|Year : 2017 | Volume
| Issue : 2 | Page : 120-127
Pathological gambling: An overview
Shalini Singh, Ganesh Kumar Mallaram, Siddharth Sarkar
Department of Psychiatry and NDDTC, All India Institute of Medical Sciences, New Delhi, India
|Date of Web Publication||14-Mar-2017|
Department of Psychiatry and NDDTC, All India Institute of Medical Sciences, New Delhi - 110 029
Source of Support: None, Conflict of Interest: None
Gambling activities are popular as a form of recreation and have been a source of income for many people worldwide. Although gambling has been common across continents and time, and a subset of individuals experience problems with gambling. This review attempts to provide an overview of problem gambling for clinicians who are likely to encounter such patients in their practice. The review discusses the relevance, nosology, and epidemiology of gambling. We also discuss the associated comorbidities and principles of management of pathological gambling.
Keywords: Gambling disorder, pathological gambling, problem gambling, review
|How to cite this article:|
Singh S, Mallaram GK, Sarkar S. Pathological gambling: An overview. Med J DY Patil Univ 2017;10:120-7
| Introduction|| |
Gambling activities are popular as a form of recreation and have been a source of income for many people worldwide. It has been a part of human behavior since antiquity and still remains popular. Two fascinating aspects of gambling are its universality and versatility. People have gambled with a variety of commodities and bets have been placed on anything and everything under the sun throughout history. Placing bets on cockfights have been of cultural and religious relevance in the Indian peninsula since many centuries. Just as gambling has been described in various historical scriptures, the society has since those days understood the problems associated with gambling. Closer home, the Mahabharata describes how a righteous prince, Yudhishthira, gambled away his kingdom, his wife, and his own freedom.,
Although gambling has been common across continents and time, and a subset of individuals experience problems with gambling. This review attempts to provide an overview of pathological gambling for clinicians who are likely to encounter such patients in their practice. The review discusses the relevance, nosology, and epidemiology of gambling. We also discuss the associated comorbidities and principles of management of pathological gambling (PG).
Before a discussion about PG, it would pertinent to have an overview of terms related to gambling. Gambling is defined as placing something of value at risk in the hopes of gaining something of greater value. Recreational gambling has been considered as behavior that is carried out in moderation without loss of control or marked negative consequences. Problem gambling is typically used as a broader term for a pattern of gambling that still is related to difficulties in one's life but may or may not meet the full criteria for a disorder. However, some researchers suggest that there may not be concrete differences between recreational and problem gambling. The term probable PG is sometimes used when individuals score above a cutoff on screening instruments (e.g., South Oaks Gambling Screen [SOGS]), but standard diagnostic criteria have not been applied. Excessive or intemperate gambling refers to gambling an amount of time or money spent in gambling that exceeds an arbitrarily defined acceptable level. Disordered gambling is a general term including both problem gambling and PG while compulsive gambling is the original lay term for PG. Based on gambling preferences, contemporary gamblers have been classified into active and passive gamblers. Active gamblers engage in activities with immediate rewards, for example, slot machines, and casinos. Passive gamblers engage in activities with more delayed rewards, for example, lottery. Alternatively, gamblers have been classified into strategic and nonstrategic gamblers. Strategic gamblers train themselves and participate in the specific forms of gambling such as a game of cards, poker tournaments, betting on sporting events, and on stock market investments. Nonstrategic gamblers engage in activities that require little or no skill and decision-making.
| The Impact of Gambling|| |
Gambling, even its recreational avatar has been frowned on by the society. Sooner or later, gambling activities lead to social and economic losses. Those who gamble experience substantial debts and even bankruptcies. They often require financial bailouts and show willingness to risk close relationships to further pursue gambling., Many who gamble become a part of illegal activities and show damaging behaviors toward their family such as domestic violence, child abuse, and neglect., Gambling results in poor mental and physical health of family members of individuals with gambling problems., According to feature in Economist, gamblers around the world lost a total of $440 billion.
