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THE ADDICTION MODEL OF PATHOLOGICAL GAMBLING

The early psychoanalytic literature often referred to compulsive gamblers as ADDICTS, but it was not until the founding of Gamblers Anonymous (GA) in 1957 that the addictive-disease model became a basis for recovery. GA was initiated through the efforts of a recovering alcoholic who was both an ALCOHOLICS ANONYMOUS (AA) member and a compulsive gambler. GA adapted the TWELVE STEPS of AA, the fellowship's traditions, its spiritual base, and the general format of its meetings to aid in the recovery of gambling addicts. Gam-Anon, a twelve-step group for the friends and families of compulsive gamblers, modeled on Al-Anon Family Groups, was established shortly afterward. Local chapters of Gamblers Anonymous are increasingly available in U.S. communities as well as in treatment units, work settings, and prisons.

The growth of the alcoholism- and drug-addiction-treatment system in the 1960s gave rise to a variety of professional program models that incorporated a cooperative working relationship with twelve-step groups such as Alcoholics Anonymous. In 1971, using one of these models, Dr. Robert Custer developed the first inpatient addiction-oriented treatment unit for compulsive gamblers at the Brecksville, Ohio, Veterans Administration Hospital. Custer's approach proved useful and has been adopted with various modifications by other mental-health and addiction-treatment facilities.

COMMON CHARACTERISTICS WITH OTHER ADDICTIVE DISORDERS

The addiction model conceptualizes pathological gambling as a disease characterized by a dependence on what gamblers refer to as "being in action." The term describes their aroused euphoric state—experienced while gambling. Pathological gamblers who are also users of other drugs compare being in action to the "high" derived from COCAINE or other STIMULANTS. The addiction model is also supported by the many similarities between pathological gambling and substance dependence in risk factors, symptoms, the course of the disease, the nature of relapse triggers, treatment goals, and the process of recovery. A core symptom for both types of disorder is a loss of control over the substance use or gambling behavior. There is also an important comorbidity between the various addictive disorders. For example, a 1986 study of 458 adult inpatients admitted for alcohol and other drug (AOD) dependence to South Oaks Hospital in New York found that 9 percent satisfied diagnostic criteria for pathological gambling and an additional 10 percent had some gambling problems. These rates are many times higher than are found among the general public. In a parallel study of 100 younger AOD inpatients (average age 17), 14 percent met criteria for pathological gambling and an additional 14 percent had some gambling problems. In a later study of cocaine-dependent outpatients, Dr. Bruce Rounsaville at Yale University found pathological gambling in 19 percent of the male and 5.5 percent of the female subjects. Failure to recognize and address gambling problems during treatment for alcohol or other drug dependence often leads to relapse to substance use in a gambling situation. Less frequently, the result is a switch of addictions from alcohol or another drug to gambling.

EPIDEMIOLOGY OF PATHOLOGICAL GAMBLING

Epidemiological studies conducted during the 1980s in New York, New Jersey, Maryland, and Quebec yielded similar estimates. Approximately 1.5 percent of adults were found to be probable pathological gamblers and an additional 2.5 percent were found to have some gambling-related problems. In contrast, a lower prevalence was found in Iowa. Unlike the other jurisdictions studied, in which legal gambling was well established, Iowa had just initiated a state lottery at the time of the survey. The Iowa rate climbed over the next few years, and subsequent studies by Dr. Rachel Volberg found that the prevalence of gambling problems in several states correlated with the state's per capita lottery sales and the number of years of exposure of the state's population to legal gambling.

Dr. Howard Shaffer of Harvard and his colleagues conducted a meta-analysis of 120 epidemiological studies of gambling problems in the scientific literature to try to approximate an overall prevalence rate. They found that among adults, about 1.6 percent had a diagnosis of pathological gambling at some time in their lives and an additional 3.9 percent had gambling problems. Criteria for a current diagnosis was met by about 1.1 percent, while 2.8 percent had current gambling problems of a lesser severity.

In general-population studies in the United States, males outnumber females among probable pathological gamblers by a ratio of about two to one. This is in sharp contrast to male to female ratios observed in treatment programs and GA groups, which are closer to eight or nine males to one female. Some general-population studies in the United States have also found an overrepresentation of nonwhite adults (blacks and Hispanics) among probable pathological gamblers; but these groups, like women, are also underrepresented in treatment and GA populations.

Although less is known about the prevalence of pathological gambling among adolescents than among adults, several surveys of high school students revealed that the vast majority gamble to some extent and that many have problems. For example, a New Jersey study of nearly 900 students found that over 90 percent had gambled at some time in their lives and about 35 percent did so at least weekly. Approximately 5.7 percent of these eleventh- and twelfth-grade students—9.5 percent of boys and 2 percent of girls—were classified as probable pathological gamblers. The Shaffer study found consistently higher rates of both gambling problems and pathological gambling in adolescent and college-age populations.

