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Chapter: Essentials of Psychiatry: Impulse Control Disorders

Pathological Gambling

Gambling as a behavior is common. Current estimates suggest that approximately 80% of the adult population in the US gamble.

Pathological Gambling




Gambling as a behavior is common. Current estimates suggest that approximately 80% of the adult population in the US gamble. The amount of money wagered legally in the USA grew from $17 billion in 1974 to $210 billion in 1988, an increase of more than 1200%, making gambling the fastest growing industry in America. DSM-IV-TR covertly recognized the ubiquity of gam-bling behavior and the desire to gamble by the careful wording of criterion A for pathological gambling: “Persistent and recurrent maladaptive gambling behavior as indicated by five (or more) of the following”. This definition of pathological gambling dif-fers from some other definitions of impulse control disorders not elsewhere classified, which are worded as “Failure to resist an impulse to”. This difference implies that neither gambling be-havior nor failure to resist an impulse to engage in it is viewed as pathological in and of itself. Rather, the maladaptive nature of the gambling behavior is the essential feature of pathological gambling and defines it as a disorder.


Etiology and Pathophysiology


Pathological gambling has been included as a disorder of im-pulse control. Pathological gambling can also be viewed as an addictive disorder, an affective spectrum disorder and an obses-sive–compulsive spectrum disorder. DSM-IV-TR maintains a close relationship between pathological gambling and addictive disorders in that several of the diagnostic criteria for pathological gambling were intentionally made to resemble criteria for sub-stance dependence.


The parallels between pathological gambling and addictive disorders are manifold. Pathological gambling has been viewed as the “pure” addiction, because it involves several aspects of addictive behavior without the use of a chemical substance. The parallels between substance dependence, in particular alcohol dependence and pathological gambling have led to the successful adoption of the self-help group model of Alcoholics Anonymous to Gamblers Anonymous. Patterns of comorbidity also suggest a possible link between pathological gambling and addictions, in particular alcoholism. In addition to the comorbidity of patho-logical gambling and substance use disorders, family studies have demonstrated a familial clustering of alcoholism and patho-logical gambling. As high as 50% of patients with pathological gambling have a parent with alcoholism and a family history of substance dependence in patients with pathological gambling. There is also a greater prevalence of pathological gambling in parents of patients with pathological gambling.


The links between pathological gambling and affective disorders are also supported by family studies that demonstrate high rates of affective disorders in first-degree relatives of patients with pathological gambling as well as by high rates of comorbid-ity of pathological gambling and affective disorders. In addition, as noted by many authors and incorporated in the DSM-IV-TR criteria for pathological gambling, many patients with patho-logical gambling gamble as a way of relieving dysphoric moods(criterion A5), and cessation of gambling may be associated with depressive episodes in the majority of recovering gamblers.


The links between pathological gambling and obsessive spectrum disorders are less clear. Although a popular name for pathological gambling is compulsive gambling, the vast major-ity of patients with pathological gambling do not experience the urge to gamble as egodystonic until late in the course of their illness, after they have suffered some of its consequences. The rates of comorbidity of pathological gambling and OCD and ob-sessive–compulsive personality disorder are not nearly as high as the rates of comorbidity of pathological gambling and affec-tive and addictive disorders. Nevertheless, pathological gambling shares several characteristics with compulsions: it is repetitive, often has ritualized aspects, and is meant to relieve or reduce dis-tress. Moreover, sporadic reports on the effectiveness of SSRIs in the treatment of pathological gambling suggest a possible link to obsessive spectrum disorders (Hollander et al., 1992).


Neurotransmitter Function in Pathological Gambling


The as sociation between altered function of the serotonin neu-rotransmitter system and impulsive behaviors has focused atten-tion on a potential role for serotonin function in the neurophysiol-ogy of pathological gambling. Several studies have provided data supporting such a link. However, direct measure of cerebrospinal fluid 5-HIAA in pathological gamblers has yielded mixed results. Preliminary data supports potential utility of serotonin reuptake inhibitor medications in the treatment of pathological gambling.


