When Gambling Disorder first entered the lexicon of psychiatry in the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III), it was a disorder of impulse control, alongside others like Kleptomania and Pyromania. Several decades later, Gambling Disorder is now recognized as most similar to substance use disorders.
Although there is no substance ingestion or state of intoxication, gamblers do have a distinct pattern of hallmark behaviors. Patients appear depressed and display an irritable or anxious mood. They can’t find pleasure in their old hobbies (anhedonia) and often seclude themselves from their loved ones. They have pervasive issues with finances: over-borrowing, stealing, needing a second job, arguing about money, and trying to convince others to gamble with them. They become irresponsible in other areas of their lives, failing both at work and at home. Problem gambling can even have negative physical health effects: appetite changes, impaired sex drive, and vague physical complaints like headaches and abdominal pain.
Gamblers often have a number of rituals, superstitions, or beliefs associated with playing that they use to build an illusory sensation of control over the outcomes of the games they play. Over 80% demonstrate some dependence on “Active Illusory Control”. This term includes schemes of luck and fantasies of skill in games that are, in fact, fundamentally chance-based. The ‘gambler’s fallacy’ is another distortion wherein problem gamblers believe that the outcomes of a short series of random, individual events (such as rolling dice) are predictive of the future outcomes. For example, a gambler may expect a higher chance of rolling two sixes if that combination has not occurred recently. This fuels them to continue gambling to regain losses because they naively believe that a bad ‘run’ must turn in their favor if they keep playing.
Many gamblers are drawn in simply by the availability of games and maintained by the arousing experience. Those who use gambling to retreat from negative emotions, especially people who suffered from depression or anxiety prior to gambling, tend to have more significant difficulties with gambling. For the most severely affected, gambling is only a part of a bigger picture of drug and alcohol issues, personality disorders, and criminality.
Causes and Risk Factors
Like with other substances of abuse, people tend to be at higher risk of developing Gambling Disorder if they start at younger ages, especially under age 21. Starting at an early age, men are at consistently higher risk of developing Gambling Disorder. Adolescent problem gamblers often use gambling to escape from stress. They suffer more abuse at the hands of adults and have poor coping skills. Adolescents who develop gambling problems tend to be more impulsive, impatient, and prone to risk-taking behaviors than their peers.
Problem gambling occurs alongside depressive disorders, anxiety disorders, Attention Deficit/Hyperactivity Disorder, and Obsessive-Compulsive Disorder. Personality characteristics such as impulsivity and sensation seeking increase the risk of problem gambling. Personality disorders, like Antisocial Personality Disorder, are also more common in problem gamblers, and there are higher rates of criminal behavior.
Drug use and gambling
In both adolescents and adults, gambling on the internet is most strongly associated with Gambling Disorder and an associated Alcohol Use Disorder. In addition to alcohol, other substance use disorders are strongly correlated with problem gambling. Genes account for well over half the likelihood of developing both Gambling Disorder and another substance use disorder.
Abnormal dopamine regulation seems to play a role in Gambling Disorder because it occasionally occurs in people being treated with dopaminergic (meaning they act like dopamine does) drugs. The rate of Gambling Disorder in people on these medications (such as those with Parkinson’s Disease) is about 8%, several times higher than that in the general population, 0.42%. Genetic studies have confirmed that there is a specific dopamine receptor type in the brain shared between substance use disorders and Gambling Disorder.
Risk for suicide
Many gamblers suffer from a depressed mood, half have thought about suicide, and 17% have attempted it. Prior mental health conditions and drug and alcohol use in combination with gambling increase the risk of suicide. Suicidal gamblers tend to have started gambling earlier, lost more money, and have greater problems related to gambling than non-suicidal gamblers. They also have higher rates of interpersonal conflict in their home lives and increased frequency of divorce.
Diagnosing Gambling Disorder
Gambling Disorder is the only one of these disorders that does not involve an actual drug. However, even though there is nothing to smoke, drink, inject, or inhale, there is still a physical component. Gambling affects the brain and, through it, the body as well. People feel excited while gambling and anxious when attempting to stop.
