Wednesday, October 26, 2016

Criteria OCD, DSM-5

Specific Obsessive Compulsive Disorder Criteria

The physician or mental health professional will determine whether you meet the specific obsessive compulsive disorder criteria listed in the DSM-5, during the psychological evaluation portion of your visit. Your symptoms must meet both the general and specific characteristics of obsessive compulsive disorder.
To receive an OCD diagnosis, you must meet these general criteria:
  • You must have obsessions and compulsions
  • The obsessions and compulsions must significantly impact your daily life
  • You may or may not realize that your obsessions and compulsions are excessive or unreasonable
Your obsessions must meet specific criteria:
  • Intrusive, repetitive and persistent thoughts, urges, or images that cause distress
  • The thoughts do not just excessively focus on real problems in your life
  • You unsuccessfully try to suppress or ignore the disturbing thoughts, urges, or images
  • You may or may not know that your mind simply generates these thoughts and that they do not pose a true threat
Your compulsions must meet specific criteria:
  • Excessive and repetitive ritualistic behavior that you feel you must perform, or something bad will happen. Examples include hand washing, counting, silent mental rituals, checking door locks, etc.
  • The ritualistic compulsions take up a least one hour or more per day
  • You perform these physical rituals or mental acts to reduce the severe anxiety caused by the obsessive thoughts.

DSM 5 Criteria Tourettes

Diagnostic Criteria
Note: A tic is a sudden, rapid, recurrent, nonrhythmic motor movement or vocalization.

Tourette’s Disorder 307.23 (F95.2)
A. Both multiple motor and one or more vocal tics have been present at some time during the illness, although not necessarily concurrently.
B. The tics may wax and wane in frequency but have persisted for more than 1 year since first tic onset.
C. Onset is before age 18 years.
D. The disturbance is not attributable to the physiological effects of a substance (e.g., cocaine) or another medical condition (e.g., Huntington’s disease, postviral encephalitis).

Persistent (Chronic) Motor or Vocal Tic Disorder 307.22 (F95.1)
A. Single or multiple motor or vocal tics have been present during the illness, but not both
motor and vocal.
B. The tics may wax and wane in frequency but have persisted for more than 1 year since first tic onset.
C. Onset is before age 18 years.
D. The disturbance is not attributable to the physiological effects of a substance (e.g., cocaine) or another medical condition (e.g., Huntington’s disease, postviral encephalitis).
E. Criteria have never been met for Tourette’s disorder.
Specify if:
With motor tics only
With vocal tics only

Provisional Tic Disorder 307.21 (F95.0)
A. Single or multiple motor and/or vocal tics.
B. The tics have been present for less than 1 year since first tic onset.
C. Onset is before age 18 years.
D. The disturbance is not attributable to the physiological effects of a substance (e.g., cocaine) or another medical condition (e.g., Huntington’s disease, postviral encephalitis).
E. Criteria have never been met for Tourette’s disorder or persistent (chronic) motor or vocal tic disorder.
The “motor tics only” or “vocal tics only” specifier is only required for persistent (chronic) motor or vocal tic disorder.