Genetic Contribution


The incidence of pathological gambling among first degree family members of pathological gamblers appears to be approximately 20%. Inherited factors may explain 62% of variance in the diag-nosis and some of these genetic factors may also contribute to the risk for conduct disorder, antisocial personality disorder and alcohol abuse (Eisen et al., 2001). At this time, early molecular genetics studies of pathological gamblers point to possible as-sociated polymorphisms in genes that code for both serotonergic and dopaminergic factors (Ibanez et al., 2002).


Psychodynamic Considerations


Psychoanalytic theories of gambling were the first systematic at-tempts to account for pathological gambling. Erotization of the fear, tension and aggression involved in gambling behavior, as well as themes of grandiosity and exhibitionism, were explored by several authors during the first quarter of the 20th century. Freud (1961), in his influential essay on Dostoyevsky, suggested that the pathological gambler actually gambled to lose, not to win, and traced the roots of the disorder to the ambivalence felt by the young man toward his father. The father, the object of his love, is not only loved but also hated, and this results in uncon-scious guilt. The gambler then loses to punish himself, in what Freud labeled “moral masochism”. Freud also spoke of “feminine masochism” in which losing is a way of gaining love from the father, who will somehow reward the loser for loyalty. To lose is to suffer, and for the feminine masochist, suffering equals love. Interestingly, in the later spirit of DSM-IV-TR, Freud also con-ceptualized pathological gambling as an addiction and included it in a triad with alcoholism and drug dependence. He saw all three as manifestations of that primary addiction, masturbation, or at least masturbatory fantasies. Like most researchers after him, Freud focused only on male gamblers.


Bergler, a psychoanalyst who actually treated many pa-tients with pathological gambling, expanded on Freud’s idea that the pathological gambler gambles to lose. He traced the roots of this desire to lose to the rebellion of gamblers against the author-ity of their parents and against the parents’ intrusive introduc-tion of the reality principle into their lives. The rebellion causes guilt, and the guilt creates the need for self-punishment. Bergler thought that the gambler’s characteristic aggression is actually pseudoaggression, a craving for defeat and rejection. He saw the gambler as one who perpetuates an adversarial relationship with the world. The dealer in the casino, the gambler’s opponents at the card table, the stock exchange and the roulette wheel are all unconsciously identified with the refusing mother or the rejecting father. Overall, psychoanalytic approaches to pathological gam-bling (Lesieur and Rosenthal, 1991) generally conceptualized it as either a compulsive neurosis (Freud, Bergler, Rosenthal) or an impulse disorder. Several published case reports docu-mented the successful treatment of pathological gambling by psychoanalysis.


Learning theories of pathological gambling focus on the learned and conditioned aspects of gambling and use the quan-tifiable nature of the behavior to test specific hypotheses. One hypothesis was that patients with pathological gambling crave the excitement and tension associated with their gambling, as evidenced by the fact that they are much more likely to place last-second wagers than are low-frequency gamblers, to prolong their excitement. Higher wagers placed by patients with pathological gambling also produce greater excitement, and greater amounts of money are required to achieve the same “buzz” over time, an observation incorporated in the diagnostic criteria for pathologi-cal gambling (criterion A2).


Assessment and Differential Diagnosis


It is not difficult to diagnose pathological gambling once one has the facts. It is much more of a challenge to elicit the facts, because the vast majority of patients with pathological gambling view their gambling behavior and gambling impulses as egosyntonic and may often lie about the extent of their gambling (criterion A7). Patients with pathological gambling may first seek medical or psychological attention because of comorbid disorders. Given the high prevalence of addictive disorders in pathological gam-bling and the increased prevalence of pathological gambling in those with alcoholism and other substance abuse, an investigation of gambling patterns and their consequences is warranted for any patient who presents with a substance abuse problem. Likewise, the high rates of comorbidity with mood disorders suggest the utility of investigating gambling patterns of patients presenting with an affective episode.


