Impulse Control Disorders

Impulse Control Disorders

Gambling

·        = The addiction you can‟t see.  The new mental disorder on the block

·        Epidemiology:

o  1 – 3 % of population are pathological gamblers. There are no longer stereotypical groups – young and women also now affected

o  Maori 3 times more likely, Pacific Islanders 6 times more likely (heavy socio-economic confounding)

o  2/3 of presenting problem gamblers are under 30.  Average age is decreasing

o  90% of the population gamble (Dept Internal Affairs figures). $600 per family per year (cf $200 in the US)

o  Gambling has increased by 700% in the last decade. There has been significantly increased access to all forms of gambling (without social research)

o  Mode of gambling of people with pathological gambling disorder: 60% non-casino pokies

·        Diagnosis:

o  Should screen early on in relationship with GP: later on won‟t tell due to embarrassment 

o  Features: Preoccupation with gambling, needs to gamble more to get the same excitement (ie tolerance), repeated and unsuccessful efforts to cut back or control, restless or irritable when trying to cut down (ie withdrawal), gambles as a way of dissociation, after loosing returns to chase their losses, lies to conceal extent of gambling, has jeopardised or lost a job or relationships, etc

o   Other features: 

§  Impacts for physical health: can‟t afford to go to doctor, usually heavy smokers, often have co-morbid anxiety, depression, alcohol or drug disorder (NB – screen for depression in affected families), high suicidality 

§  Will use their own money then may resort to crime (usually fraud, forgery & theft). Crimes unsophisticated, effected in haste and often first offence

·        Theories re aetiology:

o   Reward deficiency syndrome

o   General theory of addiction: unresolved/maladaptive issues from the past

o   Behavioural/environmental conditioning

o   Social learning (eg permissive culture)

·        Phases in the course of the illness:

o   For gambler: winning, losing, desperation, critical, rebuilding, growth

o   For spouse: denial, stress, exhaustion, critical, rebuilding, growing

·        Problems with thinking in gamblers:

o   Irrational style of thinking

o   Illusions of control (“if I study the horses enough I‟ll win)

o   Superstitious beliefs (“I feel lucky today”)

o   Biased evaluations

o   By the time gambling is pathological, they don‟t care whether they win or lose, just want to do it

·        Help to offer:

o   Treat depression

o   Financial/budget advice: easy way to engage, encourage contemplation

o   Information (eg about „controlled gambling‟ as an option for „early‟ problem gamblers)

o   Helpline: 0800 NOGAMBLE

o   Referral services: outpatients, Compulsive Gambling Society, Odyssey House