Monday, October 24, 2016

Grade A paper Owning Mahowney

 Dan Mahowny, recently promoted to assistant bank manager, is initially depicted as an unassuming stable man. To celebrate, his girlfriend suggests dinner out but this staid character responds that he does not want to get all “crazy” and spend more than $30. The ribbing from his coworkers about his modest suit is taken lightly, so at this point we believe Mahowny to be a frugal man. Rather quickly, scenes unfold to show us that he may be thrifty in some ways but not when it comes to his gambling hobby. Mahowny is approached at his office by loan sharks looking to collect the $10,300 that he owes. Troubled by his visitors threat of shutting him down due to his debt, he lies to his administrative assistant as to the unsavory looking visitors’ identity (some bozos looking for a loan) and sits down to write out a false application for a new loan. From his hesitancy it appears this is the first time he has committed the fraudulent act. This points to one of the required four or more symptoms listed by the DSM-5 to diagnose a gambling disorder, that of lying “to conceal extent of involvement”. This lying will become a common theme aimed at everyone from girlfriend to employees to personal friends and ultimately even to police. A second criterion, “relying on others to provide money to relieve desperate financial situations caused by gambling” follows quickly as Mahowny increases the loan by $15,000 cash when his loan shark expresses that he doesn’t want to do business with him anymore. The shark says it so sadly with a sigh; he knows Mahowny doesn’t have the money himself and may be forced to compromise morals to continue gambling. Sweating and clearly stressed, Mahowny arrives in Atlantic City to hit the craps table. He calls Belinda, the girlfriend he was supposed to move into his home that weekend, and lies when he tells her he has to work. Mahowny has now jeopardized both his job and a significant relationship to satisfy his need to gamble. This fulfills another of the DSM’s criteria related to gambling disorder. In the casino we see that this man takes his gambling very seriously. Mahowny does not look around, instead keeping a laser-like focus on the proceedings set out before him. He does not drink and does not appear to be having fun. Yet something drives him to barrel ahead even as he loses nearly all of the $15,000, returning home with only $500. When his girlfriend asks “did you win?” he evasively responds “I came home with $500.” The question asked, along with his girlfriend’s easy going acceptance of his absence, indicates that Belinda is already onto Mahowny’s condition and may even be acting as an enabler. Next we see Mahowny at work picking up a cash loan for his client. The client has requested $200,000 yet Mahowny increases the amount to $300,000. This extra $100,000 headed for the tables gives us a fourth criterion from DSM’s list and four is the magic number. Mahowny “needs to gamble with increasing amounts of money to achieve desired excitement”. We now know that he can legitimately be diagnosed as having a gambling disorder. The phrase “achieve desired excitement” seems somewhat obscure when applied to Mahoney as his demeanor is extremely low-key nearly always. His voice is hushed and steady, and he walks with a steady gait generally keeping to himself. His calm provides proof for us that his gambling behavior is not due to a manic episode which would disqualify the DSM diagnosis. Almost serendipitously, his friend suggests that they visit Atlantic City. This provides Mahowny the opportunity to fulfill another criterion which states the gambler “after losing will return another day to get even”. Chasing his losses is a bit sweeter this time. Upon his arrival with the stolen $100,000 the casino manager upgrades his room to a lavish suite and provides him with personal service. What the manager understands well is that addicted gamblers will gamble to the bitter end if you can get them to stay. Mahowny tries to cover himself somewhat by handing off $40,000 of the money to his friend with instructions not to give it to him later no matter what happens. It isn’t long before he comes for the last of his money, calling his friend a “curse” and yelling at him to just give him the money and stay away from him. This is a good representation of the DSM symptom of becoming “restless or irritable when attempting to cut down or stop”. Mahoney loses all at the table and it is time for him to leave the casino. Despite attempting somewhat to make amends with his friend who has been hanging out up in the suite the whole time, it is clear Mahoney is rather alone in his illness. Back at work, things are escalating and Mahowny is preoccupied with thinking of new ways to get money with which to gamble, another symptom noted in the DSM. He is shown buying and selling other people’s bonds and convincing his boss to provide an unauthorized increase on his biggest client’s account. Although his assistant seems a little suspicious about a “phantom” customer of his, for the most part no one at work suspects any wrong doing on his part. He is working them well with plausible explanations to get around the bank’s safeguards and this highlights just how secretive his inner life has become. As Mahowny’s embezzlement rises, so does the risk in other parts of his life. People are watching him. The police now have his name through information acquired when wiretapping Mahowny’s bookie. Atlantic City monitors his activity in the casino when he brings his girlfriend to Vegas. At some point he is up one million dollars and the east coast casino wants him to bring his winnings back into their venue. He leaves Belinda to fend for herself on what she believed would be a romantic weekend possibly culminating in marriage. Upon his return home, Belinda confronts him about his gambling which he tries to brush off as a financial problem. Still the enabler and clueless about