Established risk factors for pathological gambling include being male, having a family history of heavy or problem gambling or of parental alcoholism, and early interest and participation in gambling activities. In addition, some studies show higher rates of problems in people who are non-Caucasian, unmarried, have less than a high school education, have less than average income, or are under the age of thirty.

CLINICAL CHARACTERISTICS

Gambling usually begins in adolescence, although women may begin gambling later in life. Pathological gambling often develops in three phases, originally described by Custer (1985): (1) the winning phase; (2) the losing phase; and (3) the desperation phase. Female pathological gamblers tend to have a later onset of the illness than males, and may never experience a winning phase.

The Winning Phase.

Pathological gamblers often start as winners. Also, in a minority of cases, a significant upsurge in gambling activity begins with a "big win"—a sum equal to half a year's income or more. With or without the big win, individuals developing a dependence on gambling often begin with some success. In this context, they develop an intense interest in gambling and derive an increasing proportion of their self-esteem from feeling smart or lucky. The high derived from being in action becomes a major source of pleasure, a solution to life problems, a remedy for boredom, anger, anxiety, depression, and other uncomfortable feeling states. Bets must be gradually increased in size, in frequency, and sometimes in riskiness to produce the desired psychological effects. This phenomenon parallels the development of tolerance in the substance-dependent patient who must continue to increase the alcohol or drug dosage to reach the preferred feeling state. At this stage of the illness, the gambler devotes a great deal of time and effort to handicapping, studying the sports page, selecting a lottery number, or following the stock market, as well as to the gambling itself. As one gambler put it, "When I'm not occupied with gambling I'm preoccupied with it." Even if the gambler is winning more often than losing, time and emotional investment are withdrawn from friends, family, work, and other interests. The gambler's spouse often senses that something is wrong, but may not identify gambling as the problem. Marital counseling is sometimes sought.

An unreasonable attitude of optimism is also common during the early phase of pathological gambling, sustained by concentrating on wins and making excuses for (or even denying) losses. Because of this denial, the gambler often cannot account for money claimed to have been won. Pathological gamblers who begin with a winning phase are often those who state they gamble for excitement or stimulation.

The Losing Phase.

All gamblers know that when on a losing streak it is wise to stop wagering, at least temporarily. For the compulsive gambler, however, losses are experienced as a severe injury to self-esteem. This produces an intense drive to continue gambling in an effort to recoup the money that has been lost, called chasing losses. Chasing losses is an important characteristic of this disease and an example of the pathological gambler's impaired control of gambling behavior. Chasing losses accelerates the gambler's losing and initiates a downward spiral. As the gambling debts mount, the pathological gambler will use any and all money available—take out loans, sell property, and gamble with money meant for family necessities. When these sources are exhausted, extended family members or friends may be approached for a "bailout," in the form of a loan or gift to relieve immediate financial pressure. In return, the pathological gambler often promises to give up gambling. However, part of the bailout money is usually gambled in the hope of another big win, and the downward spiral resumes. Although there are both wins and losses during the losing phase, the overall result is mounting emotional and financial distress as well as interference with social, vocational, and family functioning. Serious depression and a variety of stress-related somatic disorders are often experienced. Pathological gamblers report insomnia, gastrointestinal symptoms, dizziness, headache, hypertension, palpitations, chest pains, and breathing problems. Medical help may be sought, but again the connection to gambling behavior is seldom recognized. Family problems become more intense and divorce often results. Alcohol and other drug abuse may accompany gambling and/or function as a substitute when gambling is temporarily interrupted.

Pathological gamblers also describe a WITHDRAWAL syndrome when they are prevented from gambling. Symptoms include craving, restlessness, irritability, insomnia, headache, weakness, gastrointestinal symptoms, shakiness, and muscle aches.

Those pathological gamblers who do not experience a winning phase often describe themselves as gambling for "escape" (from life problems that seem insoluble). However, by the time the disease is well-developed, most pathological gamblers report gambling for both escape and excitement.

The Desperation Phase.

The desperation phase often begins when all legitimate sources of funds are exhausted. The gambling now takes on a desperate quality. The gambler's behavior during this phase may be characterized by activities inconsistent with the individual's previous moral standards, such as lying, embezzling, larceny, and forgery. These activities are justified as temporary expedients until the next big win. Pathological gamblers are often imprisoned both for white-collar crime and for illegal gambling activities such as bookmaking. Violent crime is less common. Studies of prison populations have found gambling problems in 15 to 30 percent of inmates.

