Compulsive gambling is also termed pathological gambling. Gamblingbehaviorhas given rise to much research investigating the epidemiology of gambling and disorders related to it (Gebauer et al, 2010). The need for instruments to screen people with pathological gambling has become of prime importance. Disordered gambling and other interests of the population need to continue to be diagnosed through an appropriate screen.
Pathological gambling, an uncommon phenomenon, has an incidence of 0.2% to 2.1% on a global basis. Norway has the lowest incidence of 0.2% while Australia has the highest of 2.1% among a group of studies. UK studies in 2000, 2005 and 2007 reported a prevalence of 0.7%, 0.5% and 0.7% respectively(Gebauer et al, 2010). The National US survey of 1979 reported a similar prevalence indicating 0.7%. The American society has been experiencing a burden of $5 billion even though the extent of pathological gambling comes to only a small percentage (Vachon and Bagby, 2009). The recent NESARC database indicates a prevalence of just 0.16%. Gambling prevalence can be summed up as showing no increased prevalence despite increased access to gambling. A Swiss survey showed past year pathological gambling at 0.8%. After 10 years of legalization of casinos, it has diminished to 0.2%. In essence, it is heartening to realize that pathological gambling is not too high in prevalence at any point in time (Gebauer et al, 2010). This picture allows one to believe that real-time target-oriented programs could further reduce pathological gambling and the end-point of zero is insight.
The NESARC and NCS-R were large-scale surveys that measured pathological gambling by the criteria of DSM-IV-TR. The diagnosis of pathological gambling and psychiatric disorders were found overlapping in both the NESARC and NCS-R (Gebauer et al, 2010).The awareness of pathological gambling has been increased through land-based and internet gambling. The screening for pathological gambling needs to be increased through the land-based and internet opportunities (Gebauer et al, 2010). Planning for the treatment, the situations of relapse and then recovery has to be done with care so that the co-morbidity does not result in untoward implications.
The definition of gambling disorders has been taken from the American Psychiatric Association (2000).
“Gambling disorders are broadly defined as persistent and recurrent maladaptive gambling that disrupts personal, family, or vocational pursuits”
Classification of Pathological gambling
Pathological gambling (PG) has been placed as a unitary diagnostic construct with subtypes in the 4th edition of the Diagnostic and Statistical Manual of Mental Disorders (APA, 1994). The subtypes have been termed, simple PG cluster, hedonic PG cluster and a demoralized PG cluster (Vachon and Bagby, 2009). Low rates of comorbid psychopathology and traits which are very close to normal characterize the simple PG cluster. The comorbid psychopathology being of moderate incidence and a tendency for seeking excitement with the ability to elicit a positive effect constitute the features of a hedonic PG cluster. The worst kind is the pathological gambling which shows a high incidence comorbid psychopathology known as demoralized PG cluster; a negative effect, emotionality of a low positive nature with disinhibition (Vachon and Bagby, 2009).Impulsive externalizing psychopathology is associated with pathological gambling (Petry et al, 2005). These include antisocial personality disorder, drug abuse and alcoholism. Some researchers have linked PG with internalizing psychopathology (Petry et al, 2005). The relationship of PG to depression is more evident when compared to other psychiatric disorders. Maladaptive conditions, normal conditions, availability and accessibility have been associated with PG (Vachon and Bagby, 2009).
Blaszczynski and Nower (2002) suggested different subtypes based on the pathway to PG. Vachon and Bagby (2009) have used the five factor model (FFM), measured by the Revised NEO Personality Inventory for their study. Traits that were used to predict the PG were highly reliable, stable, cross-culturally replicable and heritable (Vachon and Bagby, 2009). One subtype was assumed to be associated with the lesser co-morbid psychopathology where the FFM traits were near normal. The second group consisted of high externalizing psychopathology with extremely negative emotionality and low inhibition. The third group consisted of internalizing psychopathology with normal high negative emotionality but low positive emotionality(Vachon and Bagby, 2009). The trait scores were made on the subscales of “excitement seeking, positive emotions, feelings, dutifulness and deliberation” (Vachon and Bagby, 2009). Hedonic PGs had high scores on these subscales and simple PGs had near normal scores. High scores on the Neuroticism domain with subscales “anxiety, angry hostility, depression, self- consciousness and vulnerability”, high scores on the Impulsiveness subscales and self-discipline and deliberation showing low scores and low scores on the distrust domain with subscales trust and warmth and low scores on the poor motivation subscales of competence, dutifulness and achievement-striving all point to demoralized PGs (Vachon and Bagby, 2009).
Simple PGs were not much different from normal controls. Hedonic PGs conformed to the moderate level of comorbid psychopathology while the demoralized PGs conformed to the high class of co-morbid psychopathology. Another researcher, De Young and his colleagues (2006) have defined two higher order traits for the FFM in terms of plasticity and stability. Hedonic PGs have features of plasticity with a tendency for curiosity, exploration and sensation seeking. The demoralized PGs have low stability with little disruption in the social, emotional and motivational domains (Vachon and Bagby, 2009). Hedonic PGs had the features of positive emotionality and the tendency to seeking thrills. The demoralized PGs possessed the negative emotionality and introversion. Plasticity involved variation in the dopaminergic system while stability involves the serotonergic system. PG is an impulse control disorder by the DSM-IV Manual. The BBGS is specific to a gambling disorder (Gebauer, 2010). Different questions identify the different domains. The three-factor screen has one item from the 3 syndrome model: the withdrawal item indicates the neuroadaptation. The question about lying indicates the psychosocial features. The adverse consequence of gambling indicates the habit of obtaining money from others (Gebauer et al, 2010).
