Home > Encyclopedia of Drugs, Alcohol, and Addictive Behavior > Gambling Addiction: Assessment

BEGINNING OF TREATMENT

In the United States, the first organized program to deal with problem gambling occurred in 1957 with the founding of Gamblers Anonymous, a self-help/mutual support program. The first professional treatment program for compulsive gamblers was begun in 1972 by a psychiatrist, Robert Custer, in an inpatient alcohol program in a Veterans Administration hospital. The first state funded treatment program for compulsive gamblers began in Maryland in 1978.

ASSESSMENT AND TERMINOLOGY

Gamblers Anonymous developed 20 screening questions to help individuals decide whether they are compulsive gamblers. This questionnaire was the primary instrument utilized by professionals until 1980, when the mental health establishment recognized a gambling problem as a psychiatric disorder, naming it pathological gambling. Diagnostic criteria for this disorder were specified in the Diagnostic and Statistical Manual (DSM III) used by mental health and addiction clinicians (American Psychiatric Association, 1980). The most widely used term in society referring to this disorder is still compulsive gambling, while the terms addictive, chronic and disordered gambling are also currently in use. The term problem gambling is used generically to refer to an unspecified level of severity and is also used in an assessment context to refer to a gambling problem of mild to moderate severity, encompassing those at risk for developing pathological gambling.

DSM IV DIAGNOSIS

The diagnostic criteria were modified in DSM III-R (American Psychiatric Association, 1987) and in DSM IV (American Psychiatric Association, 1994). The diagnostic criteria for pathological gambling in DSM IV are provided below.

1. 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
2. The gambling behavior is not better accounted for by a Manic Episode.

Key features in these criteria include: obsessive preoccupation (including craving); progressive inability to control all aspects of gambling; and continuation of gambling despite increasing negative consequences of gambling.

To assist certified clinicians who are not experts in pathological gambling in making a reliable diagnosis of pathological gambling, several DSM IV based structured interviews have been developed but no validation studies have been reported.

It would be clinically useful to include in the future revision of DSM the less severe category of gambling abuse to parallel the current substance abuse diagnostic categories in DSM IV.

DEVELOPMENT OF SCREENING INSTRUMENTS

Pathological gambling is a progressive disorder with very serious life consequences at the later stages. Early identification is especially important because of the devastating individual, family and social impacts of high rates of bankruptcy, suicide, and crime and other individual and societal problems related to pathological gambling (Blaszczynski, et al., 1989; Lesieur, 1998; Phillips, et al., 1997).

The first valid and reliable screening instrument for pathological gambling was the South Oaks Gambling Screen (SOGS) developed in 1987 and still the primary instrument in the field for clinical screening and prevalence research (Lesieur & Blume, 1987). As the SOGS has twenty items, there is a need for a briefer screening instrument which is rapidly scorable. Screening instruments which have been developed to assess problem and pathological gambling in youth are the MAGS (Shaffer, et al., 1994), DSM IV-J (Fisher, 1992) and SOGS-RA (Winters, et al., 1993). Self-report instruments are useful for self-screening and initial professional screening but are not to be used for diagnostic purposes.

ASSESSMENT OF THE FAMILY SYSTEM

In addition to conducting an assessment of the gambler in the clinical context, assessment of other key family members is important for the following reasons (Steinberg, 1993):

• Identification of current and imminent crises.
• Orientation of family members to the treatment setting in preparation for potential involvement in the process.
• Gaining the perspective of significant others provides a more accurate picture of the nature and extent of the gambler's problem.
• Observation of family dynamics provides a clearer understanding of family deficits and strengths.
• Opening an avenue of communication with family members provides earlier detection of signs of relapse.
• It increases the likelihood of help for the family even if the gambler drops out of treatment.
• The impact of the gambling on children in the family can be better determined.

PROGRESSION OF THE DISORDER

Assessment of problem gamblers in less advanced stages is more difficult. Increased public awareness of the signs of pathological gambling coupled with more human services professionals receiving training in the disorder is resulting in detection of a gambling disorder early in its progression. Instruments that identify the degree of current problem and risk for developing pathological gambling are still needed.

Custer and Milt (1985) identified in clinical practice three stages in the progression of a gambling disorder (for almost exclusively male action gamblers).

Winning stage: Characterized by an initial large win.

