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Gambling Addiction Back to Course Index

 

 


Gambling addiction or gambling disorder is defined as a persistent and recurring problematic gambling behavior that causes distress and impairs someone’s overall livelihood. Gambling addiction affects roughly 0.2% to 0.3% of the general U.S. population and tends to affect males more than females, though this gender gap has narrowed in recent years.  Gambling problems can co-occur with other behavioral health conditions, such as substance use disorders (SUDs). Behavioral health treatment providers need to be aware that some of their clients may have gambling problems in addition to the problems for which they are seeking treatment. This course provides a brief introduction to pathological gambling, gambling disorder, and problem gambling as well as explores signs, symptoms, and treatment modalities.

Gambling is defined as risking something of value; usually, money, on the outcome of an event decided at least partially by chance. Lottery tickets, bingo games, blackjack at a casino, the Friday night poker game, the office sports pool, gambling Websites, horse and dog racing, animal fights, and slot machines—there are now more opportunities to gamble than ever before.

More than 75 percent of Americans ages 18 and older have gambled at least once, and many people view gambling as a harmless form of entertainment.  For some, it is; for others, gambling can become a serious issue.

When people seek help, financial pressures resulting from their gambling problem are often the main reason they seek treatment, not a desire to abstain from gambling.

 

In addition, people with a gambling problem are more likely to have sought help for other behavioral health conditions than for their gambling problem.

Behavioral health services providers need to be aware of signs and financial and legal consequences that may indicate excessive gambling.

The following behaviors are potential signs of gambling addiction:

  • Needing to gamble using increasing amounts of money to achieve the desired rush and excitement.

  • Feeling restless or irritable when trying to reduce or stop gambling.

  • Inability to control, reduce, or quit gambling despite numerous repeated attempts.

  • Preoccupation with gambling, such as devising ways to get more gambling money and reliving past gambling experiences.

  • Gambling when experiencing feelings of distress, helplessness, guilt, anxiety, and depression.

  • Chasing after your losses to get even after losing money gambling.

  • Lying to conceal the severity of gambling behaviors and the addiction.

  • Loss of personal relationships, job, and educational pursuits due to gambling.

  • Relying on others to provide money to resolve financial situations caused by gambling, such as a threat of eviction from the home.

Those with a mild gambling addiction may exhibit between four and five of these behaviors, while those with a moderately severe gambling addiction may exhibit six to seven of these behaviors. People who suffer from severe gambling addiction will usually exhibit all nine behaviors. Moderate to severe cases of gambling disorder tend to be more common than mild cases.

If the client assessment reveals a problem with gambling, then that disorder (and its consequences) is a major issue in the client’s treatment for any behavioral health condition. Furthermore, a variety of other problems can be related to gambling, including victimization and criminalization; social problems; and health
issues, including a higher risk of contracting sexually transmitted diseases and HIV/AIDS.

Gambling problems are associated with poor health, several medical disorders, and increased medical utilization—perhaps adding to the country’s healthcare costs.

People with pathological gambling tend to have lower self-appraisal of physical and mental health functioning than those who gamble little or not at all; people with gambling problems are significantly more likely than low-risk individuals to rate their health as poor. People with gambling problems are also more likely to have received expensive medical services during the prior year, such as treatment in an emergency department.

As shown here, a gambling disorder can affect physical health, mental health, and social functioning and lead to the loss of important relationships with friends and loved ones. An individual may also suffer a decline in work or school performance and feel more restless and bored with all other areas of life that don’t involve gambling.

Those who suffer from gambling addiction tend to suffer from higher rates of poor general health than those who don’t gamble. Tachycardia and angina are common health problems among those diagnosed with gambling addiction. Many who suffer from gambling disorder also tend to experience distortions in thinking surrounding their addiction, such as superstitions, overconfidence, and a sense of power over the outcome of chance events. Nearly 50% of those receiving treatment for gambling disorder experience suicidal ideation, while an estimated 17% have tried to commit suicide.