The interest in Internet gambling is expected to facilitate problematic gambling (Matthews et al, 2009). Gambling websites have increased to about 3000. Research into online gambling is limited but has concluded that there is a relationship between the internet gambling and problem gambling. 43% of the internet gamblers in one study had moderate or severe problem gambling. Internet gamblers were mostly males and males were more predictive of being problem gamblers (Matthews et al, 2009). A study by Wood et al indicated that one-fifth of the participants were assessed to have problem gambling by the DSM-IV criteria (2007). Problem gambling arose due to the negative mood states after the gambling especially when the gambling was being resorted to as a manner of escaping problems (Wood et al, 2007). Heart rate measurements in some studies have indicated an excitement or a form of arousal occurring along with the gambling habit (Griffiths, 1993 cited in Matthews, 2009). Problem gambling theories have suggested that the gambling was sought after by emotionally unstable gamblers to change their mood states and to reach psychological desire. Mood states and escapism are other reasons found in studies which reinforce the gambling habit (Wood, 2007b). It has also been decided in other studies that problem gambling and depression are related (Kim, 2006). One- third of the participants in Matthews’ study had some problem gambling. Eighteen percent were potential pathological gamblers while nineteen percent were probable pathological gamblers. The online gambling frequency suggested a relationship to problem gambling. 54% of probable pathological gamblers went online for gambling twice a week. Problems are usually seen in internet gamblers when compared to non-internet gamblers. The problem of severe gambling was 37% in Matthew’s study when compared to 43% in another one (Wood, 2007c). The negative mood states are the best predictors of problem gambling directly after the gambling. An exalted score on the affect scale could also be another predictor of problem gambling. The negative moods could be “disgust, anger, scorn, guilt, fearfulness and depression” (Matthews, 2009).
The limitations in Matthews’ study affected the findings. A generalization was not possible as the sample was self-selected. The gambling types were not differentiated. Future studies may have to consider the differences in online gambling. The rate of problem gambling may overshoot because of the scale used: the SOGS. However recent literature has accounted for the validity of using SOGS. A larger population sample could make better predictions.
Gender Differences in Problem Gambling
Clarke and Clarkson (2008) have indicated that older adults hardly participate in gambling; hence gender differences in gambling behavior and the reasons which initiated the gambling have not been investigated sufficiently. McKay (2005) has contributed a contradictory idea that the greatest percentage of gamblers was seen in the age group bearing the older adults, especially the women. The difference of opinion probably indicates that each author has seen a picture in a different situation or state. McKay (2005) claims that it has been noticed that adults above 65 years of age doubled in number of gamblers in the coming years. The number was directly proportional to the number of gaming machines and casinos (Boreham, 2006). With the steady increase in the number of casinos the number of visitors grew immensely. Lesser interest was noted for the horse betting and bingo games.
Regular continuous gamblers were differentiated from regular non-continuous gamblers. Continuous gambling included scratch tickets, track betting and casinos and referred to gambling activity weekly for the past 6 months. Males were more likely to indulge in regular continuous gambling. The regular non-continuous gambling was indulged in more for the stimulation or entertainment or socialization facets (Clarke and Clarkson, 2008).
Problem gambling has become the central focus of research; gambling as a leisure phenomenon has been practically neglected. There is less chance of older adults becoming problem gamblers. However the activity could improve their health benefits (Clarke and Clarkson, 2008). The improved social integration, the increase in self-esteem, more activity, enhanced travel and cognitive stimulation contributed to the health benefits. People who are active gamblers in their youth tend to turn out to active gamblers even in their old age by the activity theory (Clarke and Clarkson, 2009). However another study indicates that the continuation of gambling into older age much depends on the meaning eachperson has put into gambling, the individual preferences, attitudes and motivations (Zaranek and Chapleski, 2005).
Clarke’s study compared the behavior of 41 male and 63 female participant gamblers in a new casino in New Zealand. The main motivational triggers were the rewards and escapism from boredom. The ages examined were from 66 to 87 and significant gender differences were not elicited. The gender and skill preferences for motivation showed no significant diversity. Regular persistent gamblers were attracted to horse races, scratch tickets of non-casino gaming machines (Clarke and Clarkson, 2008). The continuous gamblers also had a greater expenditure.
Three types of motivation factors, intrinsic, extrinsic and amotivation factors have been identified in gambling motivation. Both intrinsic and extrinsic motivation has three facets each. The intrinsic motivation is for working towards knowledge through curiosity, towards accomplishment through improved skills at betting and towards stimulation by excitement and entertainment. The extrinsic motivation has external regulation by gambling with the aim of securing rewards. Introjected regulation aims at relaxation while gambling. Gambling for social recognition is known as identified regulation. Gambling activities, when neither intrinsically nor extrinsically motivated and have no specific purpose and the gamblers do not apply any meaning to their activities, are considered under a motivation.
Research has noted that men are more intrinsically motivated while women are externally motivated to chance activities like lotteries, raffles and scratch tickets (Delfabbro, 2000 cited in Clarke and Clarkson, 2008). Women are more prone to introjected regulation to escape daily stress of family responsibilities and have some control in their lives. Excitement and learning skills were more seen in men (Walker et al, 2005). The tendency to gamble for fun lay with the women. Men were more curious. The reasons quoted by older adults for gamblingin Alberta, Canada were stimulation and socialization (Munro et al, 2003). Stimulation and rewards were the opinions of older adults in a Manitoba telephone survey (Wiebe and Cox, 2005).Older adults in Queensland had a different opinion when compared to the Canada group; they believed that winning money was more important (Boreham et al, 2006).
It may be right to conclude that men gamble for knowledge and accomplishment while women gamble for escape from stress (Clarke and Clarkson, 2008). The intrinsic motivation suits older adults than the extrinsic one. Studies from New Zealand, Australia indicate that stimulation and socialization are important but winning is more important. Where EGMs and casinos were established, identified regulation in extrinsic motivation was less than amotivation. Gender differences were investigated in very few researches (Clarke and Clarkson, 2008).
Clarke and Clarkson’s study (2008) indicated that 64% of the sample gambled weekly or more regularly. 74% spent NZ$10 or less in one session. Only one person spent more than NZ$10. Most of the sample enjoyed the Lotto and the scratch tickets. They would spend more on races and bingo. Horse and dog races were more popular here as horse-breeding farms were found in the area. New casinos also increased the popularity for casinos unlike as found in the National Survey (Clarke and Clarkson, 2008).Auckland and Ontario both had new casinos. Gambling to win appeared to be the biggest motive in the New Zealand, Australian and Canadian studies but was not so in the American studies (Wiebe et al, 2004). Excitement and relaxation were the main reasons for gambling by the taxonomy of motives and the activity theory.
Gender differences were not obvious in Clarke and Clarkson’s study (2008). Gender-wise diversity was investigated in the total number of activities, the regularity of sessions, the biggest amount spent in any session, favorite gaming activity and the seven facets of motivation. The groups had equal numbers of males and females. However skill activities were a favorite of men while chance activities were a favorite for women (McKay, 2005).
