Am Fam Physician. 2000 Feb 1;61(3):741-748.
See related patient information handout on gambling, written by the authors of this article.
This article exemplifies the AAFP 2000 Annual Clinical Focus on mental health.
Pathologic gambling and problem gambling affect approximately 5 to 15 million Americans and are common in young people. The community-minded family physician is in a good position to identify and assist patients who have gambling-related problems and thereby prevent or treat the resultant personal, family and social disruptions. Provider and community education about the depth and breadth of this condition is crucial for the identification and treatment of a growing problem. As with many psychologic conditions, identification of the disorder and treatment of the patient by the family physician comprise the primary treatment. Screening tools, treatment programs and self-help groups provide additional resources for the family physician. An illustrative case report demonstrates the importance of heightened awareness of and screening for this common condition.
Pathologic gambling is identified in every social class. Unfortunately, no systematic process of educating, screening and treating pathologic gamblers is currently in place. Family physicians need to have a heightened awareness about the impact of the pathologic gambler's behavior on the family and should be familiar with screening instruments and treatment options.
Continued growth in the gambling industry raises concerns about a possible increase in the prevalence of problem and pathologic gambling. In 1991, 80 percent of the United States' population gambled in some manner, compared with only 61 percent in the 1960s.1 In 1978 only two states had legalized gambling; in 1998, however, only two states had not legalized gambling.2 The Worldwide Survey of Substance Abuse and Health Behaviors Among Military Personnel3 is a large-scale epidemiologic study that screened personnel for gambling-related problems. The survey reported that in 1992 and 1998, 7.1 percent and 8.1 percent, respectively, of all Department of Defense personnel had at least one gambling-related problem, and 2 percent exhibited behaviors suggestive of pathologic gambling. This high prevalence of gambling-related problems in military personnel is not surprising, given the younger demographics of this population. Most pathologic gamblers began gambling in their youth; 11- to 18-year-olds in one study showed a 4 to 7 percent prevalence rate of problem gambling behaviors.4
Comorbidity with Alcohol Abuse and Depression
Because pathologic gambling is likely to be increasing in incidence, it is important for family physicians to identify and treat this condition as a psychiatric disorder. It is also important to recognize the high incidence of comorbidity of alcohol abuse and depression in gamblers. In one study,3 approximately 12.9 percent of heavy drinkers had one or more gambling-related problem compared with 5 percent of nondrinkers. Eighteen percent of persons with probable alcohol dependence had at least one gambling-related problem, and 10 percent of heavy drinkers were probable pathologic gamblers.
A major depressive disorder is likely to occur in 76 percent of pathologic gamblers, with recurrent depressive episodes likely to occur in 28 percent of pathologic gamblers. Because of this high correlation, the coexistence of depression and gambling may help discriminate pathologic from nonpathologic gambling; however, the severity of depression does not correlate with the amount of money spent on gambling.5 Suicide risk is also high in pathologic gamblers—Las Vegas, Nev., and Atlantic City, N.J., have some of the highest suicide rates in the nation.6
A 51-year-old businessman presented with complaints of fatigue and weight loss. Pertinent findings revealed evidence of alcohol dependence and depression. The patient's spouse provided additional history of withdrawal from family and social activities, and a lifelong history of compulsive gambling. In the previous three years alone, he had lost over $13,000 playing the state lottery and slot machines. His spouse was concerned about possible economic and personal ruin if her husband's gambling persisted. The patient acknowledged that he had claimed nonexistent winnings, gambled more than intended, felt guilty, had difficulty stopping, hid the evidence of his gambling and secured loans to cover gambling debts. He related a long history of gambling and binge alcohol consumption beginning as a teenager. The patient had had a successful military career and retired from the Army to own a small business.
The patient was referred to Gamblers Anonymous and Alcoholics Anonymous, and he also received assistance from community mental health services. The patient's spouse attended Al-Anon meetings. Although he attended only one Gamblers Anonymous meeting and one Alcoholic Anonymous meeting, he believed he could control his behaviors without the assistance of these services. However, he continued to attend counseling sessions and supportive visits with his family physician. His spouse continued to regularly attend Al-Anon meetings.
The patient's depressive symptoms and behavior improved; he reduced alcohol consumption, ceased gambling and attended individual and family counseling sessions conducted by his family physician. The patient and spouse reported improvement in their relationship and communication. She reported being satisfied with his “controlled” drinking and felt less fearful of potential financial ruin.
Social and Cultural Issues
Forms of gambling are recorded through the ages and across cultures. Although the personal costs of gambling rarely gain public attention, one prominent example is that of Pete Rose, who was denied induction into the Baseball Hall of Fame as a result of sports gambling.
