Pathological
gambling usually begins in adolescence in men and later in life in women. The
onset is usually insidious, although some individuals may be “hooked” by their
first bet. There may be years of social gambling with minimal or no impairment
fol-lowed by an abrupt onset of pathological gambling that may be precipitated
by greater exposure to gambling or by a psychoso-cial stressor. The gambling
pattern may be regular or episodic, and the course of the disorder tends to be
chronic. Over time, there is usually a progression in the frequency of
gambling, the amounts wagered, and the preoccupation with gambling and with
obtaining money with which to gamble. The urge to gamble and gambling activity
generally increase during periods of stress or depression, as an attempted
escape or relief (criterion A5). Rosenthal (1992) described four typical phases
in the course of a typical male patient with pathological gambling: winning,
losing, desperation and hopelessness.
Winning Many male gamblers become
involved with gambling because they
are good at it and receive recognition for their early successes. Women with
pathological gambling are less likely to have a winning phase. Traits that
foster a winning phase and are typical of male patients with pathological
gambling are competi-tiveness, high energy, ability with numbers and interest
in the strategy of games. The early winnings lead to a state in which a large
proportion of the gambler’s self-esteem derives from gam-bling, with
accompanying fantasies of winning and spectacular success.
Losing A string of bad luck or a feeling
that losing is intolerable may be
the precipitant of chasing behavior; previous gambling strategies are abandoned
as the gambler attempts to win back ev-erything all at once. The gambler
experiences a state of urgency, and bets become more frequent and heavy. Debts
accumulate, and only the most essential are paid. Covering up and lying about
gambling become more frequent. As this is discovered, relation-ships with
family members deteriorate. Losing gamblers use their own and their family’s
money, go through savings, take out loans and finally exhaust all legitimate
sources. Eventually, they cannot borrow any more, and faced with threats from
creditors or loss of a job or marriage, they go to their family and finally
confess. This results in the “bailout”: debts are paid in return for a promise
to stop or cut down gambling. Any remission, if achieved at all, is
short-lived. After the bailout there is an up-surge of omnipotence; the gambler
believes that it is possible to get away with anything, bets more heavily and
loses control altogether.
Desperation This stage is reached when the
gambler begins to do things that
would previously be inconceivable: writing bad checks, stealing from an
employer, or other illegal activities. Done once, these behaviors are much more
likely to be repeated. The behavior is rationalized as a short-term loan with
an inten-tion to pay it back as soon as the winning streak arrives. The gambler
feels just one step away from winning and solving all the problems. Attention
is increasingly taken up with illegal loans and various scams to make money.
The gambler becomes irritable and quick tempered. When reminded of
responsibilities or put in touch with guilt feelings, the gambler responds with
an-ger and projective blame. Appetite and sleep deteriorate and life holds
little pleasure. A common fantasy at this stage is of start-ing life over with
a new name and identity, the ultimate “clean slate”.
Hopelessness For some gamblers, there is a
fourth stage in which they suddenly
realize that they can never get even, but they no longer care. This is often a
revelation, and the precise moment when it occurred is often remembered. From
this point on, just playing is all that matters. Gamblers often acknowledge
knowing in advance that they will lose and play sloppily so that they lose even
if they have the right horse or a winning hand. They seek action or excitement
for its own sake and gamble to the point of exhaustion.
Few
gamblers seek help in the winning phase. Most seek help only during the later
phases and only after a friend, family member, or employer has intervened.
Two-thirds of the gamblers have committed illegal activities by then, and the
risk of suicide increases as the gambler progresses through the phases of the
illness.
Without
treatment, the prognosis of pathological gambling is poor. It tends to run a
chronic course with increasing morbidity and comorbidity, gradual disruption of
family and work roles and relationships, depletion of financial reserves,
entanglement with criminals and the criminal justice system and, often, suicide
at-tempts. In the hands of an experienced psychiatrist, it is an “ex-tremely
treatable disorder” with a favorable prognosis (Rosen-thal, 1992). The
difference between a poor and a good prognosis depends on treatment, and
treatment depends on a diagnosis. As noted earlier, the diagnosis of pathological
gambling is often missed in clinical settings because mental health
professionals do not think to ask about it. Because most patients with
pathological gambling do not see themselves as having a disorder and many of
them do not even consider themselves as having a problem with gambling,
collateral information from a family member may be extremely helpful.
The goals
of treatment of an individual with pathological gam-bling are the achievement
of abstinence from gambling, rehabili-tation of the damaged family and work
roles and relationships, treatment of comorbid disorders and relapse
prevention. This ap-proach echoes the goals of treatment of an individual with
sub-stance dependence. Inpatient treatment in specialized programs may be
considered if the gambler is unable to stop gambling, lacks significant family
or peer support, or is suicidal, acutely depressed, multiply addicted, or
contemplating some dangerous activity.
No
standard treatment of pathological gambling has emerged. Despite many reports
of behavioral and cognitive in-terventions for pathological gambling, there are
minimal data available from well-designed or clearly detailed treatment
stud-ies. Pharmacologic treatments offer promise, but research-guided
approaches are still insufficient to offer a standardized approach. Therefore,
general approaches, based in clinical experience and available resources (such
as Gamblers Anonymous or other sup-port groups) should be considered.
The
treatment of pathological gambling may consist of participation in Gamblers
Anonymous, individual therapy, fam-ily therapy, treatment of comorbid disorders
and medication treatment. As is the case for substance dependence, the gambler
needs to be abstinent to be accessible to any or all of these treat-ment
modalities. For many gamblers, participation in Gamblers Anonymous is
sufficient, and it is an essential part of most treat-ment plans. Gamblers
Anonymous is a 12-step group built on the same principles as Alcoholics
Anonymous. It utilizes empathic confrontation by peers who struggle with the
same impulses and a group approach. Gam-Anon is a peer support group for family
members of patients with pathological gambling. Extensive data are lacking, but
overall Gamblers Anonymous appears some-what less effective than Alcoholics
Anonymous in achieving and maintaining abstinence.
Individual
therapy is often useful as an adjunct to Gam-blers Anonymous. Rosenthal (1992)
stressed that to maintain abstinence and use Gamblers Anonymous successfully,
many gamblers need to understand why they gamble. Therapy involves confronting
and teasing out the vicissitudes of the patient’s sense of omnipotence and
dealing with the various self-deceptions the defensive aspects of the patient’s
lying, boundary issues, and problems involving magical thinking and reality.
Relapse prevention involves knowledge and avoidance of specific trig-gers. In
addition to psychodynamic therapy, behavioral treatment of pathological
gambling has been proposed, with imagined de-sensitization achieving better
rates of remission than aversive conditioning.
The
greatest differences between the treatment of patho-logical gambling and other
addictions are in the area of family therapy. Because relapse may be difficult
to detect (there is no substance to be smelled on the patient’s breath, no
dilated or con-stricted pupils, no slurred speech or staggered gait) and
because of a long history of exploitative behavior by the patient, the spouse
and other family members tend to be more suspicious of, and angry at, the
patient with pathological gambling compared with families of alcoholic
patients. Frequent family sessions are often essential to offer the gambler an
opportunity to make amends, learn communication skills and deal with
preexisting intimacy problems. In addition, the spouse and other family members
have often acquired their own psychiatric illnesses during the course of the
patient’s pathological gambling and need individualized treatment to recover.
Although
research reports of the pharmacological treatment of pathological gambling have
begun to emerge, there are still, as yet, insufficient data to come to any
conclusions about the utility of medication. Small trials have reported on the
use of SSRIs, mood stabilizers and naltrexone with the recommendation of dosing
at the high end of usual treatment ranges.
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