What counts as gambling?
Gambling usually brings to mind cards being dealt, a roll of the dice, and the lights and bells of slot machines. But people can gamble on any unpredictable event, like sporting events, lotteries, and animal races, and most gamblers have a preferred style. The common theme is that the players take a risk for the chance of winning a greater reward.
Patients with Gambling Disorder meet at least four of nine criteria over a 12 month period.
- They need to gamble with progressively larger sums of money to gain the same levels of thrill
- Patients have failed multiple times in their efforts to stop or cut back
- They become irritable and anxious when trying to stop
- Gambling is an obsession, pervading patients’ daily thoughts, dominating their memories, and sapping their productive energy
- Patients often use gambling to deal with unpleasant emotions
- After losing money, they try to regain their losses by continuing to gamble
- Patients lie about how much they gamble
- Gambling has negatively impacted patients’ family, social, and work domains
- They often have to ask others for money when they have lost too much
Symptoms can be constant, separated by periods of abstinence of many months, or patients can even have periods of controllable gambling. Symptoms cannot be due to a manic episode.
Treating Gambling Disorder
Retrain the brain with Cognitive Behavioral Therapy
CBT focuses on the irrational beliefs and behaviors that patients have surrounding gambling. By understanding the thought processes that lead people to continue to gamble when they continue to lose, CBT can be customized to target Gambling Disorder. In fact, this is one of the key differences between non-problem gamblers and those with Gambling Disorder: Gambling addicts cannot stop even when they are behind.
Patients have inaccurate ideas about the concept of randomness and about their ability to affect the outcome of the games. CBT involves changing these cognitive distortions which are specific to Gambling Disorder. Treatment programs also teach social skills, problem solving techniques (such as budgeting and finance management), and trigger avoidance (identifying and dealing with situations that put patients at risk to relapse).
Adding peer support
Gamblers Anonymous (GA) focuses on the “medical model” of problem gambling, painting it as a disease with no gray areas and for which the best treatment is abstinence. GA follows a 12-step model like that of Alcoholics Anonymous but stands out because of its greater focus on the financial issues unique to gamblers. Unfortunately, despite its association with the successful 12-step model, GA experiences high drop out rates, and there is a lack of evidence supporting its use beyond as a supplemental treatment.
The majority of gambling disorder treatment is targeted therapies and group support programs, but recent studies show some promise with medications. A few studies support treatment with selective serotonin reuptake inhibitors (SSRIs), like Luvox (fluvoxamine). Unfortunately, there is a significant placebo effect that blurs these results.
Naltrexone, which is useful in treating alcohol and opiate use disorders, helps reduce urges and craving in problem gambling. Three-quarters of patients in a study of naltrexone showed significant progress on standardized gambling severity scales over 6 weeks of treatment.
Managing Gambling Disorder
The National Council on Problem Gambling (NCPG) offers a national hotline (1-800-522-4700) available 24/7, and some states offer more local helplines. Help is also available via text messaging to the same number and online chat. These hotlines will refer callers to treatment resources in their areas. Gamblers Anonymous also provides state-by-state hotlines with resources and local referrals.
These hotlines can also help in triggering situations. Once a patient has managed to stop gambling, the focus is on preventing relapse. It is a bad idea to tempt this with a single bet, which can rapidly lead to a full return to uncontrollable behavior.
Gamblers should not avoid treatment because of fear the expense. Despite its lack of strong evidence, GA is, if nothing else, a good place to start simply because it is free. Additionally, SMART Recovery, a self-help group focusing on urge management and behavior modification, offers much-needed free recovery services. Financial issues plaguing problem gamblers resolve rather quickly after treatment is begun. When the periodic drain of gambling is removed, people are able to begin the process of settling their debts.
If you think you or someone close to you may have a problem with gambling, GA’s 20 question quiz is an easy, at-home assessment tool that closely approximates clinical diagnostic criteria. You can also ask your doctor about the South Oaks Gambling Screen (SOGS), a gambling severity screen used in research. The National Council on Problem Gambling also provides an online self assessment tool.