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8.98: Pathological Gambling (312.21)

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    23294
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    Pathological gambling (PG) involves being unable to resist the impulse to gamble. The transition from recreational gambling to pathological gambling may occur gradually, or it may transition suddenly in response to a stressful event such as job loss (Bayer, 2000).

    Some features associated with pathological gamblers include denial, overconfidence, delusions of grandeur, development of superstitions, highly competitive, and overly concerned with approval from others (Bayer, 2000). In order to be diagnosed as a pathological gambler, the individuals symptoms must be persistent and recurrent, and the individual must be preoccupied with reliving past gambling experiences or planning future gambling excursions (Bayer, 2000). After some time, the individual may feel compelled to take higher risks to produce the desired level of excitement. This disorder can result in a host of occupational, social, and legal problems. Compulsive gamblers often find themselves lying to their family members and friends to hide the severity of their problem. They may even resort to illegal, but typically nonviolent, means of acquiring money to gamble (Bayer, 2000).

    Compulsive gamblers are more prone to medical conditions that are brought about by stress such as hypertension, peptic ulcers, and migraine headaches (Bayer, 2000). They may also have comorbid mood disorders, substance-related disorders, antisocial behavior, attention-deficit disorder, or hyperactivity (Bayer, 2000). Compulsive gambling can be confused with bipolar disorder, which sometimes accompanies compulsive gambling (Bayer, 2000).

    This impulse-control disorder is more common among men than women. Women who do have this disorder are often hesitant to seek treatment; this may be because society tends to view gambling as less acceptable for women than men.

    Pathological gambling typically begins in adolescence for boys and later in life for girls (Bayer, 2000). It may be regular or episodic, but it is often chronic (Bayer, 2000). Environmental stressors or depression may increase the frequency of gambling (Bayer, 2000).

    Treatment for compulsive gambling includes inpatient & outpatient programs, residential care, halfway houses, behavior modification, individual and group therapy, and traditional psychoanalysis (Bayer, 2000). Relapses are common.

    DSM-IV-TR criteria

    A. Persistent and recurrent maladaptive gambling behavior as indicated by five (or more) of the following:

    1. is preoccupied with gambling (e.g., preoccupied with reliving past gambling experiences, handicapping or planning the next venture, or thinking of ways to get money with which to gamble)
    2. needs to gamble with increasing amounts of money in order to achieve the desired excitement
    3. has repeated unsuccessful efforts to control, cut back, or stop gambling
    4. is restless or irritable when attempting to cut down or stop gambling
    5. gambles as a way of escaping from problems or of relieving a dysphoric mood (e.g., feelings of helplessness, guilt, anxiety, depression)
    6. after losing money gambling, often returns another day to get even (“chasing” one’s losses)
    7. lies to family members, therapist, or others to conceal the extent of involvement with gambling
    8. has committed illegal acts such as forgery, fraud, theft, or embezzlement to finance gambling
    9. has jeopardized or lost a significant relationship, job, or educational or career opportunity because of gambling
    10. relies on others to provide money to relieve a desperate financial situation caused by gambling

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

    Associated features

    Pathological gambling (PG) is characterized as a chronic, progressively maladaptive, impulse-control disorder, that is distinguished by continued acts of gambling despite compounding severe negative consequences. Individuals with PG may present distortions in thinking and may believe that money is both the cause and solution to all of their problems. Individuals with PG tend to be highly competitive, energetic, and easily bored. They may be overly concerned with others’ approval and may be extravagantly generous. When they are not gambling, they may considered to be workaholics or “binge” workers. They may be at risk for medical conditions associated with stress, and those seeking treatment have high rates of suicidal ideation and attempts. Individuals who suffer from PG often have problematic interpersonal relationships. These relationships become increasingly strained during the progression of the disorder. Some individuals with PG may try to legally finance gambling and living expenses through loans. Others may also commit illegal acts such as forgery, fraud, theft, or embezzlement in order to gain financing. There is evidence to support comorbidity of PG with alcohol abuse and depression. A 1992 study showed that 12.9% of heavy drinkers had a gambling problem, compared to 5% of nondrinkers. Comorbidity rates of PG and major depressive disorder can reach as high as 76%. Other associated features of PG include unemployment, substance abuse, and suicide attempts. Most pathological gamblers tend to deny their problem and therefore do not get help. Associated features also include repetitive behaviors which shares features with obsessive-compulsive disorder.