The study showed limitations in that older adults who did not gamble were excluded while the crowd at the casinos where the regular continuous gamblers and the unmarried people who were middle income earners(Clarke and Clarkson, 2008). Failing memory could also cause the distortion of details of gambling behavior. The self-administered questionnaire could also distort the findings. The situation can be sorted out in future studies by using friends and families to provide details of gambling behavior. Incorrect estimation about expenditures could also influence the results. Regular continuous gamblers could be hiding the large amount of winsfor fear of stigma or shame. The number of participants needs to be large to compare the picture in different gaming activities(Clarke and Clarkson, 2008).
Women in problem gambling
More women are turning to the previously male-dominated gambling spending time and money for poorgames of chance (Li, 2007). The increase of women gambling is being accompanied by low income, working class women through a growing addiction problem among women (Davis and Avery, 2004).Underprivileged groups are disproportionately represented among the senior citizens and minority group of immigrants (Welte et al, 2004).
The tendency to gamble arises from problems in interpersonal relationships, domestic issues and unresolved issues of mental trauma like the loss of dear and near ones (Li, 2007). These women also have a likelihood of moving onto compulsive gambling. Women tend to go in for gambling at a later stage in life when compared to men. They also have more associated psychiatric problems. Emotional involvement causes them to become addicted. Preferences for certain games, motivation for gambling, involvement and progressionare different in women. Less strategic games are usually selected by women.
Studies elaborating compulsive gambling in women had been superficial in that the purpose was sheer comparison with males (Li, 2007). The social contexts of gambling and the experiences of the women gamblers have not been investigated. Several reasons have been quoted to explain the poor research. Apart from the comparison studies, attempts were not made to investigate with evidence-based analysis what gambling meant to women. These studies also did not view gambling as a positive activity; gambling addiction was considered a disease needing treatment, without considering the social aspects and the experiences of the female gamblers (Li, 2007). The experiences were not coordinated with their daily social and personal life. How the gambling helped them overcome the realities and stresses of family responsibilities were also not explored. Research on compulsive gambling has yet to address high-risk groups which include the women who are under-privileged, the immigrants of minorities and seniors in the diverse gambling settings (Papineau, 2005).
Li (2007) investigated deeply into why women turned to gambling, the problems which developed and their specific gambling behaviors. Through participant observation (ethnographic) and in-depth interviewing (phenomenological), Li found that gambling had a stigma and secrecy around it. This alone could hinder the investigation process in a research study. Seven females from five different cultures and different age groups but all of low socio-economic status were interviewed separately twice. The atmosphere of questioning was made respectful, friendly and non-judgmental.
Five themes emerged: “gambling was hope, escape, therapy, reward and their social life” (Li, 2007). Being of low socio-economic status, the ladies wished to make money from their gambling. Spending money for lottery tickets could increase the possibility of chance money. Temporary escape from real problems and stress or grief made them feel better. Escaping boredom, negative thoughts and hurtful memories were other reasons for opting for gambling (Li, 2007). Momentary happiness in a miserable life was looked forward to; the reward provided self-satisfaction. The social attachments possible removed the loneliness and enabled the ladies to get away from their husbands. Poor people did not feel a different status in casinos; the casinos gave all the gamblers one status, whatever life they came from. The responses arose out of a positive attitude towards gambling (Li, 2007).
The real reasons for women taking to gambling are vastly different from those of men. Qualitative enquiry would reveal the reasons for addictive gambling. An analysis of minds is insufficient to understand the woman gambler’s mind (Li, 2007). Stereotyping or victim blaming should not be the course of exploration in compulsive gambling in women; instead historical, cultural, family and personal circumstances have to be considered. Class, gender, age and race should also be in mind when examining the negative emotions in compulsive women gamblers. Better practice could help women regulate their negative emotions without gambling (Li, 2007).
Psychiatric disorders and compulsive gambling
Psychiatric disorders are frequent with problem gambling or compulsive gambling (Desai and Potenza, 2007). Analysis was made from the data from the NESARC. It was found that past year Axis-I and lifetime Axis-II disorders were associated with the gambling problems. It was concluded that past-year compulsive gambling was associated with psychiatric disorders. As the women showed stronger associations, research has to touch on women’s issues and problems in investigation. Prevention and therapeutic interventions must account for their gender differences (Desai and Potenza, 2007). Women with depression or anxiety need to be screened more thoroughly for pathological gambling symptoms. Brief interventions like motivational interviewing could be helpful. If gambling is not identified, treatment becomes complicated with poor outcomes. Gambling goes unnoticed in seriously ill mental patients. Psychiatric research needs to focus on eliciting pathological gambling as a routine to avoid missing it (Desai and Potenza, 2007).
The number of gambling opportunities having been increased, the youth are involved to a greater extent. Many do not participate but others experiment and many more allow it to become a serious problem (Molde et al, 2009). Adolescents indulge in more risk-taking due to their apparent invulnerability. They do not gauge that gambling could lead to serious problems and adverse situations. Compared to the prevalence of between 4.6 and 7.5% for pathological gambling in adults in North America, the prevalence is four to five times higher in the youth.
Problem gambling fulfills four of the diagnostic criteria in DSM-IV while pathological gambling fulfills five of them (Shaffer et al, 2004). Instruments to measure the gambling behavior of adolescents are obtained by modifying those for the adults like SOGS-Revised for adolescents, Massachusetts Adolescent Gambling Screen, DSM-IV Adapted Multiple Response format for Juveniles (Molde et al, 2009).The past-year problem gambling rate was found to be 1.76% in Norway. In Russia, it was found to be 2.5% by SOGS-RA. Availability of gambling on the internet has actually affected the prevalence rates. Male gamblers appear to be 3-5 times more in number than females. Researchers have attributed the different status of the two genders for understanding the questions.
Ethnic minorities show a wider extent of gambling (Molde et al, 2009). Older children gambled more in earlier times but enhanced exposure may have altered the picture. Researchers have also reported a higher incidence in the low socio-economic status. Relative spending is more in the low socio-economic status than in the higher even though the amounts wagered is more in the higher status (Shaffer et al, 2004). Adolescents with a gambling problem had a low SES ratio 2:1 when compared to youths with no problems. However gambling could be a resort and not a problem if the youth were to be diverted from the possibilities of substance abuse, depression, anxiety and mental disorders (Korn and Shaffer, 1999 cited in Molde et al, 2009).