the extent of his problem, she offers him the few thousand dollars that she has put away. The movie seems to speed up as Mahowny tap dances his way around his problems. The bank is undergoing an audit and the phantom account has been caught as having no verification for the loan. When told the audit will not pass, Mahowny calmly replies that the loan was paid off just that day and the auditors accept his word. His deception must now be weighing heavily upon him yet instead of pulling back, Mahoney heads off to the airport with abundant cash. “Gambling when feeling distressed” is another DSM symptom indicating a gambling disorder. At the airport, cash is flashed and this raises the suspicion of security employees. He makes it out the door where a private driver talks him into forgoing the wait for a cab and taking his service instead. A stop in a seedy area of town scares him into thinking he will be robbed and he steals the car to speed away. Mahowny heads straight to the casino where, instead of relating his fear to his gambling addiction, he simply decides he will not carry cash anymore. Being a good customer of the Atlantic City casino, the establishment works out a way for him to wire his money directly to them. Upon arrival he can collect chips and head straight for the tables. They even work out a way for him to do the same when traveling to Vegas. These elaborate measures that Mahowny must now go through in order to continue to gamble seem outrageous. It seems he will go to any lengths to feel the high he receives when placing bets. Even as danger seems to be getting ever closer to Mahowny, events at the bank enable him to tap into a no limit open line of credit belonging to his client. The police are now actively following him as they believe the amount of money changing hands at the airport must be a sign of drug ring activity. In a somewhat humorous moment, we see Mahowny argue the cost of a $5 duffle bag that he needs to purchase in order to carry his money. Even as he is acquiring and losing outrageous sums of money, he still has occasions that bring out his frugal nature. Although this seems not to make sense, it actually points out that money put up for gambling is somehow not the same to him as money earned and spent in day to day life. As he continues the rise to betting $70,000 poker hands in Atlantic City, he is able at one point to “bust” the table thus taking all the winnings. The personal assistant assigned to him by the casino tries to talk him into walking away with his winnings. There is an interesting moment as Mahowny is sitting at the table with nine million dollars in winnings piled in front of him. He looks up and in a moment of depersonalization he sees himself standing across the table looking back at him. Mahowny is no longer himself it seems and he has completely become his disorder. Even now, he cannot move into the light; this amount of money could pay all his debt back, likely with plenty left over. Unfortunately, the descent into self destruction is somehow internally rewarding, and in true addictive behavior he simply cannot stop. As the crowd watches practically in horror, he loses every cent. The movie continues with Mahowny literally losing everything: his money, his girlfriend, even his car breaks down. And, in that moment, he is surrounded by police and arrested for fraud and theft. Even now, charged with stealing 10.2 million dollars, Mahowny denies he has a gambling disorder, instead defining the situation as a financial problem. The movie ends with Mahowny seeming to realize that he has hurt others such as the 13 coworkers fired at the bank for their unintentional involvement in the crime. The story is then tied up neatly with a scrolling paragraph telling the viewer that Mahowny spent 6 years in jail, married his girlfriend, and has had wages garnered ever since. Whether or not this film does an excellent job in the portrayal of the true events that took place for the person this movie was based upon can only be assessed by that man himself. An online search reveals no information that would suggest any criticism of the accuracy of the screenplay. The movie did offer an excellent portrayal of an individual suffering from gambling disorder and is a true textbook example according to DSM-5’s criteria. It was easy to see all but one of the symptoms listed, that which reads the afflicted person “has made repeated unsuccessful efforts to control, cut down or stop”. The actor, Philip Seymour Hoffman, did an outstanding job representing the descent into addiction’s self-destruction much like the characters in the film Days of Wine and Roses depicted addiction to alcohol. A welcomed difference in this film is that it lacked the Hollywood glamour of Days of Wine and Roses which only made Hoffman’s character seem even more authentic. If forced to come up with at least one area the movie perhaps did not do well, this reviewer would only be able to point to the neat wrap-up at the close. Although Mahowny did pay a harsh price for his addiction through incarceration, the movie did not in any way allude to the difficulty one goes through trying to quit their addiction or address the fact that it is a chronic disorder. The ending statement that Mahowny never placed a bet again might make some viewers believe it was sudden and easy for him to quit the habit. This possible misrepresentation does not give nod to the great difficulty usually encountered when an individual attempts to override their brain’s pleasure center and quit their addiction. However, this movie was subtle in many ways and perhaps even this point was made when, in therapy, Mahowny is asked what level of thrill he received from gambling on a scale of 1 to 100. His response? “100” The biggest thrill ever received outside of gambling? “20” All in all, the movie Owning Mahoney accurately and more than adequately provides proof that its main character suffers from a gambling disorder as defined by DSM-5.