The impact of gambling is seen on health as well. Those who gamble have a higher incidence of hypertension, insomnia, gastrointestinal complaints, and cardiac arrests. All of these disorders are likely to be a result of the heightened stress that gamblers experience due to gambling. Indicators of acute stress such as increased salivary cortisol levels and an overdrive of the sympathetic nervous system have been seen during gambling activities. Thus, gambling can lead to many kinds of complications. The impact is seen on the health, interpersonal relations, social stature, and the financial status of an individual and it could also have legal implications as well.
| Nosology of Gambling Disorders|| |
PG debuted as a diagnosis in the 3rd Diagnostic and Statistical Manual (DSM-III) in 1980. The diagnosis was based on the expert opinion of clinicians at the time. The DSM-III classified PG as an impulse control disorder. It began with a statement as “the individual experiencing progressive loss of control” and then listed seven items, with an emphasis on damage and disruption to the individual's family, personal or vocational pursuits, and money-related issues. The diagnosis continued to remain classified as an impulse control disorder in DSM-IV and DSM-IV TR., Specifically, it was classified as impulse control disorders not elsewhere classified, along with compulsive hair pulling, intermittent explosive disorder; kleptomania and pyromania. An individual needed to meet a minimum of 5 of the 10 diagnostic criteria to be diagnosed with PG. A subclinical diagnosis of problem gambling was considered for those who did not five full criteria for a diagnosis. The criteria for DSM-IV were revised based on the criticism of the earlier criteria. Changes were made to reflect the similarity of the diagnosis to substance dependence, such as the addition of the criterion, “repeated unsuccessful attempts to control, cut back or stop gambling.” Substance use disorders and gambling disorders share many commonalities. Features such as “loss of control,” “craving/withdrawal,” and “neglect of other areas in life” are common among the two diagnoses. Several changes were made to the DSM-5 diagnosis of gambling disorder addresses the critiques of DSM-IV TR's definition of PG. The key issues were that the earlier DSM manual did not account for the evidence that gambling problems present across the spectrum of impulse control disorders and substance use disorders. The definition of PG was based on the findings in those who sought treatment for their gambling. Subclinical pathological gamblers were missed at the time of diagnosis due to the high diagnostic threshold. The major revision from DSM-IV-TR to DSM-5 was the removal of the diagnosis from impulse control disorders and addition to the category labeled substance-related and addictive disorders that also includes substance use disorders. The diagnosis is renamed as PG and the criterion of “illegal acts” has been removed. The diagnostic threshold is lowered from the five to four criteria for PG. Some other key differences are that in DSM-5, to diagnose a gambling disorder, the criteria need to occur within a 12-month period, unlike the DSM-IV which did not provide a period for symptoms. [Figure 1] shows the evolution of nosological changes of the diagnosis in DSM.
|Figure 1: Nosological changes in the diagnosis of gambling disorder in Diagnostic and Statistical Manual-V|
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The International Classification of Diseases (ICD-10) (1992) classifies PG under “habit and impulse disorders” along with pyromania, kleptomania, and trichotillomania similar to the previous DSM classifications. PG is described as a “disorder of frequent, repeated episodes of gambling that dominate the patient's life, to the detriment of social, occupational, material, and family values and commitments.” An individual should demonstrate two or more episodes of gambling over a period of 1 year, and the person should not have had a “profitable outcome” from gambling activities. PG is likely to be classified under impulse control disorders in the ICD-11.
| The Epidemiology of Pathological Gambling|| |
The first USA national survey on gambling was performed in 1976 by Kallick et al., who conducted a telephone survey of 1749 adults, indicating a lifetime prevalence estimate of 0.8%. Two decades later, the National Gambing Impact Study was carried out on 2400 USA residents and the lifetime prevalence estimate was found to remain constant at 0.8%. The National Epidemiological Survey of Alcohol and Related Conditions did a longitudinal study assessing a broad range of psychiatric and other disorders and behaviors. This is the largest survey to date and was performed between 2001 and 2005 where over 43,000 respondents were surveyed in person. The study found a lifetime prevalence estimate of PG 0.4% and past-year prevalence estimate of 0.2%. The analysis of prevalence values from 80 separate studies in 30 countries that have been undertaken in the last decade put the worldwide prevalence of problem gambling to be 1.5%.
PG activities are twice as common among men than women, but women may suffer from more physical and mental health complications due to gambling. Gender differences are also seen in the way people gamble: men gamble more frequently and wager larger amounts, begin at an earlier age, and prefer skill-based games., Gambling has different motivations for different people. Men are more likely to have excitement seeking as their motivation, whereas women are more likely to report gambling as a form of escape or relief from dysphoria or boredom. Recreational gamblers tend to be younger, with impaired impulse control and more frequent reports of gambling associated complications. Sociodemographic differences exist between early and later onset PG [Table 1].,
|Table 1: Classification of gamblers based on the age of onset of pathological gambling|
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The epidemiological analysis of PG is ridden with certain limitations. The studies on the prevalence of PG are only available from some developed countries, and resource-poor nations have limited research on gambling prevalence rates. This prevents the calculation of a true global estimate of the problem. In addition, quantifying the harms related to using these available data has proved to be difficult so far due to methodological limitations.
| Pathological Gambling: Etiology|| |
In an attempt to understand the cause of PG, researchers have explored neurochemical pathways, neuroanatomical regions, genetic predispositions, maladaptive cognitions, and environmental influences as factors associated with PG [Figure 2]., PG shares neurobiological commonalities with the both substance use disorders and impulse control disorders.
