulfill these early basic needs is transformed into unconscious gambling pathology in adolescence and adulthood. Jeřábek (2008) also pointed out in the past that in addicted individuals it is necessary to consider primarily developmental (traumatic history) and secondary (resulting from addiction) deprivation of the above-mentioned needs. Addicted individuals thus suffer from a specially defined motivational disorder (autonomization of incongruent and distorted motives).

1 THEORETICAL BACKGROUND FROM THE PERSPECTIVE OF THE PSYCHOLOGICAL-PSYCHOANALYTIC THEORY OF PATHOLOGICAL GAMBLING

Excessive gamblers in most cases stimulate their cognitive representations with the false belief that they can control the slot machine and thus bring about a win. They construct various strategies and create illusory techniques to "beat" the slot machine. Eventually they come to believe them and deny any losses. This vicious cycle of gambling becomes a stereotype in the individual's behavior.

From the perspective of the issue of pathological gambling as a socio-pathological phenomenon, it can be viewed within the framework of the "theory of differential cognitive style" proposed by Walters and White (1989). Within this theory, they created a model of eight primary cognitive characteristics. These characteristics were adapted for recidivist delinquents, but they can also be attributed to the personality of a problem gambler. They were also described by Fischer and Škoda (2009). They are:

• tendencies to justify one's undesirable behavior through "rationalization" (an unconscious defense mechanism);
• lack of concern about the consequences of planned action or deed (disinhibition of behavioral defenses);
• feeling of privilege, entitlement to disregard "norms" (social, familial);
• orientation toward power, dividing people into strong and weak, feeling of power and the ability to control others;
• sentimentality, tendency toward superficial emotional bonds, without willingness to give up anything and take responsibility for one's undesirable behavior, self-deception about correct conduct;
• overvalued optimism, an extreme form of self-confidence, conviction of unconditional success in any activity, inability to learn from a genuinely threatening situation;
• discontinuity of thinking, inability to hold lasting convictions, easy susceptibility to external influences (e.g., social group pressure).

Connections to the development of pathological gambling are also found in the analysis of the formation of early maladaptive schemas (EMS) in relation to the cognitive component of personality, as well as within the theory of personality vulnerability. EMS are formed in childhood as a response to unmet needs. The triggering of these undesirable schemas in adulthood can cause "anxiety", which may lead to maladaptive behavior in the form of addictive behavior – gambling pathology. According to Kaplan and Sadock (In Praško et al., 2007), in the general concept of addiction, 31% of variables can be attributed to genetic factors, 25% is the influence of family, and 44% are environmental and other non-family factors. (In Praško et al., 2007).

Source: Praško et al., 2009, p. 69

The phenomenon of narcissistic vulnerability also builds on the topic of early maladaptive schemas and the theory of vulnerability. "Narcissistic vulnerability is thought to arise from early experiences of helplessness, loss, or rejection. The sadness associated with these experiences is interpreted by children as a sign of personal harm, damage, or weakness, of being incompetent or unloved. They may even interpret this sadness somatically as something physically wrong in the body, developing unconscious fantasies of bodily harm or damage. If children experience these difficulties as immutable aspects of their identity from an early age, fantasies of failure, loss, and harm originating from these early experiences may persist or be easily evoked in later periods of life and may determine affective response." (Busch, Rudden, Shapiro, 2006, p. 79). Damage resulting from adverse early experiences (narcissistic vulnerability) can, from our perspective, be carried into later developmental periods as a risk factor for the emergence and deepening of gambling pathology.

In relation to the development of gambling pathology, one can also consider the influence of unconscious defense mechanisms, where this type of undesirable behavior serves as a form of escape from problematic situations. That is, the more the problems deepen, the more gambling is maintained and intensified. Past traumas or the presence of post-traumatic stress likely also play a role. According to Ehlers (in Kaščáková, 2007, p. 80), the main function of defense is "to protect consciousness from threatening, conflictual, internal stimuli (drives, wishes, emotions), as well as from external overwhelming stimuli (traumas)."

