Pathological Gambling (312.21)

DSM-IV-TR criteria:

• A. Persistent and recurrent maladaptive gambling behavior as indicated by five (or more) of the following:
  • (1) is preoccupied with gambling (e.g., preoccupied with reliving past gambling experiences, handicapping or planning the next venture, or thinking of ways to get money with which to gamble)
  • (2) needs to gamble with increasing amounts of money in order to achieve the desired excitement
  • (3) has repeated unsuccessful efforts to control, cut back, or stop gambling
  • (4) is restless or irritable when attempting to cut down or stop gambling
  • (5) gambles as a way of escaping from problems or of relieving a dysphoric mood (e.g., feelings of helplessness, guilt, anxiety, depression)
  • (6) after losing money gambling, often returns another day to get even (“chasing” one’s losses)
  • (7) lies to family members, therapist, or others to conceal the extent of involvement with gambling
  • (8) has committed illegal acts such as forgery, fraud, theft, or embezzlement to finance gambling
  • (9) has jeopardized or lost a significant relationship, job, or educational or career opportunity because of gambling
  • (10) relies on others to provide money to relieve a desperate financial situation caused by gambling
• B. The gambling behavior is not better accounted for by a Manic Episode.

Associated features

Pathological gambling (PG) is characterized as a chronic, progressively maladaptive, impulse control disorder that is distinguished by continued acts of PG despite compounding severe negative consequences. Individuals who suffer from PG often have problematic interpersonal relationships. These relationships become increasingly strained during the progression of the disorder. In one extreme, individuals with PG may try to legally finance gambling and living expenses through loans. To a higher extreme, individuals may also commit illegal acts such as forgery, fraud, theft, or embezzlement in order to gain financing.There is evidence to support comorbidity of PG and alcohol and depression. A 1992 study showed that 12.9% of heavy drinkers had a gambling problem as compared to 5% of nondrinkers. Comorbidity rates of PG and major depressive disorder can reach as high as 76%. Other associated features of PG include: unemployment, substance abuse, and suicide attempts. Most pathological gamblers tend to deny their problem and therefore do not get help. The South Oaks Gambling Screen (SOGS) is a very common and validated tool used to assess gamblers. Associated features also include repetitive behaviors which shares features with obsessive compulsive disorder.

Child vs. adult presentation

Historically, PG has been stereotyped as an adult disorder, but with the vast growth of casino expansion and the creation of internet gambling, adolescent rates of PG have superseded adult prevalence rates by two to four times. According to a 2006 Adolescent Psychiatry article written by Timothy W. Fong, gambling is a media-driven, socially acceptable form of behavior. Fong also states that 86% to 93% of all adolescents have gambled for money at least once, 75% of those did it within the confines of their home, while 85% of parents did not care. He states that adolescent gambling is the most popular risk taking behavior seen in adolescents, trumping cigarettes, alcohol, drugs, and sex. The reasons why adolescents start gambling vs. reasons why adults start gambling are very different. Adolescents start because: it is a form of excitement and relief of boredom, a need to keep playing for spectator success, use gambling as a coping mechanism or relief from daily stress, and lastly, it is a socially acceptable form of competition.

Gender and cultural differences in presentation

More men are typically diagnosed with pathological gambling than women, and men tend to start sooner. The gender ratio is 2:1 with men being twice more likely than women. Culturally, PG is more prevalent in minority groups. Socioeconomic status also strongly correlates to PG and it is more prevalent in the lower class, who cannot afford to gamble. Pathological gambling affects 2%-5% of Americans, where symptoms and means of gambling vary.

Epidemiology

As gambling facilities become more prevalent, so do PG prevalence rates. In fact, 2 million Americans are considered to be pathological gamblers, with another 3 million considered being “problematic gamblers,” and 15 million more considered to be at risk. There is a 4% prevalence rate in America, while prevalence rates vary in other countries. Worldwide rates vary from 2% to 6%. Gambling usually begin in early adolescence in men, and from ages 20-40 in women.