    Child vs. adult presentation

    Historically, PG has been stereotyped as an adult disorder, but with the vast growth of casino expansion and the creation of internet gambling, adolescent rates of PG have superseded adult prevalence rates by two to four times. According to a 2006 Adolescent Psychiatry article by Timothy W. Fong, gambling is a media-driven, socially acceptable form of behavior. Fong also noted that 86% to 93% of all adolescents have gambled for money at least once (2006). Seventy-five percent of those did it within the confines of their home, while 85% of parents did not care (Fong, 2006). Fong stated that adolescent gambling is the most popular risk-taking behavior seen in adolescents, trumping cigarettes, alcohol, drugs, and sex (2006). The reasons why adolescents start gambling in comparison to the reasons why adults start gambling are very different. Adolescents use gambling as a form of excitement, a relief of boredom, and a coping mechanism or relief from daily stress. Adolescents have a need to keep playing for spectator success, and gambling is a social acceptable form of competition.

    Gender and cultural differences in presentation

    More men than women are diagnosed with pathological gambling, with a 2:1 ratio, and men have a higher tendency to start at a younger age. Gambling usually begins in early adolescence in men and from ages 20-40 in women. Culturally, pathological gambling is more prevalent in minority groups. Socioeconomic status also strongly correlates; it is more common in poor individuals who cannot afford to gamble and who inevitably feel as though they cannot afford not to gamble.

    Epidemiology

    • As gambling facilities become more prevalent, so do PG rates. In fact, 2 million Americans are considered to be pathological gamblers, with another 3 million considered being “problematic gamblers,” and 15 million more considered to be at risk. There is a 4% prevalence rate in America. Prevalence rates in other countries vary. Worldwide rates range from 2% to 6%.
    • Pathological gambling usually begins in early adolescence in males and later in life in females. A few individuals are “hooked” with their first bet, but for most the course is more insidious. Years of social gambling may be followed by an abrupt onset that may be precipitated by greater exposure to gambling or to some stressor. The pattern may be regular or episodic, and the course of the disorder is often chronic.

    Etiology

    The causes do not seem to be biological as there is no evidence to support it. A psychological cause is more likely. A pathological gambler typically has symptoms of depression or alcoholic tendencies. They usually turn to gambling to get the “high” of winning to escape from everyday problems or more serious life problems.

    Empirically supported treatments

    • Treatment for PG includes therapy and possibly medication. Before treatment can begin, the individual must first realize that they do indeed have a problem and that they need help. Announcing this to friends and family is usually best. Treatment is based on behavior changes. The counselor will usually start by uncovering the underlying cause of the gambling addiction. If the patient is depressed then the depression is treated accordingly. For several of the people who stay in treatment, it is successful. On average, however, 50% drop out of the therapy.
    • Aversion therapy is one option available to pathological gamblers. During aversion therapy, the patient is exposed to the stimulus while also being exposed to something that would cause them discomfort. Treatments usually try to help the patient overcome their impulses and learn to control urges. Also, the gambler must learn to overcome the illusion that they will “win the next time.”
    • There are also self-help groups like Gamblers Anonymous that the patient can join. Groups for the family are also available.
    • It is often recommended that the individual never return to gambling. It is also recommended that the individual never return to the places that he or she gambled, because returning causes the patient to be at high risk for a relapse.
    • Medications such as antidepressants and opioid antagonists (naltrexone) may help, also.
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