In connection with the psychological-psychoanalytic theory and the issue of cognitive distortions, it is also necessary to mention the psychiatric comorbidity of pathological gambling. Individuals with various psychological disorders have a greater predisposition to problem gambling and even pathological gambling. These include, for example, various diagnoses such as clinical depression, antisocial personality disorder, various types of phobias, as well as a history of alcoholism in the individual. (Cunningham-Williams et al. in George, Murali, 2005; De Castella et al., 2011). According to Hroncová et al. (2006, p. 136) "pathological gambling belongs to severe personality disorders." The authors based this on the fact that pathological gamblers are treated in psychiatric hospital wards and remain addicted for life. This disorder can be rehabilitated, but not completely cured.

2 THEORETICAL BACKGROUND FROM THE PERSPECTIVE OF THE COGNITIVE-SUBJECTIVIST THEORY OF PATHOLOGICAL GAMBLING

Within the cognitive-subjectivist theory of pathological gambling, we also consider it necessary to present the cognitive-behavioral theory in general with application to the subject matter. According to Matoušek et al. (2013), cognitive-behavioral theories provide a conceptualization of the phenomena of human behavior. They utilize knowledge from behavioral and cognitive theory. From the perspective of behavioral theories, the significance of the socialization process and the phenomenon of learning within it can be assumed. It is assumed that the personality of the pathological gambler is in interaction with a certain social environment (family system) that shapes him and in which he develops certain patterns of behavior and functioning in the wider social environment. All our abilities and ways of behaving are learned, but can be influenced by various types of conditioning (classical, operant, and observational). The techniques of these types of conditioning are used for the correction and modification not only of behavior, but also of various intrapsychic and interpsychic problems. Cognitive theories put forward the hypothesis that individuals respond to internal stimuli with certain behavior that stems more from their beliefs about reality than from the situation itself. Based on this theory, the reactions of a pathological gambler may be influenced by formed cognitive maps as well as cognitive distortions, and may contain elements of irrationality. Through cognitive maps, reality is represented and the individual's subsequent behavior is planned.

Within the cognitive-subjectivist theory, we consider it beneficial to present associations of cognitive distortions. The issue of cognitive distortions was addressed by Šerý (2001). These include, for example, "improvement in gambling dexterity," which is often accompanied by increased self-confidence. The result is an increased amount of money spent on gambling. A concomitant phenomenon is also the subjective belief that the player has discovered an effective way to win the largest amount of money in a shorter time. Another cognitive distortion of the pathological gambler is "talismanic, ritual, and cognitive superstition." Most gamblers believe that a certain object (a ring) or ritual (a specific place in the gambling hall) brings them luck in the game. In the case of cognitive superstition, one can mention, for example, a situation where a gambler believes that a certain mental state or mood will bring them luck in the game. Gambling activity is also associated with the process of rationalization (the tendency to explain repeated losses). A gambler is often convinced that if they are losing a larger amount of money at a given moment, it is a harbinger of a big win. They may also think that they cannot only lose and that logically the randomness of losing streaks is followed by a streak of wins. Šerý (2001) further mentions in his article "anthropomorphism" in the form of attributing human characteristics to slot machines.

Cognitive processes are the crucial link that mediates an individual's emotional, physiological, and behavioral responses to stimuli from the surrounding environment. "The individual does not respond primarily to stimuli from the environment, but to mental representations of these stimuli." (Meichenbaum in Praško et al., 2009, p. 59). Cognitive theories assume that personality is a set of cognitive structures (schemas) on the basis of which the individual thinks, feels, and acts. This includes, for example, the "theory of personal constructs" (Kelly); "social learning theory" (Bandura); "learned helplessness theory" (Seligman); and the "theory of dysfunctional cognitive schemas." (In Praško et al., 2009).