Depression has been found associated with problem and pathological youth gamblers when compared to the occasional gamblers. Frequent alcohol intoxication and antisocial behavior has been found as an association of the high-frequency gambling of male youth. The period of adolescence is a high-risk period for deviant behavior though the tendency is not as high as expected by the deviant behavior theory (Molde et al, 2009). The tendency was at the highest in late adolescence and early adulthood.
Gambling has also been found along with other addictive behaviorslike tobacco, drugs and alcohol (Jacobs, 2000 cited in Molde et al, 2009). Understanding the factors which contribute to the addictive behaviors is of prime importance in research. The “illusion of control” is a cognitive belief that the outcome of games can be skillfully handled. Pathological gamblers harbor positive outcome expectancies in the hope of winning money (Ladouceur et al, 2002 cited in Molde et al, 2009).A much necessary escape from reality or mere mood elevation may be the reasons for indulging in gambling. Molde’s study indicated that the male-female prevalence was 12:1, probably because males were more prone to taking risks (Chalmers and Willoughby, 2006). Social norms may also be responsible for preventing females to participate as early as the males. Females become more involved at a later age. Risk factors identified by Molde et al (2009) were being male, having depression, alcohol abuse and dissociation while gambling; alcohol was considered a weaker predictor. Alcohol and drug abuse were more associated with males while mood disorders were associated with the females. This study had the limitation that longitudinal design was not used for monitoring the gambling behavior over time.
The 2008 Prevention Needs Assessment Survey which investigated gambling in grades 8 to 12 in Putnam County, New York found that the prevalence of gambling exceeded the habits of drinking and marijuana use. Sixty percent of the teenagers betted on cars, sports and online games (Alcoholism and Drug Abuse Weekly, 2009). The purpose of the survey was to replace risk factors with protective factors.
Researchers have identified individual impulsivity, problem gambling in the family, substance abuse, the availability of gambling sources, exposure to peer gambling as being associated to problem gambling (Welte et al, 2009). The possibility of some games being more risky of leading to problem gambling has also been considered. Problem gambling was more seen with gambling machines and scratch cards. Welte’s study (2009) focused on the type of games which had had a larger risk of problem gambling. The results were obtained through a random telephone survey of 2274 residents between the ages of 14-21. The type of game which caused particular symptoms was analyzed. Card games and casino gambling have caused problems of compulsive gambling. The same goes for betting on favorite games of golf, basketball and pool. The biggest risk was for 14 days casino gambling. Welte et al (2009) concluded that the fast type of games did not necessarily cause problem gambling as had been stipulated by other researchers. Gambling on cards was the most likely game which caused problems in gambling as had been indicated by the US youth studies. Though casino gambling is prohibited for adolescents, they manage to get around the restrictions. Betting on different issues like ‘who would shoot the biggest deer”, fights in school and on whether a particular vice can be overcome by a friend constituted the “other gambling” which was investigated.
Welte’s study (2009) could not confirm that sports betting were significant as suggested by other researchers. Risk was small for machine games. It was also noted that females who had gambling symptoms indulged in card games more than males. The involvement of females becomes deeper probably knowing fully well that the game was more a male form of gambling. The notion that machine gambling was problematic for females was not upheld by Welte’s study. Age and socioeconomic status were also not found to have an association with problem gambling. Internet gamblers had a high rate of problem gambling symptoms; 64.8% had at least one problem gambling symptom. This result was similar to that of Wood and Williams’ study which found that 42.7% internet gamblers were problem gamblers (2007 cited in Welte, 2009). The limitations in this study were that, all respondents did not have a land phone and the participants who agreed to respond may not be representative of a populationfor the purpose of generalization.The facts that the participants were giving were taken from memory. This could be false to a certain extent. Welte concluded that the commonest forms of gambling may not always cause the biggest gambling problems. It was also indicated that adolescents and youths were having the problems of gambling even thoughthey did not go to a casino or patronize a state lottery (Welte et al, 2009).
Neuroscience and gambling
Dopamine agonists in the therapy for Parkinsonism have been found to be associated with newly developed uncontrolled behaviors (Cilia et al, 2008). Among the drugs for Parkinsonism, it is known that pathological gambling, hypersexuality, compulsive eating and buying are believed to be examples of uncontrolled behavior. Impulse disorders are the results of behavior accidents. The single photon emission computed tomography (SPECT) was used to study the brain activity in patients with pathological gambling (Cilia et al, 2008). The design of the study was a case study with controls. A history was taken of cognitive impairment, earlier surgery and Dopamine Replacement Therapy for Parkinsonism. It was indicated that the participants who had Parkinsonism and had DRT, had the uncontrolled behavior. The control patients were also consuming DRT(Cilia et al, 2008). Reduced blood flow was not seen in the PD patients with pathological gambling. The PD control patients had reduced blood flow. The pathological gambling was assumed to be due to the enhanced dopaminergic stimulation of the meso-cortical limbic pathways rather than the neurodegenerative process that had been the stipulation till then. The risk factors that were investigated were the consumption of dopamine agonists, male gender, personal or family history of disorders of addiction. Non physiological stimulation of the post-synaptic dopamine receptors of the D3 sub-type and the dopaminergic actions of the medications produced impulsivity and sensitivity to reward. Functional neuroimaging techniques were used to decide the association between pathological gambling and the increased sensitivity to “impulse control, reward, reward- based learning, motivation and memory” (Cilia et al, 2008). The results of this study were enhanced due to the involvement of two groups of controls, PD and non-PD. The possibility of a biological explanation also was a strength. A limitation in this study was the small number of participants. It could be safely concluded that the PD patients had a behavioral addiction. Further study needs to elaborate the mechanisms of this compulsive gambling habit (Cilia et al, 2008).
Dysregulation of brain dopaminergic activity could explain the development of pathological gambling (Crockford, 2008). A suggestion that psychiatric or substance use co-morbidity causes pathological gambling led to the study by Crockford (2008). An association between Pathological gambling and dopamine agonists has been indicated by Dodd et al (2005). Other researchers have also tried to explain the association (Avanzi et al, 2006; Grosset et al, 2006; Weintraub et al, 2006). The lifetime prevalence of pathological gambling at a tertiary care center was found to be3.4%.Pathological gambling was especially seen in patients who developed Parkinsonism earlier. Weintraub et al (2006) discovered that a dose-dependent relationship existed between the total levodopa dosage and pathological gambling. In a study of 388 patients who received medications for Parkinsonism and had started off with no pathological gambling, 8% who were taking Dopamine agonists soon developed DSM-IV pathological gambling (Grosset et al, 2006). The various studies focused on men and neglected the women. 6.1 % of Parkinsonism patients satisfied the criteria for pathological gambling compared to only 0.25% of the general patients (Avanzi et al, 2006). This study use Dopamine agonists in general, not levodopa specifically. The pathological gambling declined with the advancing age (Petry, 2005).