Monday, October 17, 2016

Example of Grade A paper for Mr Jones

The Depiction of Bipolar Disorder I in Mr. Jones

The film Mr. Jones presents the audience with a portrait of bipolar disorder I in its titular character as he experiences the highs and lows of the disorder, as well as the effects of treatment. Richard Gere inhabits the character with, what seemed to this writer, a strong understanding of how such an individual would interact with the world. The movie also deals with the interaction between Mr. Jones and psychiatrist Dr. Elizabeth Bowen, portrayed by Lena Olin, who encounters him in treatment. This essay will consider the presentation of bipolar disorder I in Mr. Jones from the perspective of a Psychology student, and attempt to evaluate the accuracy of the symptoms presented, any inaccuracies, and what the film could have done to improve its depiction of the illness. The two main symptoms of bipolar disorder I, mania and depression, both clearly on display in the film, will each be evaluated, and a subsequent paragraph will offer evaluation of additional elements germane to the character’s diagnosis. Finally, the essay will conclude with a summary of this writer’s evaluation, as well as further thoughts on the presentation offered by the film, and how it may affect the audience’s perception of individuals with bipolar disorders.
Before turning to the evaluation of how Mr. Jones portrays mania and depression, it may be helpful to outline the symptoms of each. Mania can include exaggerated euphoria (feelings of exceeding happiness and/or contentment), irritability (up to and including aggression and agitation), distractibility (lacking capacity to focus attention on an activity for any sustained length of time), insomnia (including high energy state), grandiosity (expressing immense self-esteem, sometimes to the point of delusions of celebrity or godhood), flight of ideas (racing thoughts), increased activity (increased intensity in goal pursuit related to work, school, social, and/or sexual activities), rapid speech, and poor judgement (engaging in high-risk activities, usually pleasure oriented, that can lead to social and professional ramifications, and, in some cases, life threatening behavior). Due to the positive feeling engendered by many of these symptoms, individuals with bipolar disorder I often view their manic periods favorably, which can be a challenge in treatment. Symptoms of depression, meanwhile, include sadness, fatigue (or diminished energy), sleep problems (such as insomnia, excessive sleep, and/or poor sleep), appetite changes, loss of concentration and decision making ability, agitation (or high sedation), low feelings (such as guilt, pessimism, lack of self-confidence, and/or lack of self-agency), anhedonia, and suicidality. Nearly all the symptoms for mania, and many for depression, can be found in Gere’s character over the course of the movie.
Mr. Jones opens the movie as a seemingly exuberant individual riding his bike to a construction job. Very quickly, however, it becomes clear that he is in the midst of a manic episode. Over the course of the film, Gere’s character spends much of his time manic, and ticks off nearly every symptom by the end. The opening sequence can be viewed as one demonstration of exaggerated euphoria, once one is aware of the character’s diagnosis. Others include his mood while working on the roof, and even when he’s up on the beam, when he is released from the hospital for the first time and is talking to Dr. Bowen, afterward when he does a little dance and sings, in the piano store, at the concert he eventually interrupts, when Dr. Bowen agrees to buy him food and on the dock while they’re talking, and finally again at the end of the movie when he goes to get his tools at Howard’s house. In contrast with the many displays of euphoria, Mr. Jones’ irritable moments are few and far between. The first comes when he is strapped to the bed after interrupting the concert. In the scene he gets agitated and angry with the doctors, yelling at them at one point. Another seems to come during a ping-pong game while he is in treatment, but potentially skipping meds. This incident is quickly followed by a verbal explosion at a nurse trying to give him meds, knocking over her tray, and later by a verbal altercation with Dr. Bowen before checking himself out. It is never made clear if he is, in fact, off his meds and in a manic episode during this period.  The lack of clarity of the inpatient portion of the movie will be discussed at greater length in a later paragraph. The final incidents of irritability come during a clear manic episode at the end of the movie. The first occurs when he is walking down a street, looking upset, kicks a garbage can and yells at a shop keeper. The second when he yells at Howard after showing up at his house.  