A frequent symptom of cognitive distortion in gamblers is "selective memory for wins." It consists of remembering wins (especially large ones) and having difficulty recalling losses. A concomitant phenomenon is also the "illusion of control over 'luck' in the game," which is characterized as the gambler's belief that luck oscillates between periods of good and bad fortune. They also often think that intuition helps them in their effort to win (have luck in the game) (the possibility of winning in certain types of games). When remembering a big win associated with external phenomena in a given period, the gambler may also create so-called "illusory correlations," based on which they anticipate a win in the next period as well. (Toneatto, 1999). Cognitive distortions in pathological gamblers were also addressed by Clark (2010) and Clark et al. (2013).

Theories of gambling behavior that relate to cognitive aspects seek the origin of pathological gambling in the existence of so-called "thought errors" (cognitive distortions). They then place incorrect thought processing in direct connection with gambling behavior. (Rogers; Roneatto in Prunner, Hroncová, 2009). The effort to identify specific errors in thinking that worsen (or directly cause) problem gambling led to their categorization:

• "Superstitions" – players proceed from the belief that there are objects ("fetishes") that bring luck. Likewise, they tend toward specific and strictly observed rituals intended to increase the probability of winning.
• "Interpretive bias" – players attribute winning to the abilities and experience of the player. Losses are then attributed to bad luck.
• "Temporal telescoping" – when expecting a win, players firmly believe that naturally occurring wins are statistically evenly distributed and they are the ones who, based on probability, will be favored with a win sooner. They believe that a win will come to them sooner than it usually occurs in other cases. They are convinced that a win will come to them preferentially over other players.
• "Selective memory" – in pathological gamblers, the selectivity of cognitive processes very often causes them to remember wins while forgetting losses. Likewise, the player adds up wins and forgets to also record the amount of money lost.
• "Subjectively produced illusory correlations" – players attribute causal connections to a "contextual stimulus" that has only a random relationship to winning or losing. They elevate randomly occurring connections above lawful mutual causal relationships. (Prunner, Hroncová, 2009).

3 METHODOLOGICAL BACKGROUND

From the perspective of methodological context, we can state that the phenomenon of cognitive distortions has not yet been addressed by any professional in practice within our conditions. We also found only minimal theoretical outlines, which, however, given their publication year, can be considered outdated and do not reflect the current state of pathological gambling in our context, especially from the perspective of playing virtual gambling games.

Abroad, the issue of cognitive distortions in pathological gamblers has been addressed by several authors, such as Goodie and Fortune (2013); Fortune and Goodie (2012); Subramaniam et al. (2017); Barrault and Varescon (2013); Ciccarelli et al. (2017); Michalczuk et al. (2011); Myrseth, Brunborg, Eidem (2010); Romo et al. (2016); Kai-Ching Yu and Fu (2013); Mathieu et al. (2017); and Xian et al. (2008).

Goodie and Fortune (2013) conducted a meta-analysis of studies on cognitive distortions in pathological gamblers. The results of the analyses showed that cognitive distortions occur more frequently in pathological gamblers compared to other disorders. The variability of cognitive distortions is also somewhat higher. In another study by the authors (Fortune, Goodie, 2012), cognitive distortions were analyzed from the perspective of focused treatment in the context of cognitive restructuring within cognitive-behavioral therapy.

Cognitive distortions of pathological gamblers were also examined by the authors of the study Subramaniam et al. (2017) in adult Asian pathological gamblers, specifically pathological gamblers living in Singapore. The aim of the study by these authors was to describe the construction of cognitive distortions in pathological gamblers based on a narrative qualitative analysis of their stories. As in our case, so too in this qualitative research study, the occurrence of cognitive distortions was recorded in all pathological gamblers. This confirmed the assumption verified in the study by Goodie and Fortune (2013), as well as in the study by Michalczuk et al. (2011) and the study by Myrseth, Brunborg, Eidem (2010), that the occurrence of these phenomena is very frequent in pathological gamblers. This holds true regardless of socio-cultural specifics.

