Problem gambling

For patient information click here

Overview
Problem gambling (ludomania) is an urge to gamble despite harmful negative consequences or a desire to stop. The term is preferred to compulsive gambling among many professionals, as few people described by the term experience true compulsions in the clinical sense of the word. Problem gambling often is defined by whether harm is experienced by the gambler or others, rather than by the gambler's behavior. Severe problem gambling may be diagnosed as clinical pathological gambling if the gambler meets certain criteria.

Definition
Debate over how problem gambling should be defined. Research by governments in Australia led to a universal definition for that country which appears to be the only research based definition not to use diagnostic criteria.


 * Problem gambling is characterised by many difficulties in limiting money and/or time spent on gambling which leads to adverse consequences for the gambler, others, or for the community.

Most other definitions of problem gambling can usually be simplified to any gambling that causes harm to the gambler or someone else in any way. However, these definitions are usually coupled with descriptions of the type of harm or the use of diagnostic criteria such as the South Oaks Gambling Screen, Canadian Problem Gambling Index or the Victorian Gambling Screen.

Pathological gambling
Extreme cases of problem gambling may cross over into the realm of mental disorders. Pathological gambling was recognized as a psychiatric disorder in the DSM-III, but the criteria were significantly reworked based on large-scale studies and statistical methods for the DSM-IV. As defined by American Psychiatric Association, pathological gambling is an impulse control disorder that is a chronic and progressive mental illness.

Pathological gambling is now defined as persistent and recurrent maladaptive gambling behavior meeting at least five of the following criteria, as long as these behaviors are not better explained by a manic episode:
 * 1) Preoccupation. The subject has frequent thoughts about gambling experiences, whether past, future, or fantasy.
 * 2) Tolerance. As with drug tolerance, the subject requires larger or more frequent wagers to experience the same "rush".
 * 3) Withdrawal. Restlessness or irritability associated with attempts to cease or reduce gambling.
 * 4) Escape. The subject gambles to improve mood or escape problems.
 * 5) Chasing. The subject tries to win back gambling losses with more gambling.
 * 6) Lying. The subject tries to hide the extent of his or her gambling by lying to family, friends, or therapists.
 * 7) Stealing in order to feed their gambling addiction.
 * 8) Loss of control. The person has unsuccessfully attempted to reduce gambling.
 * 9) Illegal acts. The person has broken the law in order to obtain gambling money or recover gambling losses. This may include acts of theft, embezzlement, fraud, forgery, or bad checks.
 * 10) Risked significant relationship. The person gambles despite risking or losing a relationship, job, or other significant opportunity.
 * 11) Bailout. The person turns to family, friends, or another third party for financial assistance as a result of gambling.

As with many disorders, the DSM-IV definition of pathological gambling is widely accepted and used as a basis for research and clinical practice internationally.

Biological basis
According to the Illinois Institute for Addiction Recovery, recent evidence indicates that pathological gambling is an addiction similar to chemical addiction. It has been seen that some pathological gamblers have lower levels of norepinephrine than normal gamblers.

According to a study conducted by Alec Roy, M.D. formerly at the National Institute on Alcohol Abuse and Alcoholism, norepinephrine is secreted under stress, arousal, or thrill, so pathological gamblers gamble to make up for their under-dosage.

Further to this, according to a report from the Harvard Medical School Division on Addictions there was an experiment constructed where test subjects were presented with situations where they could win, lose or break even in a casino-like environment. Subjects' reactions were measured using fMRI, a neuro-imaging technique very similar to MRI. And according to Hans Breiter, MD, co-director of the motivation and Emotion Neuroscience Centre at the Massachusetts General Hospital, "Monetary reward in a gambling-like experiment produces brain activation very similar to that observed in a cocaine addict receiving an infusion of cocaine."

Deficiencies in serotonin might also contribute to compulsive behavior, including a gambling addiction.

Relation to other problems
As debts build up people turn to other sources of money such as theft, or the sale of drugs. A lot of this pressure comes from bookies or loan sharks that people rely on for capital to gamble with. Also, a teenager that does not receive treatment for pathological gambling when in their desperation phase is likely to contemplate suicide. 20% of teenagers that are pathological gamblers do consider suicide.

Abuse is also common in homes where pathological gambling is present. Growing up in such a situation leads to improper emotional development and increased risk of falling prey to problem gambling behavior.

Pathological gambling is similar to many other impulse control disorders such as kleptomania, pyromania, and trichotillomania. Other mental diseases that also exhibit impulse control disorder include such mental disorders as antisocial personality disorder, or schizophrenia.

