Pathological gambling disorder

Pathological gambling disorder

Definition

Pathological gambling disorder occurs when a person gambles compulsively to such an extent that the wagering has a severe negative effect on his or her job, relationships, mental health, or other important aspects of life. The person may continue to gamble even after they have developed social, economic, interpersonal, or legal problems as a result of the gambling.

Description

Pathological gambling disorder is characterized by uncontrollable gambling well beyond the point of a social or recreational activity, such that the gambling has a major disruptive effect on the gambler's life. People who are pathological gamblers may lose their life savings, and may even commit crimes (stealing, embezzling, or forging checks) to get money for their "habit." Relationships and jobs may also be lost as a result of the disorder.

Pathological gambling disorder is an example of a process, or behavioral, addiction , as distinct from an addiction to such substances as food, drugs, tobacco, or alcohol. In process addictions, the characteristic "rush" or "high" comes from the series of steps or actions that are involved in the addictive behavior. With gambling, the "high" may be stimulated by the social atmosphere or group setting of the casino, race track, or bingo hall as well as by the excitement of risk-taking. Some gamblers have a "lucky" outfit, item of clothing, or accessory that they wear or take along when gambling; sometimes putting on the outfit or item in question is enough to start the "rush."

People with pathological gambling disorder may engage in many different types of gambling activities. These may include games of chance that are found in casinos, such as slot machines, card games, and roulette. Many of these games are now available on the Internet, the chief difference being that the bettor uses a credit card instead of cash or chips. Other gambling activities may include the state lottery, horse or dog racing, or even bingo. The person may place bets on the outcome of an election, baseball or football games, or even the weather on a particular day. Pathological gambling usually develops slowly over time; people tend to begin with acceptable levels of social or recreational gambling and slowly progress to pathological gambling. In most cases the disorder develops slowly over a period of years; however, there are cases of patients who gambled socially for decades and then began to gamble compulsively under the impact of a major life stressor, such as divorce or being laid off from work.

Causes and symptoms

Causes

There are no known biological causes of pathological gambling disorder. Some studies have found interesting differences between compulsive gamblers and the general population on the biological level, but none that are thought to be an actual cause of pathological gambling. Many people, however, have significant psychological causes for excessive gambling. They may use gambling as an emotional escape from depression; this pattern appears more often in females with the disorder than in males. Some people who are pathologic gamblers are seeking the mood alteration associated with gambling— specifically the excitement and energy that they find in the activity— more than the money involved. In other words, the person with the disorder is reinforced by an emotional "high" rather than by the money itself. Some researchers have found that males diagnosed with pathological gambling disorder were more likely to have been diagnosed with attention-deficit/hyperactivity disorder as children than males in the general population. Other researchers have described compulsive gamblers in general as highly competitive people who are restless and easily bored.

Other theories about the causes of pathological gambling emphasize cognitive distortions rather than mood problems. Pathological gambling has been associated with dysfunctional thinking patterns; many people with this disorder are highly superstitious or believe that they can control the outcome of events when they are gambling. Many people diagnosed with the disorder also have distorted beliefs about money, tending to see it at the same time as the source of all their problems and the answer to all their problems. Patients diagnosed with pathological gambling disorder have an increased risk of either having or developing histrionic, narcissistic, or borderline personality disorder .

One social change that has been linked with the rise in the number of adults diagnosed with pathological gambling disorder in the United States is the increased availability of legalized gambling.

Symptoms

The symptoms of pathological gambling include preoccupation with gambling activity, often to the extent of interfering with the person's occupational or social functioning. The person is often unable to control the gambling behavior, continuing to place bets or go to casinos in spite of attempts to cut back or stop. A common behavior in persons with pathological gambling disorder is "chasing," which refers to betting larger sums of money or taking greater risks in order to undo or make up for previous losses. The person may also lie about their gambling or engage in such antisocial behaviors as stealing, credit card fraud, check forgery, embezzling from an employer, or similar dishonest behaviors in order to obtain more money for gambling.

Demographics

More males than females in the United States are diagnosed with pathological gambling disorder; the sex ratio is thought to be about 2:1. Relatively few women, however, are in treatment programs for the disorder, most probably because of the greater social stigma attached to women who gamble. As a rule, men diagnosed with pathological gambling disorder began gambling as teenagers, whereas women tend to start compulsive gambling at a later age. Pathological gambling disorder tends to be more common in minority groups and in people with lower socioeconomic status. About 25% of people diagnosed as pathological gamblers had a parent with the disorder. People who smoke tobacco or abuse alcohol are more likely to have pathological gambling disorder than people who do not use these substances.

As many as 4% of the general population in the United States may meet criteria for pathological gambling disorder at some point in their lives. In some countries such as Australia the number is thought to be as high as 7%.

