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Gambling Addiction
Rebecca Collins, DO, MPH, FAAFP
image BASICS
DESCRIPTION
Gambling is the act of placing something of value at risk in the hopes of gaining something of greater value. Pathologic gambling (PG) and problem gambling affect up to 15 million Americans with the number of those affected increasing, especially in young people. The essential feature of gambling disorder is persistent and recurrent maladaptive gambling behavior that disrupts personal, family, and/or vocational pursuits. Individuals with gambling disorder have high rates of comorbidity with other mental disorders (substance use, depression, anxiety, and personality disorders). There is a debate as to whether gambling addiction is an impulse-control disorder or a non-substance abuse-related disorder.
EPIDEMIOLOGY
  • Predominant sex: male > female, though gap narrowing
  • Rates of pathologic and problem gambling are higher in adolescents and middle-age persons than older adults.
  • The younger a person starts gambling, the more likely he or she is to become a pathologic gambler.
  • Economics: $0.5 trillion wagered in United States annually.
Prevalence
  • Lifetime gambling disorder prevalence is 0.4-1% in the U.S. adults.
    • Males 0.6%, females 0.2%
    • African American 0.9%, Caucasian 0.4%, Hispanic 0.3%
  • Living in closer proximity to a casino increases prevalence.
GENERAL PREVENTION
  • Focus on treatment; patient education; awareness of risk factors, associated conditions, and warning signs of pathologic or problematic gambling behaviors.
  • Primary prevention using educational programs that target at-risk youth and adults
  • Public health interventions: Decrease available gambling locations and lottery venues, ban advertising for gambling activities, keep lottery tickets out of sight, add warning label of risk of problem gambling to packaging of gambling products, enforce legal age of gambling, moratorium on building new casinos (1).
ETIOLOGY AND PATHOPHYSIOLOGY
  • DSM-5 characterizes gambling disorder as a nonsubstance related and addictive disorder; however, there is a debate whether it is an impulse-control disorder or possibly both.
  • Impulse control: changes in serotonin metabolites in pathologic gamblers and patients with impulse-control disorders
  • Substance abuse: similarities found between PG and substance use (tolerance, withdrawal, anticipatory craving, relapses)
  • The brains of pathologic gamblers may have some predisposition to illness. Functional MRI studies indicate that the ventromedial prefrontal cortex is less activated when gambling stimuli are presented to pathologic gamblers.
  • Abnormalities in the neurotransmitters serotonin, norepinephrine, dopamine, and glutamate may be implicated in PG.
    • Norepinephrine: Low levels seem to help a patient avoid gambling, whereas high levels may lead to poor decision making.
    • Serotonin: involved in impulse control by helping a patient weigh the risks of gambling
    • Dopamine: High levels in the nucleus accumbens while gambling lead to a pleasurable rush may induce reversible PG in Parkinson patients who take dopamine agonists.
  • Medicine classes for each category have been used to treat.
Genetics
  • SLC6A4 serotonin transporter gene has been associated with PG in males but not in females.
  • Dopamine receptor genes DRD1, DRD2, DRD3, and DRD4 have been correlated with PG.
  • More prevalent among first-degree relatives of alcoholics than among general population.
RISK FACTORS
  • Some types of gambling present a greater risk to cause PG than other types: pull tabs, casino gambling, bingo, and card games outside a casino
  • Being involved with several gaming modalities is related to PG and suggests that the gambler is very captivated with risking money for excitement as opposed to risking money for social pleasure or for an interest in sports.