Connections between cognitive distortions and psychological distress (anxiety and depression) in pathological gamblers were verified by Barrault and Varescon (2013). The target group consisted of non-problem gamblers (N=146), problem gamblers (N=55), and pathological gamblers (N=45) who primarily play poker for money. The research study was quantitative in nature and involved 245 online poker players, who were administered several questionnaires via an online forum: the SOGS questionnaire ("South Oaks Gambling Screen"), the HADS questionnaire ("Hospital Anxiety and Depression Scale"), and the GRCS ("Gambling-Related Cognition Scale"). The results of the study showed that all poker gamblers, regardless of the degree of gambling pathology, exhibited higher anxiety than depression. Significant differences were recorded in the occurrence of cognitive distortions in relation to the occurrence of gambling pathology. The main predictors of pathological gambling in poker players were identified as the inability to stop playing poker, illusion of control over gambling, depression, and anxiety. Again, it was confirmed that cognitive distortions play a significant role in the development and deepening of gambling pathology.

Another significant study is the study by Ciccarelli et al. (2017), which verified the connections between the occurrence of cognitive distortions, emotional distress, and decision-making ability. The research sample consisted of pathological gamblers, who were compared with a control group without gambling pathology. From the perspective of cognitive distortions (irrational beliefs about gambling), it can also be stated that significant risk factors include low decision-making ability and emotional factors, such as negative emotional affect. The study used a quantitative methodological strategy employing four research methods: the SOGS questionnaire ("South Oaks Gambling Screen"); the IGT ("Iowa Gambling Task"); the GRCS ("the Gambling Related Cognitions Scale"); and the DASS-21 ("Depression Anxiety Stress Scale"). As could be expected, the study results showed significant differences in the level of experienced emotional distress, the level of decision-making ability, and the level of occurrence of cognitive distortions between pathological gamblers and the healthy population, with pathological gamblers scoring high on all variables. Cognitive distortions in pathological gamblers correlated with low decision-making ability. No associations were found between the variables of emotional distress and level of decision-making ability. As in the case of the study by Barrault and Varescon (2013), this study also demonstrated that emotional distress is a significant predictor of the emergence and deepening of gambling pathology. Low decision-making ability is also a predisposition for the development of pathological gambling disorders.

An interesting finding in the context of the occurrence of cognitive distortions in pathological gamblers is that the study by Romo et al. (2016) demonstrated a connection between the occurrence and variability of cognitive distortions in pathological gamblers and attention deficit hyperactivity disorder – ADHD. Studies by Mathieu et al. (2017) and Xian et al. (2008) demonstrated that the disposition to cognitive distortions is not only a concomitant phenomenon of pathological gambling but also a predictor or risk factor for its development.

The aim of our research was to determine the occurrence and variability of cognitive distortions in problem gamblers who meet the diagnostic criteria for pathological gambling.

3.1 METHODS AND RESEARCH SAMPLE

We verified cognitive distortions in problem gamblers through qualitative analysis using the method of a self-designed interview. The interview contained questions aimed at the occurrence and variability of cognitive distortions in problem gamblers. Cognitive distortions were divided into individual categories, each with a corresponding set of interview questions. The categories of cognitive distortion types in problem gamblers and example questions were as follows:

1. Interpretive bias / self-confidence and reinforcement of gambling skills (Do you feel more and more that you are becoming more skilled at gambling?; Do you feel confident when you play?)
2. Effective way to "win" (Do you think you have discovered some way to win as much money as possible?)
3. Talismanic ritual superstition / superstitions (Do you have any talisman that you believe brings you luck in the game?; Do you have any rituals before starting to play?)
4. Subjectively produced illusory correlations / psychological state during play (Do you think that when you are in a good mood for some reason you have more luck in the game and win more often?; Do you think that when you are in a bad mood for some reason you have less luck in the game and win less often?)
5. Rationalization – tendency to explain losses (Do you think that if you have been losing for a long time, a big win is waiting for you and you need to wait for it and keep playing?)
6. Anthropomorphism (Have you ever talked to a slot machine even when playing alone?; Have you ever thought that a slot machine has some human characteristic compared to other machines around it?)
7. Selective memory for wins (What do you remember more often, wins or losses?; How many significant losses do you remember?; How many significant wins do you remember?)
8. Temporal telescoping / illusory correlations, illusion of control over luck (Have you ever had a premonition that a period of big and frequent wins was coming?; Have you ever thought that if you played a certain type of game, you would definitely win?).