Diagnosis

Pathological gambling disorder is more likely to be diagnosed when the affected person's spouse or family becomes concerned than to be self-reported. Denial is common among persons with the disorder. The professional handbook, the Diagnostic and Statistical Manual of Mental Disorders , fourth edition, text revision, or DSM-IV-TR, specifies that the patient must have at least five of the following symptoms to meet criteria for the disorder:

• thinks about gambling all the time
• uses larger and larger amounts of money when gambling
• has tried to stop gambling but failed
• is moody or cranky when trying to stop gambling
• uses gambling as a way to escape problems
• keeps gambling to try to make back money that had previously been lost ("chasing")
• lies about the extent of gambling
• has tried to make money for gambling by engaging in illegal or immoral behavior
• has problems at work or home caused by the gambling
• relies on other people to get him or her out of financial problems caused by the gambling

Pathological gambling disorder is distinguished from social gambling, in which the person is typically socializing with friends, gambling for a limited period of time, and gambling with a limited sum of money that they can afford to lose. Pathological gambling disorder is also distinguished from professional gambling, in which participants limit their risks and discipline their behavior. Lastly, pathological gambling disorder must be distinguished from a manic episode ; in most cases, the distinguishing feature of the disorder is that the manic-like behavior disappears after the person leaves the gambling setting.

Treatments

There are a number of different treatments for pathological gambling disorder. Psychodynamic psychotherapy attempts to uncover any underlying psychological factors that trigger the gambling. For people who are gambling to escape, such as those who are depressed, this approach may be very successful. Treating any substance abuse problems that may coexist with the pathological gambling can also be helpful. Other types of treatments involve behavioral techniques used to teach relaxation and avoidance of stimuli associated with gambling. Aversion therapy appears to be successful in treating pathological gambling disorder in highly motivated patients with some insight into the problem, but is not helpful for patients who are less educated or resistant to behavioral methods of treatment.

Gamblers Anonymous, or GA, is a Twelve-Step program patterned on the model of Alcoholics Anonymous (AA). The gambler's admission that she or he does have a gambling problem and a willingness to go to meetings are considered the first steps in treating pathological gambling disorder. Looking realistically at what gambling has done to a person's life, and a willingness to work hard to stop gambling are also important parts of the GA program. People involved in this program are expected to attend meetings regularly, try to make amends for wrongs that their gambling has caused, and find a sponsor (usually of the same sex) to help them through the program. Gamblers Anonymous also expects that people who stop gambling to understand that they probably will never be able to gamble again socially, just as recovering alcoholics cannot drink socially.

Prognosis

There are very few statistics on the number of people successfully treated for pathological gambling disorder. Treatment for any underlying psychological disorders or substance abuses can be very helpful. Sometimes family therapy is recommended. Some types of relaxation or behavioral therapy can also be helpful. Gamblers Anonymous can help in many cases, although the program has a high dropout and recurrence rate. For many people, a combination of more than one of these approaches is probably the most effective. Even when a person has successfully stopped compulsive gambling, it is unlikely that he or she will ever be able to gamble socially again, or even spend time in places where he or she once gambled.

Prevention

Prevention of pathological gambling disorder is very difficult because it is impossible to predict when someone will react to gambling in a way that leads to compulsive gambling. If a person begins to feel, however, that he or she may have a problem, immediate treatment can prevent the development of a disorder that affects all areas of life and may have legal as well as economic consequences.

See also Internet addiction disorder; Self-help groups

Resources

BOOKS

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed., text revised. Washington D.C.: American Psychiatric Association,2000.

Forward, Susan, Ph.D., and Craig Buck. "Compulsive Gambling." Chapter 5 in Money Demons. New York and Toronto: Bantam Books, 1994.

Sadock, Benjamin J. and Virginia A. Sadock, eds. Comprehensive Textbook of Psychiatry. 7th ed. Vol. 2. Philadelphia: Lippincott Williams and Wilkins, 2000.

PERIODICALS

Emerson, Jim. "Gamblers." Direct 12, no. 8 (June 2000): 83.

Manisses Communications Group Inc. "Study Finds Other Psychiatric Ills Accompany Pathological Gambling." The Brown University Digest of Addiction Theory and Application 18, no. 7 (July 1999): 4.

Nicol, John. "Gambling It All Away: The Spread of Casinos in Canada is Posing a Threat to the Country's Growing Population of Seniors." Maclean's February 7, 2000:16.

ORGANIZATIONS

Gamblers Anonymous. P. O. Box 17173, Los Angeles, CA 90017. (219) 386-8789. <www.gamblersanonymous.org>.

Tish Davidson, A.M.