Gambling has become a major recreational activity in the United States. In the past, legalized gambling was confined to a few states, such as Nevada and New Jersey, but in the past two decades gambling opportunities have expanded. Some form of legalized gambling exists now in all but two states; 37 have lotteries, and 27 have casino gambling. A 1999 survey showed that nearly 90% of the adult population participates in some form of legalized gambling, especially instant lottery games, slot machines, office pools, and card games. In the 23 years from 1974 to 1997, gambling expenditures more than doubled as a percentage of personal income.
While most persons gamble responsibly, between 3.5% and 5% of the general population develops problematic gambling. Pathological gambling (PG), the most severe form of problematic gambling, may affect as much as 1% to 2% of the adult general population, which suggests that more than 2 million Americans suffer from this disorder, with roughly twice that many having gambling related difficulties without meeting the criteria for the disorder as described in Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV). PG is characterized by continuous or periodic loss of control over gambling.
Recognized for centuries, criteria for PG were first enumerated in 1980 in DSM-III. The criteria are patterned after those used for substance dependencies and emphasize the features of tolerance and withdrawal, both of which have been described in persons with PG and in those with substance dependence.
The DSM-IV enumerates 10 specific maladaptive behaviors, and 5 or more are required for the diagnosis.
Research suggests that PG may be even more common among youth. Gambling itself is on the rise; a national survey reported that 82% of respondents had gambled at least once in the past year, with lottery and casino gambling showing the largest rates of increase from earlier surveys. The psychosocial costs of PG include financial, legal, employment, and relationship difficulties as well as psychiatric complications such as depression, substance misuse, and suicide.
Although PG is widely conceptualized as an addiction, its classification remains controversial. Some experts have included PG as part of an “obsessive-compulsive spectrum” of disorders, while others have linked it with impulse control disorders, such as compulsive buying and kleptomania, or even to the mood disorders.
One quarter to one third of all pathological gamblers are women. Women tend to begin gambling later in life, often in their early 30s, while men start in their late teens or early 20s. Women tend to have a more rapid progression to pathological gambling, a phenomenon known as telescoping. Special populations at risk for developing PG include adults with mental health or substance use disorders, persons who have been incarcerated, African Americans, and persons of lower socioeconomic status.
Persons with PG are highly likely to have comorbid mood and anxiety disorders and to misuse substances. Other impulse control disorders (e.g., compulsive buying, kleptomania), and attention deficit hyperactivity disorder are also frequently comorbid with PG. Lifetime drug or alcohol dependence has been consistently reported in persons with PG, and one survey showed that the rate of alcohol or other drug abuse was nearly 7 times higher among persons with PG than among nongamblers or recreational gamblers. From 30% to 50% of treatment-seeking pathological gamblers have histories of substance misuse.
Personality disorders are also relatively common in persons with PG, although there is no specific “gambling personality.” A small but significant subset of persons with PG has antisocial personality disorder, which appears to run in families.
Researchers have attempted to identify subtypes, but this work has not been empirically validated or led to clinically meaningful distinctions among persons with PG. Perhaps the most widely discussed scheme is the distinction among the “escape-seekers” and “sensation-seekers.” Escape-seekers are often older individuals who may gamble out of boredom or to fill time, and they may choose passive forms of gambling, such as slot machines. Sensation-seekers tend to be younger and prefer card games or table games, which involve active input on the part of the gambler.
An association between crime and PG is well established. The prevalence of criminal activity among pathological gamblers has been estimated to range from 20% to 80%. Illegal behaviors reported by persons with PG include writing bad checks and engaging in embezzlement, larceny, tax fraud, and prostitution (among women). The addictive nature of PG is thought to represent an important criminogenic factor.
There have been no careful longitudinal studies to determine its natural history, but PG is widely assumed to be chronic with a continuous, unremitting, or episodic course. Several phases have been described in the progression of PG. During the “winning” phase, increased accessibility of and exposure to gambling-related activities are listed as causes of the gradual progression from social gambling to PG. Many pathological gamblers are thought to derive a substantial proportion of self-esteem from gambling and rely on gambling to manage their disappointments and negative mood states. A string of bad luck or unexpected losses leads to the “losing” phase, a phase that centers on the behavior known as chasing. With chasing, the gambler desperately attempts to recover the lost money. Wagering is more frequent and often in larger amounts. The gambler may lie to important persons in his or her life, including spouse, parents, and children in order to hide losses. The uncontrollable spiral of losing and chasing losses leads the gambler to the “desperation” phase, in which the gambler may begin to engage in illegal activities to support the gambling problem. Fantasies of escape and thoughts of suicide are reportedly common during this phase. Some gamblers may experience a fourth phase of “giving up” or hopelessness and may seek treatment, often at the insistence of others. Depression, thoughts of suicide, and stress-related symptoms, including hypertension, heart palpitations, sleep disorders, or gastrointestinal distress may occur.
PG can wreak havoc in nearly all domains of the pathological gambler’s life, including the social, financial, professional, and personal spheres. Persons may begin gambling as a hobby or way to socialize. As gambling interest progresses, the gambler may begin to isolate himself or herself from family or friends; many will develop feelings of loss of control, guilt, or shame in relation to their gambling. One of the first casualties of PG is the loss of support and trust of family members, including the spouse. Work-related problems develop, as urges and thoughts of gambling are difficult to control, resulting in absenteeism or poor work performance; job loss is not infrequent. Bankruptcy filings are relatively common among persons with PG, and in one study nearly 44% of persons with PG reported having no savings or retirement funds; 22% had lost their home or automobile or had pawned valuables to pay off the gambling losses. In some cases, the consequences of PG can lead the individual to attempt or complete suicide. Attempted suicide has been reported in from 17% to 24% of Gamblers Anonymous members in treatment for PG.
Family history data suggest that PG, mood disorders, and substance misuse are more prevalent among the relatives of persons with PG than in the general population. Twin studies also suggest that gambling has a heritable component. Functional neuroimaging studies suggest that among persons with PG, gambling cues elicit gambling urges and a temporally dynamic pattern of brain activity changes in frontal, paralimbic, and limbic brain structures, suggesting to some extent that gambling may represent dysfunctional frontolimbic activity.
There is no standard treatment for PG, but therapeutic approaches have emphasized individual and group psychotherapy, 12-step programs, and inpatient programs. Research suggests that cognitive-behavioral therapy can be effective, particularly when combined with motivational interviewing. Gamblers Anonymous, a 12-step program founded in 1957, may be helpful. Unfortunately, attendees often drop out in the first year, reducing its potential effectiveness. Inpatient treatment and rehabilitation programs similar to those for substance use disorders may be helpful for selected patients. The use of medications to treat PG is being actively researched but is complicated by a high frequency of placebo response and high dropout rates. The opioid antagonist naltrexone has been shown to be more effective than placebo, as has the opioid antagonist nalmefene, which is not available in the US.
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