The diagnosis of pathological gambling in selected participants was carried out using two diagnostic methods: the LBQ method ("The Lie/Bet Questionnaire") and the GA-20 method ("The Gamblers Anonymous 20 Questions"). The participant was asked to self-assess without marking answers whether they met the criteria for our selection. If they did not answer affirmatively to two questions on the LBQ and at least seven questions on the GA-20 based on subjective assessment, the participant was not suitable and did not continue cooperating with us.

The LBQ questionnaire is a two-item diagnostic tool designed for testing "pathological" gambling. The authors are Johnson et al. (1997, 1998). Johnson further states that this questionnaire demonstrated sensitivity of 0.99; specificity of 0.91; positive predictive value of 0.92; and negative predictive value of 0.99, specifically within the research sample of respondents who were members of the self-help group "Gamblers Anonymous." When determining these associations, the results were compared with a control group that did not contain problem gamblers. In the second study by Johnson et al. (1998), the questionnaire demonstrated sensitivity of 1.00, specificity of 0.85, positive predictive value of 0.78, and negative predictive value of 1.00. The LBQ is also mentioned in the works of Prunner (2013) and Benkovič, Martinove (2011).

The GA-20 research method was created by the organization "Gamblers Anonymous" (1984), which mostly uses it more to strengthen motivation for abstinence than for diagnosis, but it is also usable in the diagnosis of problem gambling in general. The research method has been published by several authors, such as Nešpor et al. (2011) and Prunner (2013) in Czech; Benkovič and Martinove (2011) in Slovak. Nešpor et al. (2011) state that the questionnaire has not been validated for either the American or our population, but most researchers consider this diagnostic tool sufficiently valid. In the case of this questionnaire, a person who answers yes to seven out of twenty presented questions is identified as a problem gambler. The questions concern gambling and can be answered either "yes" or "no." Interestingly, the organization "Gamblers Anonymous" also created a similar questionnaire tool for the wives of pathological gamblers. (Nešpor et al., 2011).

The research involved 32 participants, of whom 29 were men and 3 were women. Even in the case of the selected research sample, or the availability of participants, it can be confirmed that gambling is predominantly engaged in by the male population, which is significantly dominant in this case across all categories of gambling. This is based on the assumption of genetic predispositions that increase the likelihood of developing pathological gambling more in the male population compared to the female population. Participants were active visitors of both commonly available and virtual gambling halls and casinos. The research sample met the diagnostic criteria for pathological gambling; however, given that the designation "pathological gambler" also requires medical diagnosis and assessment, we decided to refer to the participants in terms of "problem gambler" within the terminology. The selection criteria were as follows:

• the participant was an active gambler (played at least three times a month for at least the past year);
• the participant had engaged in gambling at least once in the past two weeks;
• the participant answered affirmatively to 2 questions on the LBQ questionnaire during diagnosis;
• the participant answered affirmatively to at least 7 out of 20 questions (GA-20) during diagnosis.

2.2 INTERPRETATION OF RESULTS

The qualitative analysis of the obtained data demonstrated the following facts regarding the occurrence/frequency and variability of cognitive distortions, which we present in the following Table 1. We coded the average frequency of occurrence of each category of cognitive distortions based on answers to interview questions on a scale from 1 to 5, where "1" meant never and "5" meant very often.

Table 1 Occurrence and average frequency of cognitive distortions in problem gamblers

From the results of the qualitative analysis of cognitive distortions in problem gamblers in terms of their categorization, occurrence, variability, and frequency, it is evident that the most common cognitive distortions in this target group are in the form of interpretive bias / self-confidence and reinforcement of gambling skills, as well as in the form of selective memory for wins. In contrast, the least common cognitive distortions in problem gamblers are anthropomorphism and subjectively produced illusory correlations / psychological state during play. Frequently occurring cognitive distortions in problem gamblers are an effective way to "win" and temporal telescoping / illusory correlations, illusion of control over luck.

