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Pathological Gambling Disorder

Definition

Description

Causes and symptoms

Demographics

Diagnosis

Treatments

Prognosis

Prevention

Resources

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 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

Pathological gambling is considered a brain disease similar to other disorders of addiction, like alcohol or drug addiction. The primary mechanism underlying the development and persistence of pathological gambling is the brain’s dopamine-based reward system, which is thought to underlie many disorders of addiction or impulse control. The central pathway involved is the mesolimbic pathway of dopamine signaling. This pathway exhibits alterations in dopamine levels or signaling in response to some substances, and a similar dopamine response is thought to underlie process addictions, including pathological gambling. The key feature in the brain involved in this process is the nucleus accumbens.

There also are, however, significant psychological factors that may contribute to excessive gambling, often associated with the common co-morbidities of pathological gambling, including depression and substance use disorder. People who are pathological gamblers 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 seek 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. People with this disorder exhibit many features in common with those who have substance use disorder, including the urge to engage in the behavior, mounting tension before engaging in the behavior,

relief or euphoria during the behavior, a return of the urge, and the presence of external cues that may trigger the behavior.

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. Studies show that proximity to a casino is associated with increased rates of pathological gambling in a population.

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 often cannot 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 his or her 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

About twice as many males than females in the United States are diagnosed with pathological gambling disorder. Relatively few women, however, are in treatment programs for the disorder, 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 and develop a gambling problem faster than men. 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 much 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 (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(GA) is a twelve-step program modeled after 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 GA. 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. GA also expects people who stop gambling to understand that they probably will never be able to gamble again socially, just as recovering alcoholics cannot drink socially.

Pharmacological treatments for pathological gambling and other process addictions are still being developed and explored. In studies reported thus far, the most effective pharmaceutical treatment has been opioid antagonists, such as naltrexone or nalmafene, possibly because of their effects on opioid pathways that interact with dopamine signaling pathways in the brain reward system. Treatment may also target co-morbidities of pathological gambling, such as using selective serotonin reuptake inhibitors (also known as SSRIs) if mood disorder or obsessive-compulsive disorder is present.

Prognosis

There are very few statistics on the number of people successfully treated for pathological gambling

KEY TERMS

Aversion therapy —An approach to treatment in which an unpleasant or painful stimulus is linked to an undesirable behavior in order to condition the patient to dislike or avoid the behavior.

Chasing —Betting larger and larger sums of money, or taking greater risks, in order to make up for money previously lost in gambling.

Denial —A psychological defense mechanism that reduces anxiety by excluding recognition of an addiction or similar problem from the conscious mind.

Dopamine —a neurotransmitter involved in the reward pathways in the brain

Process addiction —An addiction to a mood-altering behavior or series of behaviors rather than a substance.

Reinforcement —A term that refers to the ability of a drug, substance, or behavior to produce effects that will make the user want to take the substance or perform the behavior again.

Rush —The initial intensely pleasurable sensation experienced from injecting a narcotic or stimulant drug. The term has also been applied to the feeling of excitement experienced from the behaviors involved in process addictions.

SSRI —selective serotonin reuptake inhibitor

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, and there are no studies fully analyzing the benefits or efficacy of the program. For many people, a combination of more than one of these approaches may be 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. Given the role of proximity to available gambling in the development of the disorder, this factor may be a target in prevention.

See alsoInternet addiction disorder; Self-help groups.

Resources

BOOKS

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

Forward, Susan, Ph.D., and Craig Buck. “Compulsive Gambling.” Chapter 5. Money Demons. New York: 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 12.8 (June 2000): 83.

Manisses Communications Group Inc. “Study Finds Other Psychiatric Ills Accompany Pathological Gambling.” The Brown University Digest of Addiction Theory and Application 18.7 (July 1999): 4.

Grant, Jon E., JD, MD, M.P.H., Judson A. Brewer, MD, Ph.D., and Marc N. Potenza, MD, Ph.D. “The Neurobiology of substance and behavioral addictions.” CNS Spectrums 11 (2006): 924–30.

Lobo, Daniela S.S., MD, Ph.D., and James L. Kennedy, MD, F.R.C.P.C. “The genetics of gambling and behavioral addictions.” CNS Spectrums 11 (2006):931–9.

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.

WEB SITES

“Pathological gambling.” National Library of Medicine. <http://www.nlm.nih.gov/medlineplus/ency/article/001520.htm>

ORGANIZATIONS

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

Tish Davidson, A.M.
Emily Jane Willingham, Ph.D.

views updated

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.

views updated

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Gambling, pathological

Preoccupation with gambling and uncontrollable impulse to gamble, regardless of the problems caused in daily life.

The Commission on the Review of the National Policy Toward Gambling reported that 61% of the U.S. population engaged in some form of gambling. The group also estimated that there were 1.1 million compulsive gamblers in the United States. While for many people gambling is a form of harmless recreation, for others it is an uncontrollable and all-consuming pursuit, often eclipsing everything else in their life. Some gamblers borrow or steal money when their funds run out; some lose their jobs and homes; and in almost all cases, their relationships with family and friends are aversely affected.

Pathological gambling is defined as a pattern of repeated gambling and preoccupation with gambling. The term was not included in the American Psychiatric Association 's Diagnostic and Statistical Manual of Mental Disorders until 1980. Since then psychologists have proposed several theories as to why people gamble. For some, they state, it is a form of risk taking, which may be an inherent personality trait. For many others, it is the lure of a possible financial payoff. Psychologists are still unsure, however, why some gamblers become pathological gamblers. Some psychiatrists have proposed the "disease model," stating that, like alcoholism, gambling is a disease or a sickness of the mind. Behaviorists, on the other hand, see it as a learned, conditioned response . Because gamblers are reinforced intermittentlywinning one hand and losing the nextthey are motivated to keep playing until they receive a positive reinforcement . Various research studies have shown that any behavior that is tied to partial schedules of reinforcement are extremely difficult to stop.

Pathological gambling often begins in adolescence in males, and somewhat later in females. Individuals with this disorder often experience a progression in their gambling, becoming increasingly preoccupied with gambling, increasing the amounts wagered, and often continuing to gamble despite attempts to stop or control the behavior.

Unfortunately, pathological gambling is often difficult to treat, but there are several treatment options. Perhaps the most widely practiced treatment is group therapy , such as is found in Gambler's Anonymous. Pain aversion therapy has also been used, in which a electric shock is associated with gambling. In another therapy called paradoxical intention, the therapist orders the client to gamble according to a strict schedule, whether the gambler wants to or not.

See also Impulse control disorders

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gam·ble / ˈgambəl/ • v. [intr.] play games of chance for money; bet: she was fond of gambling on cards and horses. ∎  [tr.] bet (a sum of money) in such a way: he was gambling every penny he had on the spin of a wheel. ∎ fig. take risky action in the hope of a desired result: the British could only gamble that something would turn up. • n. [usu. in sing.] an act of gambling; an enterprise undertaken or attempted with a risk of loss and a chance of profit or success. DERIVATIVES: gam·bler / -blər/ n.

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gamble XVIII. prob. continuing †gamel (XVI) play games, sport, alt. (with assim. to -LE3) of †gamene, early form of GAME vb.