The spouses and significant others of patients with path-ological gambling deserve special attention. Individuals with pathological gambling usually feel entitled to their behavior and often rely on their families to bail them out (criterion A10). As a consequence, it is often the spouse of the patient with patho-logical gambling who first realizes the need for treatment and who bears the consequences of the disorder. Lorenz (1981) con-ducted a survey of 103 wives of pathological gamblers who at-tended Gam-Anon meetings (for family members of patients with pathological gambling). She found that most spouses had to borrow money and were harassed or threatened by bill col-lectors. Most spouses physically assaulted the gambler, verbally abused their children, and experienced murderous or destructive impulses toward the gambler. Although the gamblers themselves

appeared less violent than the general population norms, their spouses were more violent, possibly because of desperation and anger. Eleven percent of the spouses of patients with pathological gambling admitted to having attempted suicide, and this result was replicated in a later study. These findings have two main im-plications for the assessment of pathological gambling: first, the spouse may be a valuable and motivated informant who should be questioned about the patient’s behavior, and secondly, spouses should be specifically asked about the effects of the patient’s ill-ness on their own well-being and functioning and about suicidal ideation and attempts and the control of their own impulsivity.


An important and understudied area is the clinical pre-sentation of pathological gambling in women. Women constitute a third of all patients with pathological gambling in epidemio-logical studies. However, they are extremely underrepresented in treatment populations, and most psychoanalytic theories of path-ological gambling ignore them completely. Part of this bias may be due to the fact that gambling carries a greater social stigma for women, that women gamblers are more likely to live and to gam-ble alone, and that treatment programs for pathological gambling in the USA were first pioneered in Veterans Hospitals. Compared with men with pathological gambling, women with pathological gambling are more likely to be depressed and to gamble as an escape rather than because of a craving for action and excitement. Pathological gambling begins at a later age in female than in male gamblers, often after adult roles have been established. Big win-ning is usually less important than the need to impress. Women typically play less competitive forms of gambling in which luck is more important than skill, and they play alone. Their progres-sion into the disorder is often more rapid, and the time between the onset of the disorder and the time they present for treatment is usually much shorter than for men (3 years compared with 20 years). The shorter duration makes for a better prognosis in treat-ment, but, unfortunately, few of the women with pathological gambling ever come to treatment.


The differential diagnosis of pathological gambling is relatively simple. Pathological gambling should be differentiated from professional gambling, social gambling and a manic epi-sode. Social gambling, engaged in by the vast majority of adult Americans, typically occurs with friends or colleagues, lasts for a specified time, and is limited by predetermined acceptable losses. Professional gambling is practiced by highly skilled and disciplined individuals and involves carefully limited risks. Many individuals with pathological gambling may feel that they are ac-tually professional gamblers. Chasing behavior and unplanned losses distinguish the pathological gamblers. Patients in a manic episode may exhibit a loss of judgment and excessive gambling resulting in financial disasters. A diagnosis of pathological gam-bling should be given only if a history of maladaptive gambling behavior exists at times other than during a manic episode. Prob-lems with gambling may also occur in individuals with antisocial personality disorder. If criteria are met for both disorders, both can be diagnosed.


Epidemiology and Comorbidity


Prevalence and Incidence


Pathological gambling is considered to be the most common of the impulse control disorders not elsewhere classified. The number of people whose gambling behavior meets criteria for pathological gambling in the USA is estimated to be between 2 million and 6 million. Surveys conducted between 1986 and 1990 in Maryland,

Massachusetts, New York, New Jersey and California estimated the prevalence of “probable pathological gamblers” among the adult population to be between 1.2 and 2.3%. These states have a broad range of legal wagering opportunities and a heterogeneous population. Similar surveys in Minnesota and Iowa, states with limited legal wagering opportunities and more homogeneous populations, yielded prevalence rates of 0.9 and 0.1%, respec-tively. It thus appears that availability of gambling opportunities as well as demographic make-up may influence the prevalence of pathological gambling. The combined total of “pathological gam-blers” and “problem gamblers” is 5.5 million adult Americans. During the past 20 years, many states have turned to lotteries as a way of increasing their revenues without increasing taxes. At this time, some form of gambling is legal in 47 of the 50 states, as well as in more than 90 countries worldwide. From 1975 to 1999 revenues from legal gambling in the USA has risen from $3 to 58 billion. (Given the dramatic increase in the amounts of money wagered in legal gambling activities during the past 20 years, the prevalence and incidence of pathological gambling are expected to increase.)