The negative effects of problem gambling include:

  • Financial problems including high debt, poverty, or bankruptcy
  • Domestic violence and child abuse in families
  • Suicidal thoughts, attempts, or the act of suicide
  • Legal troubles, including arrests for theft or prostitution
  • Behavior problems in children of problem gamblers
  • Depression, anxiety, and other mental health disorders
  • Loss of relationships with friends and family
  • A decline in performance at work or school
  • Suicide and death
  • A risk for drug or alcohol abuse


What Are Pathological Gambling, Gambling Disorder, and Problem Gambling?

Pathological gambling was a diagnosis formerly included in the Diagnostic and Statistical Manual of Mental Disorders (DSM), published by the American Psychiatric Association. When the manual was revised in 2013 (DSM-5), “Pathological Gambling” was renamed “Gambling Disorder.”

DSM-5 Diagnostic Criteria for Gambling Disorder

A. Persistent and recurrent problematic gambling behavior leading to clinically significant impairment or distress, as indicated by the individual exhibiting four (or more) of the following in 12 months:

1. Needs to gamble with increasing amounts of money to achieve the desired excitement.

2. Is restless or irritable when attempting to cut down or stop gambling.

3. Has made repeated unsuccessful efforts to control, cut back, or stop gambling.

4. Is often preoccupied with gambling (e.g., having persistent thoughts of reliving past gambling experiences, handicapping or planning the next venture, thinking of ways to get money with which to gamble).

5. Often gambles when feeling distressed (e.g., helpless, guilty, anxious, depressed).

6. After losing money gambling, one often returns another day to get even (“chasing” one’s losses).

7. Lies to conceal the extent of involvement with gambling.

8. Has jeopardized or lost a significant relationship, job, or educational or career opportunity because of gambling.

9. Relies on others to provide money to relieve desperate financial situations caused by gambling.

B. gambling behavior is not better accounted for by a manic episode.

Exhibit 2 summarizes the changes in diagnostic criteria, from pathological gambling to gambling disorder. Of note:  Whereas pathological gambling was classified as an Impulse-Control Disorder Not Elsewhere Classified, gambling disorder is categorized under Substance-Related and Addictive Disorders. Reclassification may improve treatment coverage, diagnostic accuracy, and screening efforts.

 

Pathological Gambling to Gambling Disorder:

A Summary of Diagnostic Changes

• The number of diagnostic criteria that must be met as a basis for diagnosis was lowered from five to four.

• The diagnostic criteria must have occurred within 12 months.  Previous versions of the DSM had no established timeframe.

• Committing illegal acts to finance gambling was removed from the list of diagnostic criteria.

Much of the research published to date used pathological gambling criteria from the DSM-IV and DSM-IVTR as research parameters. In addition, researchers have often used the term problem gambling. This term has been used to refer to gambling that causes harm; pathological gambling has been reserved for cases in which there are harm and lack of control over, or dependence on, gambling.

Although gambling disorder has replaced pathological gambling in DSM-5, this course uses both terms pathological gambling and problem gambling.


How Common Are Gambling Problems?

Estimates from large national surveys show that about 0.5 percent of Americans have had pathological gambling at some time in their lives. Extrapolating from the survey estimates suggests that roughly 1.5 million Americans have experienced pathological gambling. As noted earlier, the milder condition, problem gambling, is more common than pathological gambling and may affect two to four times as many Americans as pathological gambling.


Who Typically Has a Gambling Problem?

Anyone can develop a gambling problem; such problems occur in all parts of society. However, men are more likely than women to have gambling problems, as noted earlier though numbers among women are on the rise.  Gambling problems show some association with adolescence and young adulthood, ethnic minority status, low income, low socioeconomic status, high school education or less, and unmarried status.