Losing stage: Losses are chased with increased gambling until a major problem occurs which is temporarily resolved by a financial bailout, followed by a higher level of gambling and increased crises.

Desperation stage: The gambler further withdraws from family and work responsibilities into gambling, often resulting in criminal and suicidal behavior. Help may or may not be sought.

Hopelessness stage: Rosenthal added the fourth stage for some gamblers who no longer care and continue to gamble without hope of winning. Custer's (1985) chart below depicts the progression and recovery cycle for those who seek help.

PATHOLOGICAL GAMBLING, SUBSTANCE DEPENDENCE, AND OTHER CO-MORBID DISORDERS

While pathological gambling is classified as an impulse disorder, it is increasingly viewed as part of the family of addictions. In fact, the criteria for pathological gambling in DSM III-R were modeled after the criteria for psychoactive substance dependence in DSM III-R. The DSM IV criteria for problem gambling blend DSM III and DSM III-R criteria. There is increasing clinical research evidence for sequential and simultaneous dual addictions involving gambling and substances e.g., alcohol, cocaine, tobacco (Lesieur & Blume, 1996). Brain chemistry research and preliminary genetic research have both pointed to biochemical and etiological commonalities for pathological gambling and substance dependence. While not as extensively researched, relationships have also been found between pathological gambling and food, sex, and work addictions. Co-morbidity has also been found between pathological gambling and other psychiatric disorders, including clinical depression and other mood disorders, anxiety, attention deficit hyperactivity disorder (ADHD), and personality disorders (Blaszczynski & Steel, 1998; Carlton, et al., 1987; McCormick, et al., 1984).

A theory is developing which places pathological gambling in a compulsive-impulsive spectrum with problem gambling as one of the impulse (ego syntonic) disorders at one end of the spectrum and obsessive-compulsive disorders (ego dystonic) at the other end (Cartwright, et al., 1998). Different degrees of impulsivity and compulsivity are experienced by pathological gamblers, depending upon the stage of the development of the disorder with impulsivity primarily at the early stage and growing compulsion at the later stage.

MULTIPLE CONTRIBUTING CAUSATIVE FACTORS

As the twenty first century begins, there is not widespread agreement as to the exact cause(s) of pathological gambling. However, as with many other disorders, a broad model is emerging which includes four major areas of risk factors for developing this disorder: biological, social, psychological, and spiritual (Rugle, 1993).

Biological.

Genetic research in the late 1990s has provided preliminary evidence of a genetic link among pathological gambling and other addictive and impulse control disorders (Comings, 1998). This is mediated by neurotransmitters which control impulsivity, emotion and the experience of pleasure. Advances in brain imaging in the late 1990s began to identify areas of deficit in brain functioning which are related to deficits of behavior functioning (e.g. attention deficit hyperactivity disorder [ADHD] (Cartwright, et al., 1998)).

Social/Environmental.

Research has provided evidence that early environmental factors in the home such as exposure to a parents excessive gambling or abuse is linked to a later gambling problem. Further, it is likely that trauma in adulthood, including losses later in life, increase vulnerability to developing a gambling problem. Such environmental factors as proximity to gambling, widespread gambling advertisements and the absence of significant education about responsible gambling and the warning signs of problem gambling are likely contributors to higher prevalence rates in certain communities.

Psychological.

Recognizable differences between pathological gamblers and non-pathological gamblers have been identified in personality patterns (low frustration tolerance, self-centeredness, mood changes), dissociation and fantasy, as well as irrational and magical thinking. Gender differences have been linked to choice of gambling activities. Men tend to more often be "action" gamblers seeking competition and games of skill (e.g., cards, sports) and women are more likely to be "escape" gamblers seeking solitary and non-competitive activity (e.g., electronic gaming machines).

Spiritual.

The 12-Step Recovery programs of Gamblers Anonymous and Gam-Anon, for family members of addicted gamblers (patterned after Alcoholics Anonymous and Al-Anon) attempt to bolster the recovery process by searching for and relying on a higher power to give new meaning to life. Addictions, including pathological gambling, involve substitution of quick fix activities for intimate relations and a spiritual life.

While it has become clearer that the above factors increase the risk of developing a gambling problem, progress toward the development of valid and reliable measures of these factors is evolving slowly but with a quickening pace.

MARVIN A. STEINBERG