Distractibility is another symptom that is infrequently, but clearly, depicted. His distraction on the job site at the beginning of the movie is probably the most obvious manifestation of this symptom in the movie. He gets distracted by an airplane mid conversation, and again while working, and bounces from conversation to work to singing. Other instances where Mr. Jones displays distractibility, albeit less clearly, include in the piano store and, later in the movie, when he is walking down the street in an agitated mood. One symptom of mania that is not truly depicted in the movie is insomnia, although it could be argued that his general high level of energy during his manic periods fall under this category, and there is a moment when he’s strapped to the bed that he tells them he won’t sleep. Grandiosity, on the other hand, is on full display throughout the manic episodes in the movie. At the beginning of the movie he shows up for a job he doesn’t have and, when the foreman tells him they don’t need more workers, Mr. Jones claims he can do twice the work of any other worker, that he is a ‘precision machine’, that it would be a huge mistake not to hire him, and that in three days he’ll have the foreman’s job. Other points of grandiose behavior in the movie include his initial attempt to ask Dr. Bowen out, his seduction of the bank teller, his attempt to conduct the orchestra at the symphony, in a portion of his interaction with the doctors when he’s strapped to the bed, in court his self-representation could be considered grandiose, not to mention that he literally states that he is grandiose in the courtroom and argues he could have done a better job as conductor, and finally in his discussion with Harold at the end of the film. Flight of ideas is a bit trickier to discern, but it could be argued that he is experiencing the symptom when he is walking out on the beam at the construction site talking about angles and trying to calculate how to fly. Another scene that seems to show a fast changing flow of thoughts is when he is strapped to the bed after interrupting the symphony. One final example might be his final conversation with Howard and his son. In contrast, increased activity is easily found in Mr. Jones. From his initial pursuit of the carpentry job, to his seductions of both Dr. Bowen and the bank teller, to his fixation on his tools, Mr. Jones exhibits goal driven behavior on multiple fronts. Even his fixation on trying to fly could be seen as tangentially related to this symptom, given his determination, though it fits much more readily into poor judgement, as discussed later. Rapid speech can also be easily found during Mr. Jones’ periods of mania. He displays it when talking with Dr. Bowen outside the hospital after his initial release, again when he is strapped to the bed after the concert interruption, and finally when talking to Howard from the motorcycle near the end. The last symptom of mania on display in the film is poor judgement related to high-risk activities which usually involve the pursuit of pleasure. This symptom features heavily in both of the clearly manic episodes in the movie. His attempts at flight serve as bookends to the narrative, and obvious examples of this behavior. He also exhibits poor judgement when he hands out excessive amounts of money, withdraws what appear to be his savings from the bank, asks out the teller, and goes on a spending spree, including the purchase of a piano, when he asks out his doctor, when he gets on stage at a concert, and finally when he steals the motorcycle at the end. It could also be argued that he is exhibiting poor judgement when he represents himself in court, although, as indicated above, that may fall more in line with grandiosity. All in all, Mr. Jones presents a well-rounded, and fairly accurate picture of what manic episodes can entail. The main difficulties this writer had with the film were not with the clear cut episodes of mania in the film, and will thus be discussed in later paragraphs.
Like mania, depression has a clear presentation in the character of Mr. Jones. Unlike mania, the depiction does not hit nearly every symptom, nor are the symptoms shown repeated as frequently. However, they do present a convincing picture of an individual in deep depression. It begins quietly, with a Mr. Jones displaying a muted mood and a lack of focus at Howard’s dinner table. His lack of concentration is such that he is unable to help Howard’s son with long division after the dinner, and he gets slightly agitated. The next scene finds him walking lethargically thorough a music conservatory, indicating fatigue, and at one point getting somewhat agitated. After that the viewer sees him unkempt, unshaven, and distracted to the point he walks into traffic. In his unwashed, unfocused, and uncaring state he is also exhibiting signs of anhedonia. When he returns to his apartment to find Dr. Bowen, he admits he can’t stop being sad. Once he is back in the hospital, he initially continues to display the flat affect commensurate with anhedonia. He also admits to an episode of suicidality in his past, although that symptom is not on display during this depressive episode. In total, he seems to display sadness, fatigue, loss of concentration and decision making ability, agitation, anhedonia, and he references a period of suicidality in his past. It could also be argued that he is experiencing low feelings, based on his demeanor, but it is not explicit. Given the relative brevity of this paragraph, compared with that on mania, the reader may reach the conclusion that depression was not as well represented in the film. In terms of length and depth of depiction, that would be an accurate conclusion. However, what is shown is a fair, and somewhat poignant representation when cast against the extremes that precede, and eventually follow it during Mr. Jones’ mania. While the depiction could have been done in more depth, and covered more of the symptoms of depression, on the whole it seemed a well done portrayal. It is possible that the reasons for the fairly brief representation could be related to the overall issues this writer had with the move, and will be discussed in the following paragraphs.