Other problems associated with compulsive gambling can be personal relationships. In a 1991 study of relationships of American men, it was found that 10% of compulsive gamblers had been married three or more times. Only 2% of men who did not gamble were married more than twice.

Prevalence
A study by the United Kingdom Gambling Commission, the "British Gambling Prevalence Survey 2007", found that approximately 0.6% of the adult population had problem gambling issues, the same percentage as in 1999. The highest prevalence of problem gambling was found among those who participated in spread betting (14.7%), fixed odds betting terminals (11.2%) and betting exchanges (9.8%).

Available research seems to indicate that problem gambling is an internal tendency, and that problem gamblers will tend to risk money on whatever game is available, rather than a particular game being available inducing problem gambling in otherwise "normal" individuals. However, research also indicates that problem gamblers tend to risk money on fast-paced games. Thus a problem gambler is much more likely to lose a lot of money on roulette or slot machines, where rounds end quickly and there is a constant temptation to play again or increase bets, as opposed to a state lottery where the gambler must wait until the next drawing to see results.

Dopamine agonists, in particular pramipexole (Mirapex), have been implicated in the development of compulsive gambling and other excessive behavior patterns (e.g., PMID 16009751).

Assessment
The most common instrument used to screen for "probable pathological gambling" behavior is the South Oaks Gambling Screen (SOGS) developed by Lesieur and Blume (1987) at the South Oaks Hospital in New York City. This screen is undoubtedly the most cited instrument in psychological research literature. In recent years the use of SOGS has declined due to a number of criticisms including that it over-estimates false positives.

The DSM-IV diagnostic criteria presented as a checklist is an alternative to SOGS, it focuses on the psychological motivations underpinning problem gambling and was developed by the American Psychiatric Association. It consists of ten diagnostic criteria. One screening measure based upon the DSM-IV criteria is the National Opinion Research Center DSM Screen for Gambling Problems (NODS). This measure is currently used frequently. The Canadian Problem Gambling Severity Index (PGSI) is another newer assessment measure. The PGSI focuses on the harms and consequences associated with problem gambling.

Treatment for Pathological Gambling
A variety of treatments exist for pathological gambling including counseling, self-help groups, and psychiatric medications. However, no one treatment is considered to be most efficacious and no medications have been approved for the treatment of pathological gambling by the US Food and Drug Administration (FDA).

Gamblers Anonymous (GA) is a commonly used treatment for gambling problems. Modeled after Alcoholics Anonymous, GA uses a 12-step model that emphasizes a mutual-support approach. Meetings are free and are held most nights of the week. See the GA website for meeting times and locations.

One form of counseling, cognitive behavioral therapy (CBT) has been shown to reduce symptoms and gambling-related urges. This type of therapy focuses on the identification of gambling-related thought processes, mood and cognitive distortions that increase one’s vulnerability to out-of-control gambling. Additionally, CBT approaches frequently utilize skill-building techniques geared toward relapse prevention, assertiveness and gambling refusal, problem solving and reinforcement of gambling-inconsistent activities and interests.

There is evidence that the SSRI paroxetine is efficient in the treatment of pathological gambling. Additionally, for patients suffering from both pathological gambling and a comorbid bipolar spectrum condition, sustained release lithium has shown efficacy in a preliminary trial. The opiate antagonist drug nalmefene has also been trialled quite successfully for the treatment of compulsive gambling.

Treatment for problem gambling
Most treatment for problem gambling involves counselling, step-based programs, self-help, peer-support, or a combination of these.

Counseling
Gambling counselling is usually delivered by professional counsellors who are often either qualified psychologists or social workers. In many jurisdictions services are free or subsidised by government agencies. Telephone counselling services are also available in many countries. Examples of services include Gamcare (UK) and Gambler's Help (Australia).

Step-based programs
One step-based program for gambling issues is Gamblers Anonymous. Gambler's Anonymous uses a 12 step program adapted from Alcoholics Anonymous and also places an emphasis on peer support. Other step-based programs (some commercially operated) that are both specific to gambling and generic to addiction have also be used to treat problem gamblers.

Peer-support
A growing method of treatment is peer support. With the advancement of online gambling, many gamblers experiencing issues use various online peer-support groups to aid their recovery. This protects their anonymity whilst allowing to attempt to self-recover often without having to disclose their issues to loved ones.

Self-help
Research into self-help for problem gamblers is showing promising results. David Hodgins research into the use of workbooks followed up with telephone support has shown benefits.