13 - 20.13 Gambling Disorder

20.13 Gambling Disorder

In some rare cases, it may be necessary to initiate treatment on an inpatient unit. Although an outpatient setting is more desirable than an inpatient setting, the temptations available to an outpatient for repeated use may present too high a hurdle for the initiation of treatment. Inpatient treatment is also indicated in the case of severe medical or psychiatric symptoms, a history of failed outpatient treatments, a lack of psychosocial supports, or a particularly severe or long-term history of substance abuse. After an initial period of detoxification, patients need a sustained period of rehabilitation. Throughout treatment, individual, family, and group therapies can be effective. Education about substance abuse and support for patients’ efforts are essential factors in treatment. REFERENCES Bonano JS, Glennon RA, De Felice LJ, Banks ML, Negus SS. Abuse-related and abuse-limiting effects of methcathinone and the synthetic “bath salts” cathinone analogs methylenedioxypyrovalerone (MDPV), methylone and mephedrone on intracranial self-stimulation in rats. I. 2014;231(1):199–207. Bryson EO, Hamza H. The drug seeking anesthesia care provider. Int Anesthesiol Clin. 2011;49:157. Frances RJ, Miller SI, Mack AH, eds. Clinical Textbook of Addictive Disorders. 3rd ed. New York: The Guildford Press; 2011. Sewell RA, Petrakis IL. Does gamma-hydroxybutyrate (GHB) have a role in the treatment of alcoholism? Alcohol Alcohol. 2011;46:1. Sinha R. The clinical neurobiology of drug craving. Curr Opin Neurobiol. 2013;23(4):649–654. Stein LAR, Lebeau R, Clair M, Martin R, Bryant M, Storti S, Monti P. A web-based study of gamma hydroxybutyrate (GHB): Patterns, experiences, and functions of use. Am J Addict. 2011;20:30. Strain EC, Anthony JC. Substance-related disorders: Introduction and overview. In: Sadock BJ, Sadock VA, Ruiz P, eds. Kaplan & Sadock’s Comprehensive Textbook of Psychiatry. 9th ed. Vol. 1. Philadelphia: Lippincott Williams & Wilkins; 2009:1237. Szerman N, Martinez-Raga J, Peris. Rethinking dual disorders/pathology. Addictive Disorders & Their Treatment. 2013;12(1):1–4. 20.13 Gambling Disorder Gambling disorder is characterized by persistent and recurrent maladaptive gambling that causes economic problems and significant disturbances in personal, social, or occupational functioning. Aspects of the maladaptive behavior include (1) a preoccupation with gambling; (2) the need to gamble with increasing amounts of money to achieve the desired excitement; (3) repeated unsuccessful efforts to control, cut back, or stop gambling; (4) gambling as a way to escape from problems; (5) gambling to recoup losses; (6) lying to conceal the extent of the involvement with gambling; (7) the commission of illegal acts to finance gambling; (8) jeopardizing or losing personal and vocational relationships because of gambling; and (9) a reliance on others for money to pay off debts. Previous editions of the Diagnostic and Statistical Manual of Mental Disorders (DSM) include pathological gambling

disorder in the impulse-control disorder category because of patient’s preoccupation or compulsion to gamble. However, the criteria for the disorder are structured more like a substance-related or addiction disorder than an impulse-control disorder, with the need to gamble with increased amounts of money to achieve desired excitement (tolerance) and feelings of irritability and restlessness when attempting to reduce or stop gambling (withdrawal). Substance use is often a common comorbidity with gambling. Thus, in the fifth edition of the DSM (DSM-5), gambling disorder is included in the section on substance use and addictive disorders and is diagnosed as a non–substance-related disorder. EPIDEMIOLOGY Although comprehensive worldwide statistics have yet to be compiled, excellent local studies all point to a 3 to 5 percent rate of problem gamblers in the general population and an approximate 1 percent rate of individuals meeting the requirements for gambling disorder. Problem gambling is more common in men and young adults than in women and older adults; however, escalation has been noted in the poor, notably poor minorities; adolescents; elderly retirees; and women. One of three pathological gamblers is now female: it has been suggested that women are gambling more because of an increased presence in the workplace that provides them with more cash. These groups are still underserved with regard to research and treatment. The prevalence of gambling disorder in individuals who have a substance use disorder is higher, with various surveys showing rates of 10 to 18 percent of patients with substance abuse being pathological gamblers. As every type of gambling has become increasingly accessible over the last few decades, the rate of normal and pathological gambling has risen spectacularly, especially in locales with legalized gambling. The most popular types of gambling are numbers/lotto (62.2 percent), slot machines or bingo (48.9 percent), gambling at a casino (44.7 percent), and office sports pools (44.3 percent) (Table 20.13-1). The least popular are betting on sports with a bookie or parlay card, internet gambling, and speculating on high-risk investments. Table 20.13-1 Lifetime Prevalence of Gambling Types