The economics of gambling are staggering. The amount of money wagered annually in the United States is estimated to be $0.5 trillion.7 Americans spend approximately $31.5 billion annually on state lottery games, with many states becoming increasingly reliant on revenues from legalized gambling.8 Legalized gambling, organized crime and violence have historically shared a long relationship. Findings from the 1999 Gambling Impact and Behavior Study8 (sponsored by the National Gambling Impact Study Commission) revealed the following changes since 1975: (1) only 14 percent of people have never gambled compared with 33 percent in 1975; (2) 50 percent of people have played the lottery, and 25 percent have gambled in casinos (double the rates from 1975); (3) approximately 2 million Americans are pathologic gamblers, 3 million adults can be considered problem gamblers and an additional 15 million are considered at-risk for problem gambling; (4) direct and indirect costs to American society from problem and pathologic gambling (e.g., health care, bankruptcy, criminal costs) are approximately $5 billion per year.
State-supported assistance programs and insurance coverage for treatment and prevention of problem gambling seems limited in comparison to the problem. The average individual gambling debt reported to a gambler's help line was $35,185.9 In contrast, the state of Georgia spent only $31,000 in 1998 on programs to assist problem gamblers despite a quadrupling of Gamblers Anonymous chapters since the start of the state lottery in 1993.10
Pathologic gambling is typically a problem of men between 21 and 55 years of age, although gambling disorders are also commonly encountered in teenagers and persons over the age of 65. Women comprised 24 percent of the problem gamblers who called the New Jersey gambler's hotline in 1997—up from 13 percent in 1990.9 No consistent data are available about the role that racial, ethnic, income or educational factors play in problem or pathologic gambling. A survey of self-reported behaviors administered to 21,297 students in 8th to 12th grades in Vermont revealed that 7 percent of these students had problem gambling behaviors. In this study, drug and anabolic steroid use, violence and carrying a weapon to school were all more common in young people who gambled, especially in those who were problem gamblers.4
“Problem gambling,” “probable pathologic gambling” and “gambling addiction” are terms used to describe gambling-related behaviors that may not meet specific DSM-IV criteria. The diagnosis of pathologic gambling requires that the patient gamble in a persistent and maladaptive manner that disrupts relationships and daily activities and is not caused by manic episodes (Table 1).11 Suicide attempts, felony convictions, spouse and child abuse, and unemployment are common in pathologic gamblers.12 Gamblers may hide or deny gambling-related problems, however, making pathologic gambling an often overlooked and undiagnosed condition.
Diagnostic Criteria for Pathologic Gambling
A. Persistent and recurrent maladaptive gambling behavior as indicated by five (or more) of the following:
1. Preoccupation 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 or 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.
Reprinted with permission from American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 4th ed. Washington, D.C.: American Psychiatric Association, 1994:615–18. Copyright 1994.
Evidence points to the common existence of narcissistic personality characteristics and impulse control problems in pathologic gamblers. High rates of personality disorders (e.g., obsessive-compulsive, avoidant, schizotypal and paranoid) are noted in several studies.8,13 Personality profiles of persons who are alcoholics and pathologic gamblers are also similar in some studies. Some experts view pathologic gambling as an addictive disorder, citing as evidence the tolerance and withdrawal symptoms exhibited by pathologic gamblers because of debt escalation behaviors.14 However, no physical or biochemical markers exist to help physicians make the diagnosis.
Several surveys are available to assist physicians in diagnosing this condition. The 1998 Gambling Impact and Behavior Study8 used a new screening tool based on DSM-IV criteria. The South Oaks Gambling Screen (SOGS) is the only extensively used, validated screening tool for the evaluation of patients who are pathologic gamblers15 (Figure 1).16 Although it is not validated, the Gamblers Anonymous Survey (Table 2), which includes 20 questions, may be helpful in providing clinical information and can orient the gambler to the Gamblers Anonymous program. Seven positive responses to the survey questions suggest the diagnosis of pathologic gambling. A similar survey, “Are you living with a compulsive gambler?”16 can be used to assist family members in coping with a problem gambler.
The South Oaks Gambling Screen
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Gamblers Anonymous 20 Questions Survey*
1. Did you ever lose time from work due to gambling?
2. Has gambling ever made your home life unhappy?
3. Did gambling ever affect your reputation?
4. Have you ever felt remorse after gambling?
5. Did you ever gamble to get money with which to pay debts or otherwise solve financial difficulties?
6. Did gambling cause a decrease in your ambition or efficiency?
7. After losing, did you feel you must return as soon as possible and win back your losses?
8. After a win, did you have a strong urge to return and win more?
9. Did you often gamble until your last dollar was gone?
10. Did you ever borrow to finance your gambling?
11. Have you ever sold anything to finance your gambling?
12. Were you reluctant to use gambling money for normal expenditures?
13. Did gambling make you careless of yourself or your family?
14. Have you ever gambled longer than you had planned?
15. Have you ever gambled to escape worry and trouble?
16. Have you ever committed or considered committing an illegal act to finance gambling?
17. Has gambling caused you to have difficulty in sleeping?
18. Have arguments, disappointment, or frustrations caused you to gamble?
19. Have you had an urge to celebrate any good fortune with a few hours of gambling?
20. Have you ever considered self-destruction as a result of your gambling?
*—Seven or more positive responses suggest pathologic gambling.