An irrational belief in the inevitability of a big win sustains hope to some degree during this phase. Family problems become more intense and mood swings are common. Severe anxiety, major depression, and suicidal behavior are increasingly noted during the late stages of the disease. Manic or hypo-manic states are also seen in some cases. Most pathological gamblers who enter treatment or Gamblers Anonymous do so in the desperation phase. Surveys of Gamblers Anonymous have reported suicide attempts by 17 to 24 percent of members.

PATHOPHYSIOLOGY

Several studies have examined neurochemical changes in pathological gamblers. One study measured levels of NEUROTRANSMITTERS and their metabolites in the body fluids of male pathological gamblers, comparing these to levels in normal male subjects. The researchers found an elevated level of a NOREPINEPHRINE metabolite in the gamblers' urine and cerebrospinal fluid, presumably caused by an increased production of the neurotransmitter norepinephrine within the brain. Furthermore, a psychological measure of extraversion in the gamblers was correlated with levels of norepinephrine and its metabolites in their body fluids. Other, less direct evidence suggests the involvement of additional neurotransmitters, including DOPAMINE and SEROTONIN. A single study of beta ENDORPHINS in pathological gamblers found lower baseline levels in those who bet on horse races than those who played poker-machines or those who were not gamblers. Although research on the pathophysiology of this disease is still preliminary, commonalities with other addictions through central nervous system mechanisms are being sought.

IDENTIFICATION AND TREATMENT

Since 1987 a valid and reliable paper-and-pencil test, the South Oaks Gambling Screen (SOGS), has been available for screening general or clinical populations for gambling problems. The maximum score on this screening test is 20. A score of 5 or more indicates probable pathological gambling, while a score of 1 to 4 signals some gambling problem. Following screening a formal diagnosis must be established. A thorough assessment of physical, psychiatric, addictive, family, social, financial, and legal problems is also necessary because multiple problems are common. Alcohol and drug dependencies, psychiatric disorders and physical problems are most effectively treated at the same time as the gambling addiction. Several psychoactive medications have been tried as adjuncts to the treatment of pathological gambling. Among them, fluvoxamine, a selective serotonin reuptake inhibitor (SSRI), has shown some promise. However, definitive studies have not yet been reported.

Treatment may be provided in both inpatient and outpatient settings. Psychoeducation, individual and group therapies, psychodrama, relaxation training, family counseling and RELAPSE PREVENTION training are commonly used treatment techniques, usually combined with an introduction to Gamblers Anonymous. Family treatment and long-term follow-up are important as well. Abstinence from all forms of gambling is one of the treatment goals, along with improved physical and psychological well-being.

Addiction model treatment may be organized either in a separate facility or as part of a combined substance-dependence and pathological-gambling program. Studies of patients involved in both models of the addiction program have yielded positive outcomes, with gambling abstinence in 56 to 64 percent of the patients who were followed, and improvement in many other aspects of their lives.

American society has paid little attention to the development and application of methods to prevent gambling problems. Most efforts to date involve regulation of the availability of gambling (e.g., minors are forbidden to buy lottery tickets or play in casinos) and posting notices of the availability of help, usually in the form of a toll-free helpline number. The government has made almost no effort to educate youth or the general public about risk factors for pathological gambling and its dangers, in spite of the high prevalence of gambling problems among adolescents. Although children of problem gamblers and alcoholics are known to be at higher risk than others, they have not been the target of organized prevention programs. Since the 1980s, makers of trading cards (e.g., baseball or basketball cards) have begun to insert valuable so-called chase cards at random into the packets of cards at pre-determined rates (e.g., one special card per 700 cards), to stimulate interest in purchasing the product. Because this is similar to a lottery, there has been concern about its immediate and future effects on the children who buy these packets in hopes of finding the valuable cards.

OTHER MODELS OF PATHOLOGICAL GAMBLING

Pathological gambling has been explained using models other than addictive disease. It has been considered, for example, a symptom of some other psychiatric disorder, a behavior disorder, learned behavior that can be "unlearned", a moral problem, or the result of a faulty gambling strategy. Based on behavioral principles, several types of behavior therapy have been applied to gambling problems. The addiction model has, however, proved a useful framework for research, intervention, treatment and self-help. As future research clarifies the neurophysiological mechanisms that underlie alcohol and other drug addiction, both the neurochemical basis of pathological gambling and a "common pathway" of addiction in the brain may also be discovered.

(SEE ALSO: Addiction: Concepts and Definitions; Addictive Personality)

SHEILA B. BLUME