Family histories of pathological gamblers show an increased rate of substance abuse (particularly alcoholism) and depressive disorders. A parent or influential relative of the patient often has been a problem or pathological gambler. The family circle is likely to be competitively and materialistically oriented, evincing intense admiration for money and associated symbols of success. In this respect, compulsive gambling has been called the dark side of the American dream. COMORBIDITY Significant comorbidity occurs between pathological gambling and mood disorders (especially, major depression and bipolarity) and other substance use and addictive disorders (notably, alcohol and stimulant abuse and caffeine and tobacco dependence). Comorbidity also exists with attention-deficit/hyperactivity disorder (ADHD) (particularly in childhood), various personality disorders (notably, narcissistic, antisocial, and borderline personality disorders), and disruptive, impulse control, and conduct disorders. Although many pathological gamblers have obsessive personality traits, full-blown obsessive-compulsive disorder (OCD) is uncommon in this group. ETIOLOGY Psychosocial Factors Several factors may predispose persons to develop the disorder: loss of a parent by death, separation, divorce, or desertion before a child is 15 years of age; inappropriate parental discipline (absence, inconsistency, or harshness); exposure to, and availability of, gambling activities for adolescents; a family emphasis on material and financial symbols; and a lack of family emphasis on saving, planning, and budgeting. Psychoanalytic theory has focused on a number of core character difficulties. Sigmund

Freud suggested that compulsive gamblers have an unconscious desire to lose, and gamble to relieve unconscious feelings of guilt. Another suggestion is that the gamblers are narcissists, whose grandiose and omnipotent fantasies lead them to believe they can control events and even predict their outcome. Learning theorists view uncontrolled gambling as resulting from erroneous perceptions about control of impulses. Biological Factors Several studies have suggested that gamblers’ risk-taking behavior may have an underlying neurobiological cause. These theories have centered on both serotonergic and noradrenergic receptor systems. Male pathological gamblers may have subnormal 3methoxy-4-hydroxyphenyl glycol (MHPG) concentrations in plasma, increased MHPG concentrations in the cerebrospinal fluid (CSF), and increased urinary output of norepinephrine. Evidence also implicates serotonergic regulatory dysfunction in the pathological gambler. Chronic gamblers have low platelet monoamine oxidase (MAO) activity, a marker of serotonin activity, also linked to difficulties with inhibition. Further studies are needed to confirm these findings. DIAGNOSIS AND CLINICAL FEATURES In addition to the features already described, pathological gamblers often appear overconfident, somewhat abrasive, energetic, and free spending. They often show obvious signs of personal stress, anxiety, and depression. They commonly have the attitude that money is both the cause of, and the solution to all their problems. As their gambling increases, they are usually forced to lie to obtain money and to continue gambling while hiding the extent of their gambling. They make no serious attempt to budget or save money. When their borrowing resources are strained, they are likely to engage in antisocial behavior to obtain money for gambling. Their criminal behavior is typically nonviolent, such as forgery, embezzlement, or fraud, and they consciously intend to return or repay the money. Complications include alienation from family members and acquaintances, the loss of life accomplishments, suicide attempts, and association with fringe and illegal groups. Arrest for nonviolent crimes may lead to imprisonment. Gerry was a 35-year-old former auto dealership owner. Two of his uncles were compulsive gamblers, and his paternal grandfather was hospitalized with major depressive illness. He played poker and had been a racecourse habitué since the age of 15 years. He had dropped out of college after a few months and become a car sales representative. Soon he was promoted to showroom manager and then went out on his own. By age 32 years, he was a multimillionaire owner of a dealership chain, happily married with two children. Gerry continued to gamble frequently. He was a successful weekend sports bettor, as well as a consistent winner at weekly gin rummy and poker games and occasional

