Pathological Gambling
What is Pathological Gambling?
Pathological gambling refers to the uncontrollable impulse to gamble, irrespective of the interference the behaviour has on the individual's life. It often results in disrupted relationships, financial problems, and/or criminal behaviour and yet the individual is unable to refrain. In contrast, "social gambling" is not characterized by this loss of control.
Official Criteria
Pathological gambling has only been classified as a psychiatric disorder since the 1980 publication of the DSM-III. Diagnosis currently requires that the behaviour cannot be better explained by a Manic phase of Manic-Depressive Disorder, and must show that 5 of the following criterion subset be present:
- pre-occupation with gambling
- repeated unsuccessful attempts to stop or slow down gambling
- irritability and restlessness during these attempts
- illegal acts to obtain money for gambling
- gambling to escape from problems or negative feelings
- persistence in gambling even after losing in attempt to recover losses
- betrayal of others by lying about the extent of the behaviour or consequences
- soliciting money from others either to gamble or to pay debts related to gambling
- loss of jobs and/or other opportunity and/or important relationships because of the gambling behaviour
- need to increase the amount of money gambled in order to experience the same adrenalin 'rush'
Prevalence
Pathological gambling appears to occur in between 0.1 to 2.3% of the population in the United States, although the DSM-IV-TR suggests that it may range as high as 3.4% generally, and up to 7% in specific geographical areas. Rates are simi liar in Canada, researchers suggest that approximately 1.2 million show signs of problem gambling. The ratio of men to women affected by pathological gambling is approximately 3:1, although the ratio in treatment programs appears to be far higher.
Manifestation
Pathological gambling in men typically begins in adolescence although it may not come to professional attention until the man is well into adulthood. The typical pathological male gambler is white, aged 40-50 years, and comes from middle to upper socioeconomic bracket.
Women tend to develop the behaviour later in life and the onset often appears to coincide with a specific stress or major loss. The gambling is initiated as an escape or an emotional response to an event.
Studies by Canadian researchers suggest that problem gamblers tend to be less well educated and have lower socioeconomic status. They have noted that Aboriginal populations experience approximately five times the rate of "full blown gambling problems". Moreover, they noted that provinces with casinos and video-lottery terminals have a much higher density of problem gambling behaviour - almost 1 in10 gamblers in Saskatchewan and Manitoba have some type of problem gambling, for instance.
There are four recognized phases of pathological gambling behaviour:
- The first is the phase of the "big win" that inspires confidence, perhaps over-confidence, and encourages continuation of the gambling behaviour on the presumption of further such wins. When the winning streak wanes, the second phase begins.
- The "losing phase" occurs when the gambler is unable to accept the loss and tries to win back the loss ("chasing the loss") with heavier and more frequent betting. In this phase, the individual will develop superstitious practices like carrying a lucky charm, blowing on the dice in a certain manner, etc.
It is during this phase that the gambler begins to cover up the extent of the problem which has begun to interfere with work or personal relationships. A sense of urgency begins to develop in this phase and he/she begins to borrow money in an attempt to "bail out" from the losses.
- The “desperation” phase begins when the gambler can no longer easily or legitimately access the amounts of money the habit is requiring. The individual resorts to uncharacteristic, sometimes illegal, behaviour to obtain the necessary funds, including writing bad cheques and embezzling from work. It is reported that about two thirds of pathological gamblers will be driven to this extreme, rationalizing their behaviour so it becomes easier each time.
- The fourth phases becomes one of "hopelessness" wherein the consequences of the gambling have reached the point where the individual sees no way out. Stress-related illness and risk of suicide increase dramatically during this final period.
Co-morbidity
There is a high level of co-morbidity with mood and anxiety disorders. Studies have show that approximately 75% of gamblers justify a mood disorders diagnosis, approximately 50% have substance abuse problems, and approximately 40% suffer from an Anxiety Disorder. Personality Disorders are also commonly noted in pathological gamblers, particularly Narcissistic and Anti-Social types.