The role of neurotransmitters in PG has been evaluated, and several neurotransmitters have been implicated to have a role in the genesis of PG. Elevated levels of norepinephrine have been found in problem gamblers, and the neurotransmitter has a role in arousal, excitement, and attention. Diminished levels of serotonin, a neurotransmitter which has been implicated in impulse control, have been found in problem gamblers. Evidence has been found for glutamate, a neurotransmitter which has been associated with compulsiveness and cognitive inflexibility. Elevated levels of dopamine have been observed among individuals with problem gambling, and this neurotransmitter has a crucial role in reward processing, reward-based learning, and reinforcement. The opioid system which influences pleasure and urges has been suggested to be involves, especially with the demonstrated therapeutic efficacy of opioid antagonist in reducing gambling behaviors. Elevated cortisol levels have been found during gambling suggesting the role of this stress hormone in PG.
The genetic contribution has been established with the help of twin studies that suggest a stronger genetic role than environmental role as perpetuating factor for gambling activities. The monozygotic concordance rate is in the range of 50%–60%. Genes those codes for dopamine D1, D2, and D4 receptors and 5HT 2, 3-dioxygenase, and monoamine oxidase A are implicated in PG.
The key cognitive bias established in those with gambling disorders is the illusion of control, i.e., a sense that one is developing some kind of skill over an outcome that is determined by chance. This thought process is the seed for other cognitive distortions that are associated with gambling disorders such as “gambler's fallacy” (making a prediction that several unfavorable outcomes would be followed by a favorable outcome), “loss-chasing” (trying to win back recently lost money by engaging in more gambling), and “near miss outcomes” (outcomes which are perceived as having been close to a win, but that are in fact losses).,
Several neuroimaging studies have also been conducted among individuals with problem gambling. Functional magnetic resonance imaging and positron emission tomography studies have suggested that individuals with PG have diminished ventromedial prefrontal cortex and striatal activation as compared to controls during simulated gambling conditions. In addition, gambling-related cues have been associated with increased activation of the dorsolateral prefrontal cortex among individuals with PG. Imaging studies have also suggested that loss chasing among individuals with PG has been associated with greater activation of dorsal anterior cingulate and less activation of ventromedial prefrontal cortex. Thus, imaging data have helped to further elucidate the neurobiological underpinnings of PG.
| Internet Gambling|| |
Internet gambling refers to the range of wagering and gaming activities offered through internet-enabled devices, including computers, mobile and smartphones, tablets, and digital television. It is popular as an alternative means to indulge in recreational gambling and some forms are especially popular. It is not a separate type of gambling activity. Rather its mode of access to gamble is different. Online gambling accounted for an estimated 8%–10% of the total global gambling market in 2012. Although the prevalence of internet gambling disorder appears to be relatively low is on the rise. For example, the prevalence rates in internet gambling rose from <1% in 1999 to 8.1% in 2011 in Australia. Internet gambling has unique features that may pose additional risks such as constant availability, easy access, an ability to bet for uninterrupted periods, facilitation by the interactive and immersive internet environment, and the use of digital forms of money (e.g., credit cards, and e-wallets). Males from the young adult age group are likely to active internet gamblers. The studies have also found high rates of physical health and mental health comorbidities, including mood disorders. Internet gamblers are likely to have cognitive distortions about self-leading to low self-esteem, poor self-efficacy, self-doubt, and a negative self-appraisal. Excessive internet gambling could lead to the same physical complications as described for PG.
| Comorbidities Associated with Pathological Gambling|| |
PG has been found to have high rates of comorbidity with other disorders. The highest comorbidity is seen with alcohol use disorders, drug use disorders, tobacco use disorders, and mood disorders. Comorbid personality disorders have also been found to co-occur in those with PG., Around 14% of substance use disorder patients demonstrate PG and around 23% of these demonstrate problem gambling.,
The reason for comorbidity of PG and other disorders is not well understood. They may arise from common vulnerability factors, such as impulsivity or risk-taking. Shared genetic and environmental contributions may also contribute to the co-occurrence of PG and other disorders. For example, first-degree relatives of individuals with PG display increased rates of mood disorder and alcohol dependence. Hence, several factors may play a synergistic role in the co-occurrence of PG with other disorders.
| Assessment and Management of Pathological Gambling|| |
Management of PG starts with establishing a diagnosis. Screening instruments can help in identifying those who are likely to have the disorder while rating scales can track the progression. Tools have been developed to screen for PG such as SOGS  and PG Severity Index. To evaluate for severity, one could use the Yale Brown Obsessive Compulsive Scale adapted for PG  and the Clinical Global Impression-Severity Scale.