Some people gamble because the activity is stimulating.  These people tend to be “action gamblers” who favor gambling forms that involve some skill or knowledge, such as playing poker or betting on sports. Most of these types of gamblers are men.

Gambling can also serve as a relief or an “escape” from stress or negative emotions. In this type of gambling (e.g., bingo, lottery, slot machines), the pure chance is determined. Most of these “escape” gamblers are women.


What Are the Links Between Gambling Problems and Other Behavioral Health Conditions?

Gambling disorder frequently co-occurs with substance use disorders and other behavioral health problems. According to the National Epidemiologic Survey on Alcohol and Related Conditions, of people diagnosed with pathological gambling, 73.2 percent had an alcohol use disorder, 38.1 percent had a drug use disorder, 60.4 percent had nicotine dependence, 49.6 percent had a mood disorder, 41.3 percent had an anxiety disorder, and 60.8 percent had a personality disorder.

Other studies suggest that between 10 percent and 15 percent of people with a substance use disorder (SUD) may also have a gambling problem.  People who have both SUD and pathological gambling have high rates of attention deficit disorder and antisocial personality disorder.

Both are characterized by loss of control, cravings, withdrawal, and tolerance. In gambling, tolerance means having to gamble using increasing amounts of money to achieve the same subjective feeling.21 The results of brain
imaging studies suggest that pathological gambling and SUDs may originate in the same area of the brain.


Impulsivity in childhood has been related to the onset later in life of pathological gambling and SUDs.  Data also suggest that as gambling problem severity increases, so does the number of gambling precipitants or high-risk
factors for relapse to gambling. The frequency with which gambling occurs in given situations—such as when the person who gambles feels tense, nervous, or anxious; wants to celebrate; feels relaxed and confident; starts thinking
about gambling debts or seeing reminders of gambling, or is out with others who are gambling—may also increase.

 

Suicidality

Pathological gambling is associated with suicide, suicidal ideation, and suicide attempts. Among the many risk factors are financial difficulties and depression. People who have pathological gambling and have a SUD may be at greater risk of attempting suicide; some research has found substance abuse to be the only factor that distinguishes people who gamble pathologically and attempt suicide from gamble people pathologically but only think about suicide.  Some people who gamble pathologically may think about making suicide look accidental so that their families can collect life insurance to pay off gambling debts. As with all clients, these individuals should be screened for suicide risk and referred appropriately.


Are There Tools for Screening, Assessing, or Diagnosing Gambling Problems?

There are numerous tools available for screening for gambling problems.

BRIEF BIOSOCIAL GAMBLING SCREEN (BBGS)

The Brief Biosocial Gambling Screen (BBGS) is a 3-item survey designed to help people decide on their own whether to seek a formal evaluation of their gambling behavior.  The BBGS is based on the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) criteria for pathological gambling.  For identifying individuals with Gambling Disorders, the BBGS has good psychometric characteristics: high sensitivity (0.96) and high specificity (0.99). The Positive Predictive Value of the BBGS is 0.37. This suggests that one of the three individuals who screen positive on the BBGS will be identified as having Gambling Disorder after a full follow-up.

The three questions include:

1. During the past 12 months, have you become restless, irritable, or anxious when trying to stop/cut down on gambling?
• Yes
• No


2. During the past 12 months, have you tried to keep your family or friends from knowing how much you gambled?
• Yes
• No


3. During the past 12 months, did you have such financial trouble as a result of your gambling that
you had to get help with living expenses from family, friends, or welfare?
• Yes
• No

A “yes” response to any single item indicates potential gambling-related problems and the need for additional evaluation.

The Lie-Bet tool has been deemed valid and reliable for ruling out pathological gambling behaviors, as well. The Lie-Bet’s two questions consistently differentiate between pathological gambling and non-problem gambling and are useful in screening to determine whether a longer tool (e.g., SOGS, DSM-IV) should be used in diagnostics. The Lie/Bet Screening Instrument consists of two questions:

1. Have you ever felt the need to bet more and more money?

2. Have you ever had to lie to people important to you about how much you gambled?

A “yes” response to one of these questions warrants further investigation using a longer tool, such as the South Oaks Gambling Screen (SOGS). The SOGS consists of 16 items and differentiates between no gambling problems, some problems, and probable pathological gambling.