  • Lower socioeconomic status
  • Adults in mental health treatment
  • Substance abuse (nicotine, alcohol, inhalants, marijuana)
  • Positive family history
  • Antisocial personality disorder, depressive and bipolar disorders, other substance abuse disorders (especially alcohol)
COMMONLY ASSOCIATED CONDITIONS
  • Poor nutrition
  • Stress-related medical conditions (e.g., peptic ulcer disease [PUD], hypertension, migraine, palpitations)
  • Suicidal ideation and attempts
  • Substance abuse disorder (especially alcohol)
  • Attention deficit hyperactivity disorder
  • Bipolar disorder and other mood disorders
  • Impulse-control disorders
  • Personality disorders
  • Incarceration
  • Financial problems (e.g., previous bankruptcy)
image DIAGNOSIS
DSM-5 criteria for gambling disorder (2):
  • Persistent and recurrent gambling behavior leading to significant impairment or distress as indicated by ≤4 of the following in a 12-month period, AND gambling behavior is not better explained by a manic episode:
    • Often preoccupied with gambling
    • Need to gamble with increasing amounts of money to achieve the desired excitement
    • Repeated unsuccessful efforts to control, cut back, or stop gambling
    • Restless or irritable when attempting to cut down or stop gambling
    • Often gambles when feeling distressed (e.g., helpless, guilty, anxious, depressed)
    • After losing money gambling, often returns another day to get even (“chasing” one's loses)
    • Lies to conceal the extent of involvement with gambling
    • Has jeopardized or lost a significant relationship, job, or educational or career opportunity because of gambling
    • Relies on others to provide money to relieve a desperate financial situation caused by gambling (“bailout” behavior)
  • Specifiers:
    • Episodic: meets diagnostic criteria at >1 time point with symptoms subsiding for at least several months
    • Persistent: continuous symptoms for multiple years
    • Early remission: After criteria met previously, none met for ≥3 months but <12 months.
    • Sustained remission: After criteria met previously, no criteria met for ≥12 months.
    • Current severity: mild (4 to 5 criteria), moderate (6 to 7 criteria), or severe (8 to 9 criteria)
P.395

DIFFERENTIAL DIAGNOSIS
  • Social gambling
  • Professional gambling
  • Bipolar disorder, manic episode
  • Personality disorder
  • Other medical conditions (patients on dopaminergic medications, e.g., Parkinson)
DIAGNOSTIC TESTS & INTERPRETATION
  • South Oaks Gambling Screen (SOGS):
    • Most extensively used and validated screening tool
    • 20-question screen for PG
    • Score of 3 to 4 suggests problem gambling.
    • Score of ≥5 indicates probable PG.
    • Criticized as having high false-positive rate and being too lengthy to administer
  • Gamblers Anonymous 20 questions:
    • Easily obtainable from Gamblers Anonymous Web site
    • Scores of >7 are indicative of problem/PG.
  • Lie/Bet method: “Have you ever had to lie to people important to you about how much you gambled?” “Have you ever felt a need to bet more money?”:
    • A patient who answers at least one question with a “Yes” suggests further investigation needed to see if criteria are met for PG.
    • This test has been shown to have >85% specificity and >95% sensitivity.
Initial Tests (lab, imaging)
None usually indicated
image TREATMENT
To treat PG, treat comorbidities first. The usual comorbid disorders are substance abuse, bipolar disorder, ADHD, and other impulse-control disorders. Nonpharmacologic therapies are more effective than pharmacologic therapies. Some data suggest that gambling abstinence is not necessary for treatment; patients can still exhibit controlled gambling.
GENERAL MEASURES
  • Get a sense of the patient's readiness for change.
  • Provide intervention/patient education. Although there are no FDA-approved drug treatments for PG, make clinically based medication recommendations.
  • Screen for and treat comorbid conditions.
  • Provide referrals:
    • Addiction psychiatrist/counselor
    • Gamblers Anonymous
    • Consumer credit organizations
    • Bankruptcy lawyers
    • Gam-Anon for family members
MEDICATION
  • There are no FDA-approved medicines for gambling addiction; pharmacotherapy is most effective when directed toward patient's comorbid psychiatric condition (3)[A].
  • SSRIs:
    • Currently seen as beneficial for treating comorbid impulse-control disorders, although their efficacy has been under question for PG
    • All studies with SSRIs limited due to small size, short follow-up, conflicting outcomes, and in some cases study design; confirmation for some positive findings need larger randomized controlled trials with extended follow-up before recommendations for use can be made
  • Opiate antagonists have the ability to decrease dopamine release in the dopamine reward pathway. Naltrexone and nalmefene have been reported to cause improvements on gambling symptom assessment scores (4,5)[B].
ADDITIONAL THERAPIES
  • Cognitive-behavioral therapy (CBT):
    • The main effective interventions for PG are psychoeducation, cognitive restructuring, problem solving, social skills training, and relapse prevention. Studies indicated that CBT resulted in significant improvement as short-term therapy.
    • CBT may be done in several formats: individual, group, brief group, and dual diagnosis. All these formats have been shown to be effective. Group therapy is favored because patients are often extroverted. Couple or family therapy also may be used.