Depictions of both mania and depression throughout the movie lend themselves nearly perfectly to the initial diagnosis of bipolar disorder I, which requires that the individual experience at least one clear episode of mania lasting at least seven days, and almost always also includes periods of depression. The qualifier of ‘nearly’ relates to one of the main, negative critiques this writer had of the film, having to do with Mr. Jones’ time as an inpatient, the lack of clarity both of timeframe and some symptomatology, and the love story. Beginning with the lack of clarity, the indeterminate length of time between many of the scenes made it difficult to determine the length of Mr. Jones’ mania and depression, as well as the speed at which they reoccurred. This is the only source of uncertainty with the initial diagnosis. It also seemed to this writer that he may have had a subtype of bipolar disorder I referred to as rapid cycling, but it is tough to tell. Given that rapid cycling is more prevalent in bipolar disorder II, and found more often in women, this writer would be hesitant to make a firm determination based on what is presented in this movie. The depiction of his stay in the mental hospital also adds to the difficulty determining for or against. It seems as though he may reenter a period of mania during his stay due to non-compliance with the drug routine, but it is never clearly established. It occurs to this writer that perhaps the clarity of the depiction of bipolar disorder I fell apart somewhat in the latter half of the film in service to the drama and build-up of the romance, and its consequences. Another aspect of symptomatology that remained somewhat unclear throughout the film was that of auditory hallucinations. If present, they would indicate the addition of ‘with psychotic features’ to the diagnosis. They are referenced in his initial intake, and potentially depicted when he is in the conservatory, near the beginning of his depressive episode, but they are never addressed directly. The love story, and the end of the film, are not just objectionable based on their depiction of a dramatically unprofessional relationship, but also in the disservice they do to the rest of the portrayal. It is not outside the realm of possibility for a doctor to have an inappropriate relationship with their patient, though it is perhaps not as romantic as the writers thought it would be when viewed from the perspective of someone intending to become a clinician. The way they end the movie is somewhat facile and unrealistic. It would have, perhaps, been more realistic, if darker, to have Gere’s character truly attempt to fly. That aside, his moment of transformation as the plane passes seems to transition him from full-blown mania to an even temperament instantaneously, letting the movie end on a happy note. This seems somewhat disingenuous after an otherwise fairly accurate portrayal. To the movie’s credit, it does present the effects of the medications used to treat bipolar disorders correctly, as well as the difficulty many patients experience maintaining a regular schedule of said medications.
Overall, Mr. Jones provides the viewer with a fairly accurate picture of how some individuals experience bipolar disorder I. While it has its failings, chiefly the fuzziness of the timeline and the ending, it should leave the viewer with a better understanding of what a diagnosis of bipolar disorder I means. One change that might have improved the movie would be to switch the focus from the romance between Dr. Bowen and Mr. Jones to fuller pictures of some of the other patients in the hospital. In particular, the patient who commits suicide near the end of the film could have served as an interesting contrast to Mr. Jones, had she been more fully realized. Criticisms out of the way, the one truly mesmerizing element of the film is Richard Gere’s inhabitation of the disorder. When he is allowed to portray it clearly, he does so with commitment and pathos. His performance makes the movie.

Wednesday, October 5, 2016

DSM 5 Criteria for Pathological Gambling

DSM­5 Diagnostic Criteria: Gambling Disorder * For informational purposes only

 * A. Persistent and recurrent problematic gambling behavior leading to clinically significant impairment or distress, as indicated by the individual exhibiting four (or more) of the following in a 12­month period:

 a. Needs to gamble with increasing amounts of money in order to achieve the desired excitement.
 b. Is restless or irritable when attempting to cut down or stop gambling.
 c. Has made repeated unsuccessful efforts to control, cut back, or stop gambling.
d. Is often preoccupied with gambling (e.g., having persistent thoughts of reliving past gambling experiences, handicapping or planning the next venture, thinking of ways to get money with which to gamble). 
e. Often gambles when feeling distressed (e.g., helpless, guilty, anxious, depressed).
 f. After losing money gambling, often returns another day to get even (“chasing” one’s losses).
 g. Lies to conceal the extent of involvement with gambling. 
h. Has jeopardized or lost a significant relationship, job, or educational or career opportunity because of gambling. 
i. Relies on others to provide money to relieve desperate financial situations caused by gambling.

 B. The gambling behavior is not better explained by a manic episode.