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December 22, 2014

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Pathological gambling: A Primer

Addiction is a lay term absent from manuals that define psychiatric disorders. Gambling addiction, most often called pathological gambling by academics and the scientific community, is best described as a pattern of self-destructive behavior centered around gambling.

In 1980, the American Psychiatric Association added pathological gambling to its Diagnostic and Statistical Manual for Mental Disorders, which is used by mental health professionals to diagnose and treat people. The manual lists pathological gambling as an impulse control disorder in the same category as pyromania (deliberate and purposeful fire setting) and kleptomania (stealing objects not needed for personal use or monetary value). Some experts categorize pathological gambling as a brain disorder similar to alcohol and drug dependence, a progressive, chronic and self-destructive condition that can be more difficult to moderate than other compulsive behaviors.

DSM-IV CRITERIA:

Diagnostic Features

The essential feature of Pathological Gambling is persistent and recurrent maladaptive gambling behavior (Criterion A) that disrupts personal, family, or vocational pursuits. The diagnosis is not made if the gambling behavior is better accounted for by a Manic Episode (Criterion B).

Impulse-Control Disorders Not Elsewhere Classified

The individual may be preoccupied with gambling (e.g., reliving past gambling experiences, planning the next gambling venture, or thinking of ways to get money with which to gamble) (Criterion Al). Most individuals with Pathological Gambling say that they are seeking “action” (an aroused, euphoric state) even more than money. Increasingly larger bets, or greater risks, may be needed to continue to produce the desired level of excitement (Criterion A2). Individuals with Pathological Gambling often continue to gamble despite repeated efforts to control, cut back, or stop the behavior (Criterion A3). There may be restlessness or irritability when attempting to cut down or stop gambling (Criterion A4). The individual may gamble as a way of escaping from problems or to relieve a dysphoric mood (e.g., feelings of helplessness, guilt, anxiety, depression) (Criterion A5). A pattern of “chasing” one’s losses may develop, with an urgent need to keep gambling (often with larger bets or the taking of greater risks) to undo a loss or series of losses. The individual may abandon his or her gambling strategy and try to win back losses all at once. Although all gamblers may chase for short periods, it is the long-term chase that is more characteristic of individuals with Pathological Gambling (Criterion A6). The individual may lie to family members, therapists, or others to conceal the extent of involvement with gambling (Criterion A7). When the individual’s borrowing resources are strained, the person may resort to antisocial behavior (e.g., forgery, fraud, theft, or embezzlement) to obtain money (Criterion AS). The individual may have jeopardized or lost a significant relationship, job, or educational or career opportunity because of gambling (Criterion A9). The individual may also engage in “bailout” behavior, turning to family or others for help with a desperate financial situation that was caused by gambling (Criterion A10).

Associated Features and Disorders

Distortions in thinking (e.g., denial, superstitions, overconfidence, or a sense of power and control) may be present in individuals with Pathological Gambling. Many individuals with Pathological Gambling believe that money is both the cause of and solution to all their problems. Individuals with Pathological Gambling are frequently highly competitive, energetic, restless, and easily bored. They may be overly concerned with the approval of others and may be generous to the point of extravagance. When not gambling, they may be workaholics or “binge” workers who wait until they are up against deadlines before really working hard. They may be prone to developing general medical conditions that are associated with stress (e.g., hypertension, peptic ulcer disease, migraine). Increased rates of Mood Disorders, Attention-Deficit/Hyperactivity Disorder, Substance Abuse or Dependence, and Antisocial, Narcissistic, and Borderline Personality Disorders have been reported in individuals with Pathological Gambling. Of individuals in treatment for Pathological Gambling, 20 percent are reported to have attempted suicide.

Specific Culture and Gender Features

There are cultural variations in the prevalence and type of gambling activities (e.g., pai go, cockfights, horse racing, the stock market). Approximately one-third of individuals with Pathological Gambling are females. Females with the disorder are more apt to be depressed and to gamble as an escape. Females are underrepresented in treatment programs for gambling. This may be a function of the greater stigma attached to female gamblers.

Prevalence

The limited data available suggest that the prevalence of Pathological Gambling may be as high as 1 percent to 3 percent of the adult population.

Course

Pathological Gambling typically begins in early adolescence in males and later in life in females. Although a few individuals are “hooked” with their very first bet, for most the course is more insidious. There may be years of social gambling followed by an abrupt onset that may be precipitated by greater exposure to gambling or by a stressor. The gambling pattern may be regular or episodic, and the course of the disorder is typically chronic. There is generally a progression in the frequency of gambling, the amount wagered, and the preoccupation with gambling and obtaining money with which to gamble. The urge to gamble and gambling activity generally increase during periods of stress or depression.

Familial Pattern

Pathological Gambling and Alcohol Dependence are both more common among the parents of individuals with Pathological Gambling than among the general population.

Differential Diagnosis

Pathological Gambling must be distinguished from social gambling and professional gambling. Social gambling typically occurs with friends or colleagues and lasts for a limited period of time, with predetermined acceptable losses. In professional gambling, risks are limited and discipline is central. Some individuals can experience problems associated with their gambling (e.g., short-term chasing behavior and loss of control) that do not meet the full criteria for Pathological Gambling.

Loss of judgment and excessive gambling may occur during a Manic Episode. An additional diagnosis of Pathological Gambling should only be given if the gambling behavior is not better accounted for by the Manic Episode (e.g., a history of maladaptive gambling behavior at times other than during a Manic Episode). Alternatively, an individual with Pathological Gambling may exhibit behavior during a gambling binge that resembles a Manic Episode. However, once the individual is away from the gambling, these manic-like features dissipate. Problems with gambling may occur in individuals with antisocial personality disorder; if criteria are met for both disorders, both can be diagnosed.

Diagnostic criteria for 312.31 Pathological 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 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.

Source: American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, 1994

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