  • Gamblers Anonymous:
    • A 12-step program similar to Alcoholics Anonymous for a person suffering from a gambling addiction.
    • Dropout rate is high if this is the only means of therapy.
    • Patients may deny need to attend in the first place, and for that reason, Gamblers Anonymous may not be appropriate for patients who are in the precontemplation stage.
  • Motivational enhancement therapy (MET):
    • Provides nonargumentative exploration of patient's stage of change
    • Patient receives positive reinforcement from clinician.
    • Motivational enhancement strategies support self-efficacy.
    • Improves patient rapport; aids in removing barriers to treatment
    • In one study, MET alone did not show any improvement, but MET and CBT together improved outcome measures.
  • Because of increased suicide rates, patients may need to be hospitalized acutely for safety and to prevent gambling.
  • Because patients are at increased risk from mental and physical illness, they benefit from relaxation exercises to reduce stress, identify triggers, substitute gambling with other activities and a complete physical and lab work with nutrition evaluation.
image ONGOING CARE
FOLLOW-UP RECOMMENDATIONS
Patients seeking treatment for gambling addiction should be followed routinely to monitor the response to treatment, tolerance to medications, and relapse.
PATIENT EDUCATION
  • Gamblers Anonymous:
    • http://www.gamblersanonymous.org/ga/
    • National hotline 1-888-GA-HELPS (888-424-3577)
  • Gam-Anon: support group for spouses, family, or close friends: http://www.gam-anon.org/
  • Responsible Gambling Council: http://www.responsiblegambling.org/
  • Humphrey H. This Must Be Hell: A Look at Pathological Gambling. Bloomington, IN: iUniverse; 2000.
  • Lee B. Born To Lose: Memoirs of a Compulsive Gambler. Center City, MN: Hazelden; 2005.
  • PROGNOSIS
  • Patients with gambling addiction can be treated but many relapse.
  • 36-39% of patients did not experience any gambling-related problems according to one study, and only 7-12% sought formal treatment or Gamblers Anonymous meetings.
  • Roughly 1/3 of patients who have a gambling addiction recover without any intervention.
REFERENCES
1. Poulin C. Gambling. CMAJ. 2006;175(10):1208.
2. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Arlington, VA: American Psychiatric Association; 2013:585-589.
3. Dell'Osso B, Allen A, Hollander E. Comorbidity issues in the pharmacological treatment of pathological gambling: a critical review. Clin Pract Epidemiol Ment Health. 2005;1:21.
4. Kim SW, Grant JE, Adson DE, et al. Double-blind naltrexone and placebo comparison study in the treatment of pathological gambling. Biol Psychiatry. 2001;49(11):914-921.
5. Grant JE, Potenza MN, Hollander E, et al. Multicenter investigation of the opioid antagonist nalmefene in the treatment of pathological gambling. Am J Psychiatry. 2006;163(2):303-312.
Additional Reading
&NA;
  • Chou KL, Afifi TO. Disordered (pathologic or problem) gambling and axis I psychiatric disorders: results from the National Epidemiologic Survey on Alcohol and Related Conditions. Am J Epidemiol. 2011;173(11):1289-1297.
  • Leung KS, Cottler LB. Treatment of pathological gambling. Curr Opin Psychiatry. 2009;22(1):69-74.
  • Nussbaum D, Honarmand K, Govoni R, et al. An eight component decision-making model for problem gambling: a systems approach to stimulate integrative research. J Gambl Stud. 2011;27(4):523-563.
  • Okuda M, Balán I, Petry NM, et al. Cognitive-behavioral therapy for pathological gambling: cultural considerations. Am J Psychiatry. 2009;166(12):1325-1330.
Codes
&NA;
ICD10
  • F63.0 Pathological gambling
  • Z72.6 Gambling and betting
Clinical Pearls
&NA;
  • Several brief screening strategies can be used to identify PG, including the SOGS, the Gamblers Anonymous 20 questions, and the Lie/Bet method.
  • To treat PG, first treat comorbidities such as substance abuse, bipolar disorder, ADHD, and other mental health/substance abuse disorders.
  • Nonpharmacologic therapies are more effective than pharmacologic therapies. There is no FDA-approved therapy for PG.
  • Patients seeking treatment for gambling addiction should be followed routinely by physicians and counselors to monitor the response to treatment, tolerance to medications, and possibility of relapse.