Participant statements further showed that problem gamblers, in terms of cognitive impairments, have poor concentration, slowed thinking, and impaired decision-making. We further found that in terms of emotional overload in problem gamblers, dysphoria and anxiety prevail, associated even with feelings of paralysis, especially in the phase when the player is actively playing and losing over a longer period. Various cognitive distortions were also found, such as referential thinking, use of ineffective coping strategies in solving gambling problems, feelings of guilt over problematic situations that have arisen, and attribution of global significance to the problem.

CONCLUSION

It is evident that problem gamblers experience symptoms of excessive emotional overload, which is related to cognitive distortions, their occurrence and variability, not only during active and long-term gambling but also within ordinary intrapsychic processes. This is reflected not only in their psychological experience and emotional affect but also in their interaction with the primary and secondary social environment.

The method of so-called "cognitive restructuring" in the context of cognitive-behavioral therapy appears to be an effective method for addressing cognitive distortions and excessive emotional overload in pathological gamblers. In this case, negative automatic thoughts and cognitive errors of pathological gamblers could also be addressed, such as catastrophizing, black-and-white thinking, exaggeration, hopelessness, and excessive self-criticism. According to Wright, Basco, and Thase (2008), the method of "cognitive restructuring" is among the primary problem-solving techniques used to reduce distracting or painful emotions. The goal of this method is to reduce tension – not to encourage avoidance of task completion.

Information obtained from a number of professional studies suggests that problem gamblers do not constitute a homogeneous group and cannot be divided into various stable subtypes in relation to personality structure and comorbid psychopathology. Divisions may also be targeted at the intensity and duration of gambling. However, in the case of cognitive distortions, it can be assumed based on the content analysis of several research studies that they occur in all individuals with gambling pathology regardless of its severity.

Author: PhDr. Michaela Dávidová, PhD. Glossary of Abbreviations

ADHD – ("Attention deficit hyperactivity disorder"); Attention deficit hyperactivity disorder; DASS-21 – ("Depression Anxiety Stress Scale"); HADS – ("Hospital Anxiety and Depression Scale"); Clinical anxiety and depression questionnaire; EMS – ("Early Maladaptive Schemas"); Early maladaptive schemas; GA-20 – ("The Gamblers Anonymous 20 Questions"); 20-question questionnaire of Gamblers Anonymous, based on which problem gambling can be identified; GRCS – ("Gambling-Related Cognition Scale"); Gambling-related cognition scale; IGT – ("Iowa Gambling Task"); Iowa gambling task; LBQ – ("The Lie/Bet Questionnaire"); Lie/Bet questionnaire.