Frontal lobe dysfunction has been reported in pathological gamblers by Rugle and Melamed (1993 cited in Petry, 2007). Other studies have reported disturbances in concentration, memory and executive abilities in pathological gamblers which were similar to the problems of substance abusers (Regard et al, 2003 cited in Petry, 2007). Potenza et al (2003 cited in Petry, 2007) used Functional Magnetic Resonance Imaging to demonstrate response inhibition. There was less activity in the left ventromedial prefrontal cortex which is usually involved with impulse regulation. These pathological gamblers had no history of substance usage. Substance users with problem gambling or pathological gambling performed worse than the substance users without the gambling problem and obviously both groups performed worse than the controls (Petry, 2007). The decision-making task showed both the substance users and pathological gamblers and the group with both problems performing poorly.
Underlying neurotransmitter effects have been found to be similar in pathological gambling and substance use disorders. Dopamine produces involvement in both processes of rewarding and reinforcement (Petry, 2007). Different studies have evoked different views though they found no difference in the levels of dopamine in the CSF(Cerebro-spinal fluid), plasma or urine of gamblers or controls; some say that CSF shows a decrease in dopamine but increase in the metabolites in the CSF of gamblers (Petry, 2007). Serotonin levels have been decreased in gamblers (Moreno et al, 1991 cited in Petry, 2007).
Substance abuse and gambling
Co-morbid substance abuse and the mood disorders that are the outcomes of the pathological gambling have been studied by Hodgins (2010). It was assumed that participants with a diagnosis of substance abuse did not have an abstinence period of less than 3 months and those who had treatment for it had a minimum period of 12 months abstinence. Resorting to treatment allows problem gamblers to achieve abstinence. Comorbid disorders have been found to be higher among the pathological gamblers than the general population (Petry and Weinstock, 2007). Two disorders which have high rates of co-morbidity with pathological gambling are substance use disorders and mood disorders. The co-morbidity of substance use disorders and pathological gambling together constitute 25-73% of the community (Petry et al, 2005). The co-morbidity of mood disorders has not been clear yet due to the smaller extent of treatment and the use of self-rating scales for depression (Petry and Weinstock, 2007). “Switching addictions” is a feature of substance abusers who change their addictions from substance abuse to gambling. Gambling relapses have also been known to occurin negative mood states.
It was interesting to note that all 101 participants were aimed at achieving abstinence and were following different methods to achieve it. During the follow-up only 2 participants were found to have remained abstinent throughout the five-year follow-up (Hodgins, 2010). Twenty-one percent attained abstinence for 12 continuous months while 68% reached 3 months. The severity of the gambling reduced in intensity over the follow-up. Outcomes may be predicted by the co-morbid psychiatric illness.
Psychiatric co-morbidity is also associated with pathological gambling. Pathological gambling has been found to be associated with depression in Parkinsonism (PD) patients; 50% of them of PD patients with PG had depression while only 29.3% of PD patients without PG had depression (Avanzi et al, 2006).
Government decision makers have viewed pathological and problem gambling with great concern as it is possible that a public health response can manage the health problem (Rush et al, 2008). Individual and protective risk factors can be identified. Population surveys help to provide the epidemiology. Even though researches have confirmed the differing situations, the findings are similar in the US and Canadian studies: the pathological and problem gambling show a prevalence rate of 1-2% and 2-3% respectively (Rush et al, 2008). Research has especially confirmed the association between substance abuse or mental health disorders and pathological and problem gambling (Petry et al, 2005). The biological, environmental and psychological pathways link substance use disorders and some mental health disorders like depression, attention deficit, and hyperactivity disorder. Aetiology could be used for classifying psychiatric disorders associated with gambling.
The Diagnostic and Statistical Manual of Mental Disorders has introduced pathological gambling as a disorder of impulse control (Petry, 2007). However it has been found that many of its diagnostic features are similar to those of the substance abuse disorders. “Pre-occupation with gambling, tolerance (indicated by the need to change the size and frequency of bets), making frequent attempts to stop or reduce the frequency of gambling, withdrawal (evidenced by restlessness or irritability when not being able to gamble) and the tendency to stop other activities just to gamble” are the five criteria which are common to both pathological gambling and substance abuse disorders (Petry, 2007). The other five criteria are continuing gambling to regain lost gambling money, gambling to escape stress or ill moods, lying to hide gambling habits, performing other illegal acts to be able to continue gambling and begging or borrowing from others to be able to gamble (Petry, 2007). The fact that more criteria are needed for diagnosis may have affected the prevalence rateof pathological gambling and brought it down.
Several national surveys have been done using various instruments but recently the instrument which follows the DSM-IV criteria, the South Oaks Gambling Screen (SOGS) is being used as it was developed with the items in DSM in mind. By this, the prevalence in the US is 1.6-4% (Welte, 2001 cited in Petry, 2007). However the problem of overdiagnosis is possible with SOGS. More recently instruments which are DSM-based are used (Petry, 2007). The National Gambling Impact Study found that lifetime pathological gambling was associated with lifetime alcohol dependence in 9.9% of participants when compared to 1.1% of non-gamblers. Welte et al (2001 cited in Petry, 2007) found this to be higher at 25% compared with 1.4% of non-gamblers. Other drugs are used by 8.1% pathological gamblers and 2% of non-gamblers. Pathological gambling induced illicit drug abuse in a four-fold manner (Petry, 2007). Nicotine dependence also occurred in pathological gamblers. Sixty percent pathological gamblers had nicotine dependence on a lifetime basis (Petry, 2007).
Substance abusers showed a prevalence rate of 14% for pathological gambling on a lifetime basis from a meta-analysis (Shaffir et al, 1999 cited in Petry, 2007). Other studies put it at 10% (Cunningham-Williams et al, 2000 cited in Petry, 2007), 13% (Langenbucher et al, 2001 cited in Petry, 2007). Toneatto and Brennan (2002 cited in Petry, 2007) found that 11% of his residential addictions treatment patients were pathological gamblers. Different studies reported pathological gambling among methadone addicts: 7% (Feigelman et al, 1995 cited in Petry, 2007), 18% (Downey, 2002 cited in Petry, 2007), 16% (Petry, 2007).