Etiology

• The causes do not seem to be biologically related due to the lack of evidence. A psychological cause, however, is more likely. A pathological gambler typically has symptoms of depression or alcoholic tendencies. They usually turn to gambling to get the “high” of winning to escape from everyday problems or more serious life problems.
• PG is consistently associated with blunted mesolimbic-prefrontal cortex activation to nonspecific rewards, whereas these areas show increased activation when exposed to gambling-related stimuli in cue exposure paradigms. Very little is known, and hence more research is needed regarding the neural underpinnings of impulsivity and decision making in PG (van Holst, van den Brink, Veltman, & Gourdriaan, 2010).

Empirically supported treatments

• Treatment consists of therapy. He/she must first realize that they do indeed have a problem and that they need help. Announcing this to friends and family is usually best. Treatment is based on behavior changes. The counselor will usually start by uncovering the underlying cause of the gambling addiction. If the patient is depressed then the depression is treated accordingly. For the 85% who stay in treatment, it is successful. On average, however, 50% drop out. Aversion therapy is an option. Here the patient is exposed to the stimulus while also being exposed to something that would cause them discomfort. Treatments usually try to help the patient overcome their impulses and learn to control urges. Also, the gambler must learn to overcome the illusion that they will “win the next time.” There are also self-help groups like gamblers anonymous that the patient can join. Groups for the family like Gam-Anon are also available. It is often recommended that he/she never return to gambling. It is also recommended that he/she does not return even to the places that they have gambled. Returning could cause a relapse. Medications such as antidepressants and opioid antagonists (naltrexone) may help also.
• Includes schizophrenia, mood problems, antisocial personality disorder, alcohol, or cocaine addiction.
• Brief intervention, motivational interviewing and cognitive and behaviour therapy are effective treatments. Treatment could be delivered in individual or group-format. Most studies proposed abstinence-based treatments (Khazaal, 2010).

Dsm5 Proposed Changes

The work group has proposed that this diagnosis be reclassified from Impulse-Control Disorders Not Elsewhere Classified to Substance Related Disorders which will be renamed to Addiction and Related Disorders

Disordered Gambling:

• A. Persistent and recurrent maladaptive gambling behavior as indicated by five (or more) of the following:

1. is preoccupied with gambling (e.g., preoccupied with reliving past gambling experiences, handicapping or planning the next venture, or thinking of ways to get money with which to gamble
   2. needs to gamble with increasing amounts of money in order to achieve the desired excitement
   3. has repeated unsuccessful efforts to control, cut back, or stop gambling
   4. is restless or irritable when attempting to cut down or stop gambling
   5. gambles as a way of escaping from problems or of relieving a dysphoric mood (e.g., feelings of helplessness, guilt, anxiety, depression)
   6. after losing money gambling, often returns another day to get even (“chasing” one’s losses)
   7. lies to family members, therapist, or others to conceal the extent of involvement with gambling
   8. has jeopardized or lost a significant relationship, job, or educational or career opportunity because of gambling
   9. relies on other to provide money to relieve a desperate financial situation caused by gambling

• B. The gambling behavior is not better accounted for by a Manic Episode.

Rationale for Change:

• Pathological (disordered) gambling has commonalities in clinical expression, etiology, comorbidity, physiology and treatment with Substance Use Disorders
  Lowered Threshold for Pathological (Disordered) Gambling Diagnosis
• Several empirical studies have supported lowering the threshold for a diagnosis of pathological (disordered) gambling. Statistical analyses bearing on this issue are also in progress.

Eliminate Illegal Act Criterion for Pathological (Disordered) Gambling Diagnosis

The illegal act criterion of pathological (disordered) gambling has been shown to have a low prevalence with its elimination having little or no effect on prevalence and little effect on the information associated with the diagnosis in the aggregate.

Severity:

Recommendations for severity criteria for this disorder are forthcoming