There appears to also be a familial component to pathological gambling. One recent study has suggested that up to 58% of those studied had at least one relative who showed problematic gambling behaviour (Grant and Kim, 2001).
Treatment
To date, there are few well-designed studies that document successful treatment approaches for pathological gambling, although some of the newer Cognitive Behavioural Therapy approaches show promise. For some individuals, twelve-step programs such as Gamblers Anonymous may be helpful.
Given the high co-morbidity of mood and anxiety disorders and substance abuse, treatment of these underlying conditions will typically also be necessary.
Research in the area continues and Canadian researchers have begun testing a new assessment tool for use specifically with adolescent gambling. Announced in February 2004, this tool will be tested over the next two years in 5 Canadian provinces.
Further Reading
Beaudoin, C. & Cox, B. (1999) Characteristics of problem gambling: A preliminary study using a DSM-IV- based questionnaire. Canadian Journal of Psychiatry, June. Full paper here.
Ladouceur, R., Jacques, C., Ferland, F., & Gerous, I. (1999) Prevalence of problem gambling. (1999). Canadian Journal of Psychiatry, Oct . Full paper here.
Custer, R.L. & Milt, H. (1985). When luck runs out. New York: Facts on File.
DeCaria, C.M., & Hollander, E. (1993). Pathological gambling. In E. Hollander (Ed.), Obsessive-compulsive related disorders (pp. 151-178). Washington, DC: American Psychiatric Press.
Dickerson, M.G. (1984) Compulsive gamblers. London: Longman.
Grant, J.E. & Kim, S.W. (2001). Demographic and clinical features of 131 adult pathological gamblers. Journal of Clinical Psychiatry, 62, 957-962.
Lesieur, H.R. & Blume, S.B. (1990). Characteristics of pathological gamblers identified among patients on a psychiatric admissions service. Hospital and Community Psychiatry, 41, 1009-1012.
Lesieur, H.R., Blume, S.B., & Zoppa, R.M. (1986). Alcohol, drug use and gambling. Alcoholism, 10, 33-38.
Linden, R.D., Pope, H.D., & Jones, J.M. (1986). Pathological gambling and major affective disorder: Preliminary findings. Journal of Clinical Psychiatry, 47, 201-203.
Moran, E. (1970). Varieties of pathological gambling. British Journal of Psychiatry, 166, 593-597.
Rosenthal, R.J. (1992). Pathological gambling. Psychiatric Annals, 22(2), 70-72.
Smart, R.G. & Ferris, J. (1996). Alcohol, drugs and gambling in the Ontario adult population, 1994. Canadian Journal of Psychiatry, 41, 36-45.
Toneatto, Tony & Millar, Goldie.(2004) Assessing and Treating Problem Gambling:
Empirical Status and Promising Trends. Canadian Journal of Psychiatry, 49:517–525 (on-line access available)
Volberg, R.A. & Steadman, H.J. (1988). Refining prevalence estimates of pathological gambling. American Journal of Psychiatry, 145, 604-606.
Volberg, R.A. & Steadman, H.J. (1989). Prevalence estimates of pathological gambling in New Jersey and Maryland. American Journal of Psychiatry, 146, 1618-1619.
Other Resources - On-Line Access
Electronic Journal of Gambling Issues. Centre for Mental Health & Addictions. Toronto, ON.
Fighting the Odds. Study of Problem Gambling in Canada Statistics Canada. December 2003.
Gambling in Canada, 2001. Canada West Foundation. (copy available for download)
Pathological Gambling: A Critical Review 1999. National Academy of Sciences Open-Book, a non-proprietry on-line viewing source.
Therapy for Sexual Impulsivity: The Paraphilias and Paraphilia-Related Disorders. Martin Kafka, MD, Psychiatric Times (on-line)
Survey Insrument for Assessing Gambling Behaviour in Adolescents - new research 2004
© Stephen Hucker, MB,BS, FRCP(C), FRCPsych 2003, 2004,2005
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