 

The NODS-SA is a self-assessment version of the NODS (the NORC Diagnostic Screen for Gambling Disorders). It was designed to assist individuals in evaluating whether to modify or seek help for their gambling behavior. 

NODS-SA


Screening for gambling problems is important because few people seek treatment for these problems and instead seek help for other complaints (e.g., insomnia, stress-related problems, depression, anxiety, and interpersonal issues). In addition, there are no obvious signs (e.g., needle marks) that can be detected by physical observation or examination.


How Can Behavioral Health Services Providers Help Clients With Gambling Problems?

People who gamble pathologically are often overwhelmed by feelings of shame and anger. Conveying empathy, unconditional positive regard, and a sense of hope can help build rapport with clients. Behavioral health services providers can offer nonjudgmental feedback to the client about gambling behaviors and assess the client’s motivation and readiness to address their gambling behaviors. Clients with gambling problems often have other problems, and they may need information on resources about the following topics:

● Financial difficulties. Money issues are the most common reason people seek treatment; addressing financial problems should be an integral part of treatment. In the face of overwhelming debts, clients may be dealing with the loss of employment or their home, depleting college or retirement savings, or incurring major debts. Some may not have enough money to buy food or pay utility bills. A behavioral health services provider can assess financial problems and include financial issues in treatment. A case manager can help clients prioritize needs and help them obtain housing, shelter, and food assistance, if necessary. Debtors Anonymous can help people learn how to budget their money and rein in their spending.


● Marital and family issues. Gambling disorder has many negative consequences on marriages, partnerships, and families. It contributes to chaos and dysfunction within the family, can contribute to separation and divorce, and is associated with child and spousal abuse. Family members may have depressive or anxiety disorders and abuse substances.

People often hide gambling problems from their families; disclosing the gambling secret can be devastating to relationships, leading to resentment and loss of trust. The financial difficulties created by pathological gambling can profoundly affect family members. The spouse or partner needs to be included in treatment to address family issues; a referral to a family or marital therapist can help families in these situations. The provider can refer the client to Gamblers Anonymous and family members and loved ones to Gam-Anon.

● Legal problems. One study found that about a quarter of people who gambled pathologically had committed at least one illegal gambling-related act, such as the writing of bad checks, stealing, and unauthorized use of credit cards. Counselors can instruct clients on how to obtain legal counsel or access public defenders or other assistance.


What Are Some Treatment Strategies for These Clients?

Although various approaches have been researched and found to be useful in treating gambling problems, none has been clearly shown to be more effective than another. Most research studies have assessed a mixture of approaches (e.g., cognitive therapy [CT], motivational interviewing [MI], relapse prevention), making it difficult to determine the relative effectiveness of the different approaches.


Behavioral Therapy

Behavioral therapy focuses on altering behaviors by reinforcing desired behaviors, modifying attitudes and behaviors related to gambling, and increasing clients’ skills to cope with environmental cues that may trigger cravings to gamble. This approach helps clients identify their cues and triggers to gamble and then helps clients develop alternative activities to gambling that compete with reinforcers specific to pathological gambling. For example, during imaginal desensitization, relaxation and other techniques are used to help the client cope with gambling stimuli and blunt the urge they create to gamble.


Cognitive therapy

CT is directed at changing distorted or maladaptive thoughts—in this case, about gambling and the odds of winning. CT educates clients about the randomness of gambling, increases clients’ awareness of their distorted thinking, helps clients doubt their irrational cognitions, and helps them restructure their thoughts. For example, a treatment provider might work on altering a client’s belief that two events are related when they are not. Examples of distorted beliefs are that a lucky item improves the chances of winning or that a slot machine must be due to hit the winning sequence because it has not hit the sequence in a long time.