The co-morbidity of substance abuse predicted poor outcomes for pathological gambling. More psychiatric problems were seen with this group. Treatment seeking substance abusers also spoke of legal issues, employment problems and family issues (Petry, 2007). Severe pathological gambling further increased the risk of sexually transmitted diseases in substance abusers (Petry, 2007).
Gambling and Suicide
Brooker and colleagues (2009) found an association between gambling and suicidal attempts. The people who were prone to problem gambling had a disposition to different maladaptive problems and behaviors. A reward-deficiency syndrome is believed to explain the co-morbidity relationship. The syndrome may include addiction, impulsivityor obsessions (McIntyre et al, 2007). These researchers used the SOGs and CPGI (Canadian Problem Gambling Index) instruments (Crockford and el-Guebaly, 1998; Doiron and Nicki, 2001; Marshall and Wynne, 2004 all cited in Brooker, 2009). Brooker et al (2009) found “positive associations betweenproblem gambling and various past-year disorders and mental health behaviors, with the strongest association being for suicide attempts” (Brooker et al, 2009). Suicide ideation, maniacal incidents, attempts to suicide, phobia for social relationships, depression and alcohol abuse were the various psychopathologies of the past year encountered here. This study further confirmed the validity of the instrument CPGI. The aim to detect and prevent problem gambling could begin by working on the psychopathologies as discovered (Brooker et al, 2009).
Newman and his colleagues studied the data from a National Health Survey in Canada conducted in 2002 (2009). The sample of 36984 participants was examined for the association between pathological gambling and attempted suicide. The assumption that suicide-related behavior was seen in problem gamblers was investigated by Newman et al (2009). Previous studies did not have controls which caused a limitation of the results for generalization. Higher completed suicidal mortalityratios had been observed by Philips et al (1997) among residents in 3 large gambling centers in Las Vegas, Reno and Atlantic City (cited in Newman, 2009). Another researcher, McCleary (1998 cited in Newman et al, 2009) conducted a wider study and found that the results were similar in many other gambling centers and that Las Vegas, Reno and Atlantic City ranked far below at 26th, 37th and 87th positions. Pathological gamblers showed an attempted suicide rate of 26.8 % while it was 7.2% in those without gambling problems (Newman et al, 2009). Newman (2009) found that a one year prevalence rate was 0.52%.
Though suicide is essential to psychiatrists and other mental health professionals, it is good to remember that suicide is not always the result of a mental disorder. Traits of impulsiveness and aggression are sufficient to induce suicide ideation especially in the youth (Cheah et al, 2008). Cheah and his colleagues (2008) studied the case of a patient who had made a lethal attempt at suicide but survived it and was willing to share his viewpoints in a psychiatric assessment. This patient did not have an Axis I or II disorder. This patient had misappropriated $6000 through gambling. The most important factors which contributed to his suicide attempt were the “threat of disgrace and possible prosecution and impulsivity” following his act of misappropriation (Cheah et al, 2008). His living in a small society where everyone is known to the other and shared a good family relationship must have made the mistake appear worse with no means of escape otherwise. There was no mental disorder or family history attached in this case.
The Role of Medication in Treating Problem Gambling
In the earlier days, the contribution of medication towards the relief of pathological gambling was not explained to the full. Hollander’s study (2005) of bipolar spectrum disorders and pathological gambling revealed that treatment with lithium reduced the symptoms of pathological gambling. There was a time when it was thought that gambling was part of the impulsivity and obsessive compulsive disorders (Westphal et al, 2008). Clomipramine, a partially selective serotonin reuptake inhibitor, was first used but its function was not satisfactory. Then the current SSRIs were used: citalopram, escitalopram, paroxetine and fluvoxamine. Opioid antagonists like naltrexone are believed to control cravings for gambling (Westphal et al, 2008). However it had side-effects like dizziness and nausea. Seventy-five percent of patients improved with the naltrezone.
Pharmacotherapy is just one method of treating pathological gambling (Chung et al, 2009). Fluvoxamine is a selective serotonin reuptake inhibitor which is used for the pharmacotherapy. Chung’s study (2009) used functional Magnetic Resonance Imaging for assessing the changing neurobiology of a patient’s brain. The patient had maladaptive gambling behavior and suffered from depression. His laboratory results were mostly normal. His gambling behavior was observed for a week. The diagnosis was dysthymic disorder (Chung, 2009). After doing the baseline fMRI, he was given fluvoxamine (50mg/day). The dosage was raised to 200 mg/day after two weeks. GSAS and the neuroimaging assessments were repeated at intervals till medication was over and then repeated during the follow-up. The inability to stop gambling could be induced by serotonin which may go about the process through behavioral initiation and disinhibition. Fluvoxamine will be stopping this behavioral difficulty and thereby preventing the patient from gambling. In other words, administration of fluvoxamine would be associated with a “decreased desire to gamble” (Chung, 2008).
The Addictive Potential of Lottery Gambling
Society problems have been known to evolve from casinos and lottery gambling (Welte et al, 2007). Young adults above the age of 29 were more prone to addictions from casinos, lottery gambling and gambling machines. Pathological gambling, according to the National Research Council (1999), is mostly associated with the bingo, lottery, racetrack and sports betting. The addiction to lottery was evident when with the abolition of video lottery machines in South Dakota, the number of pathological gamblers decreased from eleven to one. When the machines were reinstated, the number was back to eleven. Poor persons showed an increase in lottery gambling as was evident in a study (Clotfelter and Cook, 1991 cited in Welte et al, 2007). Easy access to lotteries was one major factor for the addiction. The commonest form of gambling was lottery (Welte et al, 2007). Lottery has been described as the second highest contributor to the problem of societal gambling, more so for women. The State lotteries have frequent changes which contribute to them being continuously interesting to the public and increasing its addictive potential; scratch tickets are one novelty.