It is estimated that women make-up to one-third of all Americans with pathological gambling. Nevertheless, they are underrepresented in Gamblers Anonymous, in which only 2 to 4% of the members are women. The reason for this discrep-ancy was postulated to be the greater social stigma attached to pathological gambling in women and the characteristic pattern of solitary gambling in women. Nonwhites and those with less than a high school education are more highly represented among pathological gamblers than in the general population. The demo-graphic make-up of patients in treatment for pathological gam-bling differs substantially from the demographics of all patients with pathological gambling. Jewish persons are overrepresented in treatment settings and in Gamblers Anonymous, whereas women, minorities and those younger than age 30 years are un-derrepresented in Gamblers Anonymous and in treatment.




Overall, patients with pathological gambling have high rates of comorbidity with several other psychiatric disorders and condi-tions. Individuals presenting for clinical treatment of pathological gambling apparently have impressive rates of comorbidity. Ibanez and coworkers (2001) reported 62.3% of one group seeking treat-ment had a comorbid psychiatric disorder. The most frequent diagnosis they found were personality disorders (42%), alcohol abuse or dependence (33.3%) and adjustment disorders (17.4%).


Mood Disorders


There is evidence for extensive comorbidity of pathological gambling with major depressive disorder and with bipolar dis-order. In several surveys, between 70 and 80% of all patients with pathological gambling also had mood symptoms that met criteria for a major depressive episode, a manic episode, or a hypomanic episode at some point in their life. More than 50% had recurrent major depressive episodes. A complicating factor is that recovering pathological gamblers may experience depres-sive episodes after cessation of gambling. In addition, some pa-tients with pathological gambling may gamble to relieve feelings of depression (criterion A5). Despite criterion B for pathological gambling, which essentially precludes the diagnosis of pathologi-cal gambling if the behavior occurs exclusively during the course of a manic episode, many patients have a disturbance that meets criteria for both disorders because they gamble both during andbetween manic and hypomanic episodes. Between 32 and 46% of patients with pathological gambling were reported also to have mood symptoms that meet criteria for bipolar disorder, bipolar II disorder, or cyclothymic disorder.




Although data is not yet conclusive, a meaningful association be-tween problem gambling and suicidal behavior and/or ideation appears to exist. Between 12 and 24% of patients with pathologi-cal gambling in various settings have had a history of at least one suicide attempt. In one study, 80% of patients with pathological gambling had a history of either suicide attempts or suicidal ide-ation (Lesieur and Rosenthal, 1991).


Substance Abuse and Dependence


Studies of prevalence of comorbid substance use disorders yield widely varying results; from 9.9% for alcohol and other substance dependence to 44% for alcohol dependence and 40% for illicit drug dependence. Using a structured instrument, between 5 and 25% of substance-abusing patients in several settings were found to meet criteria for pathological gambling and an additional 10 to 15% were considered to have “gambling problems” (Lesieur and Rosenthal, 1991). Among individuals with pathological gam-bling, individuals with higher socioeconomic status (SES) are more likely to have concurrent problems with alcohol abuse than are gamblers with lower SES.


Other Disorders


Again, current data are inconclusive, but OCD, panic disorder, generalized anxiety disorder and eating disorders have all been reported present in higher rates in patients with pathological gambling than in the general population. The reported preva-lence of OCD among pathological gamblers ranges from 0.9 to 16%. Narcissistic and antisocial personality disorders are be-lieved to be overrepresented in patients with pathological gam-bling, and pathological narcissism is assumed by some psycho-analysts to underlie the entitlement displayed by many patients with pathological gambling. In addition, retrospective studies suggest that many patients with pathological gambling may have had symptoms that met criteria for attention-deficit/hyperactivity disorder as children. In addition to psychiatric disorders, patients with pathological gambling may manifest greater prevalences of stress-related medical conditions, like peptic ulcer disease, hy-pertension and migraine.


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