Cognitive–Behavioral Therapy

The two approaches discussed above are frequently combined in cognitive–behavioral therapy (CBT). CBT tries to modify negative or self-defeating thoughts and behaviors. A meta-analysis by Gooding and Tarrier found that various CBTs were effective in reducing pathological gambling. CBT studies, several of which included relapse prevention interventions and found that CBT was beneficial in treating pathological gambling.  CBT to treat gambling disorder usually involves identifying and changing cognitive distortions about gambling, reinforcing nongambling behaviors, and recognizing positive and negative consequences. CBT helps people recognize that short-term experiences and sensations are not worth the long-term negative consequences of debt, legal problems, and harm to one’s family.

CBT usually incorporates some relapse prevention techniques. Relapse prevention consists of learning to identify and avoid risky situations that can trigger or cue feelings or thoughts that can lead to relapse into gambling.

The gambling risk situations clients learn to identify include places (e.g., casinos, lottery outlets), feelings (e.g., anger, depression, boredom, stress), and other difficulties (e.g., finances, problems with work or family).  In addition to techniques learned in CBT, developing a support system, attending Gamblers Anonymous meetings, and participating in continuing care may help prevent relapse.

Motivational interviewing

MI, also known as motivational enhancement, seeks to help clients address their ambivalence toward behavior change.

It has not been as well studied as CBT as a treatment for pathological gambling, but some studies have shown promise for MI.  MI is frequently combined with CBT.

Researchers have reported that even very brief motivational interventions can help people with gambling problems.

Treatment that combined MI and CBT has been delivered effectively over the Internet and with brief phone calls from trained therapists.


Gamblers Anonymous

Gamblers Anonymous, the structure of which is modeled on Alcoholics Anonymous, is a mutual-help group for people with gambling problems. Although mutual-help groups are not treatment or counseling, they can support people in recovery. Free meetings are available in many communities.


Medications

Several medications have been investigated to treat pathological gambling. However, the U.S. Food and Drug Administration has not approved any medications for treating the condition.


Prevention

Once a person is diagnosed with a gambling disorder, prevention of further harm to the person and their family is important. One such approach is having the person participate in a self-exclusion program, if available in their state. These voluntary programs allow a person to be banned from gambling venues for a defined period, even a lifetime. Depending on state policy, if the person violates the ban, they are asked to leave the venue, are required to forfeit winnings, and are potentially subject to criminal trespassing charges. The few outcome studies conducted on self-exclusion show a decrease in gambling.

A variety of prevention approaches and models have been used to try to prevent the development of gambling problems, but these have not been well-studied. Because gambling issues in youth may lead to the development of gambling disorders in adulthood, many prevention programs focus on young people. Although youth are barred from many gambling venues, some venues in which betting is available (such as race tracks) may restrict youth only from placing bets; it is not unusual for children to attend horse races with family members who bet.

Other approaches can be considered, such as public awareness campaigns that seek to make the general public aware of the risks and potential consequences of problem gambling, the way gambling products work and the real probability of winning, and warning signs for problem gambling and the availability of help.

Policy initiatives include restricting who can gamble and restricting the number of electronic gaming machines in a locality. The gaming industry has cooperated in some places by posting signage that reminds people to gamble responsibly (e.g., stay within their time and funding limits) and restricting money transfers into a casino and access to automated teller machines. Some electronic gaming machines remind players of the amount of time and money spent; others can be programmed to a slow speed or require that the player check out after prolonged periods of play.


Who Can Treat People With Gambling Disorder?

Gambling disorder is a behavioral health condition. Treating gambling disorders is within the scope of mental health counselors’ practice, licensed clinical social services providers, clinical psychologists, psychiatrists, and other professionals with licenses to treat mental disorders.

 

 

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