All addictions have common features by the World Health Organisation. An urgent desire to satisfy one’s need, a loss of control over the behavior, persistent thoughts about it are found with addictions (Moreyra, 2002). With abstinence, the person develops symptoms of irritability, agitation, difficulty to focus, and a group of other complaints. With tolerance, they tend to go in for more betting to obtain the same excitability as they used to obtain with lesser bets. Pathological gambling has all these features of addiction. These features are found in substance abuse disorders; the gamblers go in for and more gambling to attain satisfaction which is always temporary when addiction has set in (Moreyra, 2002).
The phenomenological view considers pathological gambling as a type of obsessive-compulsive disorder. Repetitive thoughts about gambling preoccupy the person’s attention (Moreyra, 2002). They gamble even if their judgment warns them of difficulties. The ego-syntonic nature of the behavior is however against the principles of an obsessive- compulsive disorder. The excessive doubting behavior of obsessive-compulsive behavior is not found in pathological gambling. Other features of the obsessive compulsive disorder like harm-avoidance, risk-aversion and anticipatory anxiety are not found in pathological gambling. Pathological gambling can be considered more of an addiction than an obsession (Moreyra, 2002).
Bipolar Disorder and Pathological Gambling
Stabilizing affective instability constituted one of the earlier bases of therapy. Due to the cyclical episodes, pathological gambling was associated with bipolar disorder.In a study sample of 101 pathological gamblers, 7 % were substance abusers in the current situation while 72% had lifetime disorders (Hodgins, 2010). The lifetime rate for other drugs like cannabis, cocaine, hallucinogens and amphetamines was 48%. Where mood disorders were concerned current disorders were found in 20% and lifetime disorders in 60%. The illness with the largest number was depression. 7% had bipolar disorder 1, 3% had bipolar disorder 2, 3% dysthymia, and 5% had depression with dysthymia (Hodgins, 2010).Pathological gambling and bipolar disorder share similar features in that both have similar features clinically and respond to mood stabilizers (Nicolato et al, 2007).
Creating public awareness about problem gambling is significant (Bannister, 2007). The National Responsible Gambling Programme in South Africa did exactly this. The campaign was endorsed by celebrities well-loved in South Africa like Dingan Thobela, lightweight boxer and Mark Fish, international soccer player. Soap opera stars also joined in. Media publicity, flyers and other campaigns for disseminating the message to stop problem gambling is essential to create appropriate public awareness about the ills of gambling and how gambling can remain a recreational activity without progressing on to pathological gambling.
Gambling has become a fairly big issue to warrant attention. Video gambling machines are found in restaurants and bars so that people of all ages are exposed to gambling (Student Affairs Leader, 2006). College students are seeking financial aid to indulge in gambling activities overlooking their priority for study. 5% of college students are having a problem and 15% are at risk. Based on the requirements of institutions, prevention programs may be established with the coordination and funding of the State Department of Human Services. Oregon campuses have decided to opt for the gambling prevention effort (Student Affairs Leader, 2006). Developing on-campus relationships or partnerships is the first recommended step. Surveying the students and disclosing the results of the survey to the students themselves would be the next step. Questions about the gambling habits, the borrowing of money for gambling purposes,developing awareness and introduction to peer programs provide an interactive awareness. Most schools have a substance abuse policy but no gambling policy. Internet gambling must be totally blocked out from campuses (Student Affairs Leader, 2006)
Treatment modalities of compulsive gambling
Gambling disorders produce a huge amount of socio-economic costs and with the gambler losing his job or a relationship and being initiated into criminal offences (Hodgins et al, 2009). Medical conditions associated with stress may be seen in pathological gamblers. They may also be suicide-prone. Mood disorders, attention deficit disorder and substance abuse may be evident. Appropriate and effective treatment is a necessary health investment by way of ethics and economics. As only a minimal number of compulsive gamblers seek treatment, it is only natural to search for effective and brief treatments (Hodgins et al, 2009)
Treatment for pathological gambling based on outcomes has been limited. Self-directed written messages or a short period of contact with the clients comprise the brief treatment. Telephone helpline services also provide immediate help to gamblers through brief treatment. Treatment process requires very little financial resources or time. One disadvantage of the brief treatment is that information materials may be disseminated far and wide but treatment access is not as widespread (Hodgins et al, 2009). However researchers have been interested in developing the brief treatment as pathological gamblers do not seek formal treatment. Ensuring that with time, more clients may seek therapy is the aim of the focusing on brief therapy.
Treatment by gender differences
Literature on treatment and recovery focus on male gamblers and neglect the special circumstances and background of female gamblers (Avery and Davis, 2008). Therapeutic strategies also remain untested; most of the approaches have been adapted from the substance abuse therapy interventions. The goal thereby is abstinence and the length of abstinence decides the effectiveness of the therapy (Avery and Davis, 2008).
Motivational support led to superior outcomes in the cognitive behavioral self-help workbook (Hodgins and Makarchuk, 2002 cited in Hodgins, 2009). Motivational support provided at the beginning as well as the end of the therapy facilitated better therapeutic outcomes. Several studies have indicated the significance of the motivational interviewing as a therapeutic ingredient for problem gamblers (Arkowitz, Miller, Westra and Rollnick, 2007; Diskin and Hodgins in press). The latter authors compared the impact of a clinical interview with a motivational interview in problem gamblers. Petry, Weinstock, Ledgerwood and Morasco (2008) opposed this viewpoint in their study. They opined that motivational interviewing did not enhance outcomes in 3 brief face-to-face interventions for pathological and problem gamblers. The participants had a ten minute behavioral advice, one motivational interviewing session followed by 3 cognitive behavioral sessions. At a follow-up after six weeks, less gambling and expenditure were found in the participants who had the ten minute advice(Hodgins, 2009). A follow-up after nine months indicated less gambling severity and expenditure in the group which had motivational interviewing than the control group but it was the group which had the ten minute advice that fared as clinically improved. Motivational enhancement was possible through the self-directed strategies (Hodgins, 2009). A telephonic motivational interview was the main method. The second approach included brief booster therapy with a telephonic interview and the workbook followed by regular telephonic support (Hodgins, 2009). Future research needs to compare the investigation of less intensive and more intensive therapeutic interventions.
Gamblers Anonymous and cognitive behavioral interventions are very useful in the treatment of pathological gambling. The aim of therapy would be the prevention of relapses through less exposure to the gambling sites (Moreyra, 2002). Prolonged exposure is an effective technique to prevent negative response.