Reprinted with permission. Available from Gamblers Anonymous International Service Office, P.O. Box 17173, Los Angeles, CA 90017.
The easiest instrument for the family physician to use is the LIE/BET questionaire,17 which is similar to the CAGE questions asked as part of alcoholism screening. It is composed of two questions that are sensitive to the core issues of pathologic gambling: “Have you ever had to lie to people important to you about how much you gambled?” and “Have you ever felt a need to bet more money?”
Central to the problem and treatment of pathologic gambling is helping the patient overcome irrational thoughts. Pathologic gamblers believe they have the ability to control random or chance events by relying on superstitious behavior or methods.18
Treatment goals for patients who are pathologic gamblers or patients who are being treated for depression or alcoholism tend to be similar in that they focus on restoring a normal way of thinking and living to patients. A variety of approaches are used in the treatment of the pathologic gambler (Table 3). Modeled after Alcoholics Anonymous, Gamblers Anonymous is the primary self-help group and uses a 12-step, abstinence-based treatment program. The efficacy of Gamblers Anonymous has not been demonstrated in controlled studies and, unlike alcoholism, some researchers have discovered that complete abstinence from gambling may not be necessary for successful treatment.
Treatment for Pathologic Gamblers
Screen patients for pathologic gambling if financial problems, alcoholism or depression are present.
Intervene if the patient is at risk for suicide.
Refer the patient to Gamblers Anonymous and family members to Gam-Anon.
Enlist support from the family to help the patient follow through with treatment recommendations.
Counsel (or seek consultation, if appropriate) to assess and address the patient's reasons for gambling, confrontation of defenses and cessation of pathologic gambling behaviors; challenge the patient's errors in thinking and reverse “learned behavior” by systematic exposure, desensitization and skill development.
Actively participate throughout the patient's treatment plan to continue assessment of related risk factors (e.g., suicide, alcoholism, depression); ensure follow-up with treatment recommendations, reinforce counseling and refer to self-help groups.
Behavioral, cognitive and cognitive-behavioral therapy appear to be the most successful treatment approaches.1 Pharmacotherapy appears to have a role in the treatment of coexisting depression, rather than as a primary treatment for pathologic gambling.14
Contemporary psychotherapeutic approaches stress identification of reasons for gambling, confrontation of defenses and cessation of chasing behaviors. Cognitive treatments focus on challenging and correcting the patient's errors in thinking; for example, exploring and understanding the illusion of control over chance events.19 Behavioral therapy considers pathologic gambling a learned behavior and relies on techniques such as systematic exposure or desensitization and skill development (e.g., relaxation techniques and improving social skills).20 Cognitive-behavioral therapy combines elements from both the behavioral and cognitive treatment approaches, using systematic exposure or desensitization, relaxation techniques, social skills training and covert sensitization, as well as relapse prevention.20
Although these counseling and treatment techniques may be beyond the comfort level and experience of most family physicians, awareness of treatment options and referral to qualified mental health providers are important in the successful treatment of pathologic and problem gamblers and their families. Unfortunately, patients are often reluctant to seek psychologic help, and one half of patients referred to mental health services fail to follow through on the referral.21 Therefore, counseling and treatment for gambling-related problems may depend solely on a trusted relationship with a family physician.
Steps the family physician can take in the treatment of patients with gambling-related disorders include: (1) enlisting family members to assist in encouraging the pathologic gambler to follow through on treatment recommendations; (2) treating the patient for comorbid conditions of depression and alcoholism, as well as intervening to reduce the risk of suicide, and (3) providing the gambler and family members with support resources. The National Council on Problem Gambling can be reached by calling 800-522-4700 or accessing their Web site (http://www.ncpgambling.org). Their hotline will route the caller to an affiliate of the national organization within the caller's state and provide information on local Gamblers Anonymous chapters and Gam-Anon meetings (for family members and friends). They also provide information about counselors who are trained in treating patients with gambling addictions and other treatment programs and resources.
Provider and community education about the depth of this problem is crucial in identifying patients who are problem or pathologic gamblers and in helping treatment programs work. Primary prevention of this condition using educational programs that target at-risk youth and adults could help establish a culture of controlled, responsible gambling behaviors among adults and their children.
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21. Spruill J. Interprofessional health care services in primary care settings: implications for the education and training of psychologists. Washington, D.C.: American Psychological Association, 1998.
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