Addictological – related to addictive behavior. Association – connection, link. A relationship between mental contents, such as ideas, concepts, feelings. These contents are connected according to associative laws. (Hartl, Hartlová, 2010). Behavioral therapy – a form of psychotherapy applying the principles of learning, operant conditioning, and Pavlovian conditioning to eliminate symptoms, to acquire desired reactions and patterns of behavior in place of undesirable ones. (Hartl, Hartlová, 2010). Coping strategies – strategies for managing stress. Depression – a mental state referred to as "morbid sadness." This state is characterized by prevailing feelings of sadness, dejection, indecisiveness, and a sense of increasing pressure. Concomitant phenomena include suppression and slowing of mental and physiological processes, loss of self-confidence, feelings of anxiety and apathy, as well as self-blame. It is a morbid condition. (Hartl, Hartlová, 2010). Depression is also understood as "dejection" in general. It is a mental disorder – a mood disorder. (Tisovičová, 2007). Deprivation (deprivational) – a state of severe long-term failure to satisfy vital psychological and social needs (stimuli, security, relationships, recognition); chronic need dissatisfaction; deficiency at the psychological level. Discontinuity – lack of continuity; disconnectedness; interruption. Distortion – a misrepresentation, skewing. Hypothesis – a theory, claim, assumption. Incongruent – not in accordance with inner conviction. Classical conditioning (behavioral theory) – gradual rooting of a certain reaction to a certain stimulus induced by repetition of a certain situation. (Matoušek et al., 2013). Cognitive distortion – distortion of perception, evaluation, and cognitive processes. Cognitive map – an internal mental image of the surrounding world (reality); includes essential features and connections related to previous experiences; influences decision-making, behavior, the system of knowledge and abilities. Cognitive restructuring (therapeutic method) – a method that helps to recognize negative automatic thoughts and correct cognitive distortions. This method is characterized by working with automatic thoughts through techniques that capture and correct cognitive errors. (Wright, Basco, Thase, 2008). Cognitive-behavioral theory (therapy) – a type of psychotherapy that emphasizes the role of thinking and attitudes in the client's feelings and behavior. It is based on learning and consists of sequential steps designed to eliminate symptoms. The most commonly used intervention techniques include assertiveness training, training in processing threatening situations, training in preventing cognitive distortions and erroneous cognitive beliefs in terms of jumping to conclusions and self-pity, training in desirable behavior, and others. (Hartl, Hartlová, 2010). Cognitive – relating to cognition; perceiving; evaluating; pertaining to cognitive processes. (Hartl, Hartlová, 2010). Comorbidity – the simultaneous occurrence of two or more disorders in the same individual, each potentially requiring different treatment. For example, dissocial personality disorder and alcohol addiction. (Hartl, Hartlová, 2010). Methodology – the science of methods of scientific inquiry. It is a "system of views on the principles, ways, methods, and possibilities of understanding the subject of a selected scientific discipline and methods of research (sociological, psychological, medical). Methodology in the humanities is currently focused on two approaches: qualitative and quantitative methodological approach. (Křivohlavý, 2006). Narcissistic vulnerability – reduced resilience to stressful situations, or overall personality vulnerability resulting from damage in early childhood related to parental behavior and family environment. It is also defined as a tendency to react to depreciation and disappointment with a significant loss of self-esteem. (Kohut; Rothstein; Spezzano in Busch, Rudden, Shapiro, 2006). Unconscious defense mechanism – referred to in foreign literature as the so-called "Ego-Defensive Mechanism." In psychoanalytic theory, it is a mechanism by which the individual defends their "self" against injury. This mechanism works unconsciously to preserve the integrity and intactness of the Ego against the destructive effects of instinctual and emotional impulses, in conflict situations, in feelings of guilt, fear, or resistance. Unconscious defense mechanisms can be various, including reaction formation, introjection, isolation, turning against the self, undoing, denial, projection, regression, sublimation, and repression. (Hartl, Hartlová, 2010). Observational conditioning (behavioral theory) – learning through imitation. (Matoušek et al., 2013). Operant conditioning (behavioral theory) – reinforcement of a certain type of behavior through positive and negative consequences, usually in the form of rewards and punishments. (Matoušek et al., 2013). Psychopathology – a field that deals with pathological mental phenomena, symptoms of mental disorders, and the classification of these disorders and borderline states. (Hartl, Hartlová, 2010). Predict (predictor) – to attribute some property or relationship. (Tisovičová, 2007). Primary environment – family environment. Rationalization – a type of defense mechanism that consists of a common way of explaining certain behavior or events. (Levenson et al., 2005; Kaščáková, 2007). Early maladaptive schemas – schemas formed in childhood as a result of negative and traumatic experiences and disrupted relationships. (Praško et al., 2009). Relapse – means the re-establishment of a diagnosis of dependence syndrome. Secondary environment – the environment of broader social relationships at the level of school, work, and society. Tension – strain, psychological pressure, inner restlessness. Vulnerability – susceptibility or increased sensitivity that are prerequisites for the development of a disease. (Hartl, Hartlová, 2010).

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