Sang-Keun Chung, et al. CASE REPORT A 36-year-old married man was admitted for his malada- ptive gambling behavior, suicide attempt, and depressive mood. He had taken over his father’s business and had worked successfully as the president of a ready-mixed concrete cooperation until he fell into gambling. This hap- pened when he lost more than 13 billion won (about 1.4 million US$) because of a downward trend in the stock market. He struggled and made every effort to recover his loss. When he went to a casino while vacationing with a friend, he gambled forty million won that he had, and he succeeded twice. Since that time, he began to visit the casino after finishing business early in the morning. The frequency of his visits increased rapidly, and he eventually visited this casino almost daily by the end of the year 2000. He played mostly ‘baccarat’ and rarely played slot machines or any other type of game. His family members and employees did not know about his repeated and maladaptive gambling behavior because he concealed it from them. As his gambl- ing continued, he lost money more frequently. However, he could not control his desire to recover all of his losses at once. As time passed, his financial losses continued to increase, and he lost not only part of his father’s property, but also fell into debt to his friends. He attempted suicide by hanging himself in his house in the autumn of 2001, at which point his family became aware of his maladaptive gambling behavior. His gambling behavior continued for more two years, and his suicidal thoughts, attempts, and depressive mood caused his mother and brother to take him to the Depressive Disorder Clinic, Department of Psychiatry, Chonbuk National University Hospital, Jeonju, Korea. He was voluntarily admitted to the psychiatric ward at Chon- buk National University Hospital in February 2002. There were no psychiatric disorders including patholo- gical gambling, substance abuse, or depression among his family and relatives. In the first interview after admission, he appeared physically healthy, but somewhat tense and confused by his abrupt admission. He felt guilty about his gambling behavior, especially toward his parents, In an unreasonable belief, however, he insisted that he could regain his gambling losses by gambling again. He had not been addicted to alcohol or other substances and demonstrated no other impulsive behaviors (e.g. sexual, aggressive). However, he was a heavy smoker at two packs a day. Immediately after admission, his laboratory results were found to be in the normal range; complete blood count (CBC), liver function test (LFT), urine analysis, thyroid function test (TFT), venereal disease research laboratory (VDRL) test, electrocariogram (EKG), chest X-ray, and other routine laboratory tests. His blood pressure was 130/80 mmHg; and respiration and other physical findings Fig. 1. fMRI before fluvoxamine administration. This figure shows the difference between the activation and resting conditions. The brain is generally activated, especially in both parietal regions and the occipital, and frontal regions. Fig. 2. fMRI one week after fluvoxamine administration. The figure shows the difference between the activation and resting conditions. There is no activated region in the occipital and temporal areas. There were activated regions in both frontal (right: Brodmann’s areas 6, 5, and 4; left: Brodmann’s areas 6, 4) and both parietal (right: Brodmann’s area 7; left: Brodmann's areas 7, 19) lobes. were in the normal range. Without any medication, he was examined for mood, thought, behavior, and craving for gambling one week after admission. He had a score of 10 in the Korean South Oaks Gambling Screening (KSOGS),7 and a score of 18 in the Gambling Symptom Assessment Scales (GSAS). According to the DSM-IV-TR, he met the criteria for pathological gambling. He did not meet the DSM-IV-TR criteria for major depressive disorder, but he met the criteria for dysthymic disorder. Baseline imaging was obtained by fMRI on the seventh day after admission (Fig. 1). On the eighth day, fluvoxamine (50 mg/day) was prescribed for him with no concomitant mediations. In the three weeks after admission, the dose of fluvoxamine was raised to 200 mg/day and maintained during a follow-up period; there were no significant adverse 442 Yonsei Med J http://www.eymj.org Volume 50 Number 3 June 2009