Compulsive gambling has given rise to much research investigating the epidemiology of gambling and disorders related to it (Gebauer et al, 2010). The incidence of pathological gambling is small but the accessibility to gambling is increasing hence making it a problem in the community. This picture allows one to believe that real-time target-oriented programmes could further reduce the pathological gambling and the end-point of zero is in sight. Psychiatric disorders and substance use disorders have been found to accompany pathological gambling. The definition of gambling disorders has been taken from the American Psychiatric Association (2000): “Gambling disorders are broadly defined as persistent and recurrent maladaptive gambling that disrupts personal, family, or vocational pursuits”. Vachon and Bagby (2009) have used the five factor model (FFM), measured by the Revised NEO Personality Inventory for their study. Traits that were used to predict the PG were highly reliable, stable, cross-culturally replicable and heritable (Vachon and Bagby, 2009). Problem gambling theories have suggested that the gambling was sought after by emotionally unstable gamblers to change their mood states and to reach psychological desire. Mood states and escapism are other reasons found in studies which reinforce the gambling habit (Wood, 2007b). It has also been decided in other studies that problem gambling and depression are related (Kim, 2006).
Gender differences in gambling behavior and the reasons which initiated the gambling have not been investigated well (Clarke and Clarkson, 2008). Males were more likely to indulge in regular continuous gambling. The improved social integration, the increase in self-esteem, more activity, enhanced travel and cognitive stimulation contributed to the health benefits (Clarke and Clarkson, 2008). Research has noted that men are more intrinsically motivated while women are externally motivated to chance activities like lotteries, raffles and scratch tickets (Delfabbro, 2000 cited in Clarke and Clarkson, 2008). Women were more prone to introjected regulation to escape daily stress of family responsibilities and have some control in their lives. Excitement and learning skills were more seen in men (Walker et al, 2005). The tendency to gamble for fun lay with the women. Men were more curious. The increase of women gambling is being accompanied low income, working class women by a growing addiction problem among women (Davis and Avery, 2004). These women also have a likelihood of moving onto compulsive gambling. Women tend to go in for gambling at a later stage in life when compared to men. They also have more associated psychiatric problems (Li, 2007). Five themes emerged: “gambling was hope, escape, therapy, reward and their social life” (Li, 2007).Research has found the association of psychiatric disorders with pathological gambling; that past year Axis-I and lifetime Axis-II disorders were associated with the gambling problems (Desai and Potenza, 2007).
Youth gambling occurs more due to the invulnerability of their age. Compared to the prevalence of between 4.6 and 7.5% for pathological gambling in adults in North America, the prevalence is four to five times higher (Molde et al, 2009). Male gamblers appear to be 3-5 times more than females. Ethnic minorities and those of low socio-economic status show a wider extent of gambling (Molde et al, 2009). However gambling could be a resort and not a problem if the youth are dissuaded from substance abuse, depression, anxiety and mental disorders (Korn and Shaffer, 1999 cited in Molde et al, 2009). Understanding the factors which contribute to the addictive behaviors is of prime importance in research. The “illusion of control” is a cognitive belief that the outcome of games can be skillfully handled. Molde’s study indicated that the male-female prevalence was 12:1, probably because males are more prone to taking risks (Chalmers and Willoughby, 2006). Social norms may also be responsible for preventing females to participate as early as the males. Researchers have identified individual impulsivity, problem gambling in the family, substance abuse, the availability of gambling sources, exposure to peer gambling as being associated to problem gambling (Welte et al, 2009). Gambling on cards was the most likely game which caused problems in gambling as had been indicated by the US youth studies. Dysregulation of brain dopaminergic activity could explain the development of pathological gambling (Crockford, 2008). Among the drugs for Parkinsonism, it is known that pathological gambling, hypersexuality, compulsive eating and buying are believed to be examples of uncontrolled behavior. Impulse disorders are the results of behavior accidents (Cilia, 2008). The pathological gambling is assumed to be due to the enhanced dopaminergic stimulation of the mesocortical limbic pathways rather than the neurodegenerative process that had been the stipulation till then. Functional neuroimaging techniques were used to decide the association between pathological gambling and the increased sensitivity to “impulse control, reward, reward- based learning, motivation and memory” (Cilia et al, 2008). Frontal lobe dysfunction has been reported in pathological gamblers by Rugle and Melamed (1993 cited in Petry, 2007). Underlying neurotransmitter effects have been found to be similar in pathological gambling and substance use disorders. Co-morbid substance abuse and the mood disorders that are the outcomes of the pathological gambling have been studied by Hodgins (2010). Comorbid disorders have been found to be higher among the pathological gamblers than the general population (Petry and Weinstock, 2007). Government decision makers have viewed pathological and problem gambling with great concern as it is possible that a public health response can manage the health problem (Rush et al, 2008). The Diagnostic and Statistical Manual of Mental Disorders has introduced pathological gambling as a disorder of impulse control (Petry, 2007). The people who are prone to problem gambling have a disposition to different maladaptive problems and behaviors. A reward-deficiency syndrome is believed to explain the co-morbidity relationship. The syndrome may include addiction, impulsivity or obsessions (McIntyre et al, 2007 cited in Brooker, 2009). SSRIs are used as medication for treating problem gambling ; they included citalopram, escitalopram, paroxetine and fluvoxamine (Westphal et al, 2008). An urgent desire to satisfy one’s need, a loss of control over the behavior, persistent thoughts about it are found with addictions as with pathological gambling (Moreyra, 2002). Pathological gambling and bipolar disorder share similar features in that both have similar features clinically and respond to mood stabilizers (Nicolato et al, 2007). Creating public awareness about problem gambling is significant (Bannister, 2007). Attempts are being made in educational institutions to reduce the problem of gambling among the youth. Appropriate and effective treatment is a necessary health investment by way of ethics and economics. As only a minimal number of compulsive gamblers seek treatment, it is only natural to search for effective and brief treatments (Hodgins et al, 2009). The goal of therapy thereby is abstinence and the length of abstinence decides the effectiveness of the therapy (Avery and Davis, 2008). Motivational support provided at the beginning as well as the end of the therapy facilitated better therapeutic outcomes. Several studies have indicated the significance of the motivational interviewing as a therapeutic ingredient for problem gamblers (Arkowitz, Miller, Westra and Rollnick, 2007; Diskin and Hodgins in press). Psycho social interventions like Gamblers Anonymous and cognitive behavioral interventions are very useful in the treatment of pathological gambling (Moreyra, 2002).
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