American Family Physician: Pathologic gambling: America's newest addiction?

In the past decade, the availability of legalized gambling, especially casino gambling, has proliferated in the United States. Some form of legalized gambling exists in every state except Utah and Hawaii, and 27 states have legalized casino gambling. Off-shore companies offer sports-book wagering through toll-free numbers and the Internet. In 1996, $586.5 billion was wagered in all forms of legal gambling in the United States. Overall, between 75 and 90 percent of Americans gamble. While most of these people gamble responsibly, a small percentage develop addiction to the "action" of gambling, and the prevalence of pathologic gambling seems to be increasing with the growth of the gaming industry.

Prevalence rates for pathologic gambling in studies conducted after 1990 are higher than those in earlier studies carried out when fewer gambling opportunities existed. The density of Gambler's Anonymous chapters is positively associated with the availability of casinos, card rooms, slot machines, sports betting, jai alai and off-track betting.[1] The most recent studies estimate the current prevalence of pathologic gambling at 1.4 to 2.8 percent with a lifetime prevalence of 3.5 to 5.1 percent in the general population.[2]

Pathologic gambling is not just a recent problem. In 1866, Dostoyevsky wrote "The Gambler," a semi-autobiographic work, in part to pay off his own gambling debts. Edmund Bergler published the "Psychology of Gambling" in 1957. That same year, the first Gambler's Anonymous chapter was organized. Based on the 12-step model of Alcoholics Anonymous, it uses the principles of group therapy. Abstinent gamblers provide peer support for people who enter the program.

In the late 1960s, Dr. Robert Custer started the first formal treatment program for pathologic gamblers at the Veterans Administration hospital in Brecksville, Ohio. In 1980, the American Psychiatric Association added pathologic gambling to the disorders of impulse control in the Diagnostic and Statistical Manual of Mental Disorders (DSM-III). In DSM-III R and DSM-IV, pathologic gambling is not only described as a disorder of impulse control but is also identified as having similarities to substance dependencies such as alcohol dependence.

The criteria for pathologic gambling are defined in DSM-IV (see table). Patients must meet five out of 10 criteria and not have an underlying manic disorder to be identified as a pathologic gambler. Criteria include the following: a preoccupation with gambling behavior, a need to increase the amount of the bet, the inability to cut back, restlessness or irritability while cutting back and using gambling as an escape mechanism. Other criteria include "chasing" losses (returning at another time to get even after losing money gambling), lying to family members or therapists to conceal behavior, committing illegal acts to cover losses, jeopardizing relationships or opportunities because of gambling, and having to rely on others to cover financial losses.

Diagnostic Criteria for Pathologic Gambling

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., feeling 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.

REFERENCES

[1]. Lester D. Access to gambling opportunities and compulsive gambling. Int J Addict 1994;29:1611-6.

[2.] Volberg RA. Prevalence studies of problem gambling in the United States. J Gambling Studies 1996;12:111-28.

[3.] Lesieur HR, Blume SB. The South Oaks Gambling Screen (SOGS): a new instrument for the identification of pathological gamblers. Am J Psychiatry 1987;144:1184-8.

[4.] Walker MB, Dickerson MG. The prevalence of problem and pathological gambling: A critical analysis. J Gambling Studies 1996;12:233-49.

[5.] Custer RL, Milt H, eds. When luck runs out: help for compulsive gamblers and their families. New York: Facts on File, 1985.

[6.] Roy A, De Jong J, Linnoila M. Extraversion in pathological gamblers. Correlates with indexes of noradrenergic function. Arch Gen Psychiatry 1989;46:679-81.

[7.] Moreno I, Saiz-Ruiz J, Lopez-Ibor JJ. Serotonin and gambling dependence. Human Psychopharmacol 1991;6(Suppl):9-12.

[8.] Carrasco JL, Saiz-Ruiz J, Hollander E, Cesar J, Lopez-Ibor JJ Jr. Low platelet monoamine oxidase activity in pathological gambling. Acta Psychiatr Scand 1994;90:427-31.

The author thanks Dr. Michael Miller, Dr. Michael Fleming and Dr. JoAnn Ellero for their assistance with this manuscript.

Dr. Pasternak is a fellow in academic family medicine at the University of Wisconsin at Madison.