While no medicine has yet been approved for the management of PG, pharmacological management of PG could be done with the help of several available psychotropic drugs and opioidergic agents [Table 2].,, Trials comparing the effect of antidepressants to placebos have demonstrated mixed results for both selective serotonin reuptake inhibitors (SSRIs) and non-SSRI drugs. Opioid-receptor antagonists have demonstrated efficacy in managing gambling urge and behavior. Several double-blind placebo controlled studies have demonstrated these findings for naltrexone and nalmefene. Other psychotropic agents such as mood stabilizers and atypical antipyschotics have proven to helpful in those with comorbid psychiatric disorders and specific subtypes of PG. Glutamatergic modulators such as topiramate, N-acetyl cysteine, and memantine have shown promise in reducing the symptoms of PG. Future research in pharmacological management of PG must overcome the limitations of existing studies, such as small sample size, use of nonrepresentative study population, and lack of longitudinal assessments. The current research fails to account for the fact that different subtypes of PG might require the different types of management.
Nonpharmacological interventions play an important role in the long-term management of PG [Figure 3]. Many types of psychotherapy could be useful such as self-help groups such as Gambler's Anonymous (GA), cognitive behavioral therapy, behavioral therapy, psychodynamic therapy, and family therapy. Individual or group therapy sessions targeting specific cognitive processes related to gambling behaviors reduced both symptom severity and the amount of money lost to gambling. A systematic review and meta-analysis of 25 studies were carried out to determine whether cognitive behavioral therapies (CBT) are effective in reducing gambling behavior. All variants of CBT (CBT, motivational interviewing, imaginal desensitization) had a significant impact although there was tentative evidence that when different types of therapy were compared, cognitive therapy had an added advantage. Effect sizes are significant at 6, 12, and 24 months follow-up periods. Overall, there was a highly significant effect of CBT in reducing gambling behaviors within the first 3 months of therapy cessation regardless of the type of gambling behavior practiced. The predictors of relapse are the presence of gambling-related cognitions, an urge to gambling, emotional disturbance, poor social support, sensation-seeking traits, and social functioning. Behavioral therapies that have been used to reduce gambling include aversion therapy, desensitization with the use of imageries, and exposure and response prevention. While the former is an unpopular way of treating PG, therapists have reported success with stimulus control and exposure and response prevention. Enrollment in GA could also be useful. There is limited research to study the usefulness of psychodynamic psychotherapy and family therapy for PG. Both forms therapy have been useful at reducing the interpersonal conflicts associated with PG. The use of harm reduction measures such as limiting playing resources, and playing with cash have been found to be effective. Gambling help lines could prove to be useful in managing the acute crises occurring as a consequence of gambling behavior. Contingency management, virtual therapy using the telephone and internet are some of the unexplored avenues of nonpharmacological interventions in PG. The most effective way to intervene is using a combination of the above approaches. The present literature suggests that early interventions are more effective.
| Conclusion|| |
PG is a persistent and recurrent maladaptive gambling behavior that disrupts personal, family, or vocational pursuits. It is associated with significant psychiatric as well as substance use comorbidity. Gambling behaviors are constantly evolving with time, so there is an ever-growing need to come up with viable treatment options. At present, management strategies include the use of a combination of pharmacological and nonpharmacological interventions. Opioid antagonists, SSRIs, atypical antipsychotics, mood stabilizers, and glutamate modulators have been used for treating PG with the opioid antagonist class of drug showing the most efficacy. Nonpharmacological interventions such as self-help groups, CBT, individual therapy, and family therapy could help reduce gambling behavior.
Translating biological understandings of gambling to interventions is an important step for future research. Further research on gambling behaviors and their management would require the use of more representative study samples, larger sample sizes, and more longitudinal assessments. This would increase the generalizability of study findings and help achieve a better understanding of the disorder. Furthermore, culturally sensitive assessment measures need to be developed and interplay of contextual social characteristics of gambling need to assessed.
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[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2]