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Chapter: Essentials of Psychiatry: Impulse Control Disorders

Pathological Gambling: Course and Treatment

Pathological gambling usually begins in adolescence in men and later in life in women.



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.


Typical Phases


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.




Overall Goals of Treatment


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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