jaunts to Las Vegas and Atlantic City. In the context of his wife giving birth to a stillborn child, Gerry started going to casinos more often, gradually increasing the size of bets at blackjack and craps. His sport wagers also escalated. His games at home gradually became boring—“there was zilch action.” He began frequenting an illegal local poker parlor that featured highstake action. Over several years, Gerry slipped into a typical gambling spiral. He accumulated several million dollars in debts and lied to family and colleagues about his whereabouts. He raided business and personal accounts, including his children’s college funds, maxed out credit cards, and borrowed from loan sharks at exorbitant rates. He grew profoundly depressed and seriously thought of killing himself in a car crash so that his insurance would “take care of my family after I am gone.” Gerry’s dire situation was unmasked when his Porsche was repossessed one Sunday morning. Initially his wife threatened to divorce him. However, a wealthy relative intervened and bailed him out. He swore never to gamble again, entered Gamblers Anonymous, and within 2 months resumed his frantic chasing. Over the next decade, Gerry underwent four more episodes of recovery and relapse. His wife divorced him, he lost his dealerships, and he had to declare bankruptcy. Gerry finally enrolled in a pilot dual-diagnostic recovery program, where he was diagnosed with atypical bipolar disorder. His treatment included Gamblers Anonymous meetings, individual and family counseling, and pharmacotherapy with bupropion (Wellbutrin) and lamotrigine (Lamictal). Gerry eventually reconciled with his wife and family. He returned to selling cars, started living modestly, and continued to attend Gamblers Anonymous meetings regularly. However, he declared emphatically that he always considers himself always one step away from becoming a “degenerate gambler” again. (Courtesy of Harvey Roy Greenberg, M.D.) PSYCHOLOGICAL TESTING AND LABORATORY EXAMINATION Male patients with gambling disorders have shown abnormalities in platelet MAO activity. Patients with pathological gambling often display high levels of impulsivity on neuropsychological tests. German studies have demonstrated increased cortisol levels in the saliva of gamblers while they gamble, which can account for the euphoria that occurs during the experience and its addictive potential. DIFFERENTIAL DIAGNOSIS Social gambling is distinguished from pathological gambling in that the former occurs with friends, on special occasions, and with predetermined acceptable and tolerable losses. Gambling that is symptomatic of a manic episode can usually be distinguished from pathological gambling by the history of a marked mood change and the loss of judgment preceding the gambling.

Manic-like mood changes are common in pathological gambling, but they always follow winning and are usually succeeded by depressive episodes because of subsequent losses. Persons with antisocial personality disorder may have problems with gambling. When both disorders are present, both should be diagnosed. COURSE AND PROGNOSIS Pathological gambling usually begins in adolescence for men and late in life for women. The disorder waxes and wanes and tends to be chronic. Four phases are seen in pathological gambling:

1. The winning phase, ending with a big win, equal to about a year’s salary, which hooks patients. Women usually do not have a big win, but use gambling as an escape from problems.
2. The progressive-loss phase, in which patients structure their lives around gambling and then move from being excellent gamblers to being stupid ones who take considerable risks, cash in securities, borrow money, miss work, and lose jobs.
3. The desperate phase, with patients frenziedly gambling with large amounts of money, not paying debts, becoming involved with loan sharks, writing bad checks, and possibly embezzling.
4. The hopeless stage of accepting that losses can never be made up, but the gambling continues because of the associated arousal or excitement. The disorder may take up to 15 years to reach the last phase, but then, within a year or two, patients have totally deteriorated. TREATMENT Gamblers seldom come forward voluntarily to be treated. Legal difficulties, family pressures, or other psychiatric complaints bring gamblers to treatment. Gamblers Anonymous (GA) was founded in Los Angeles in 1957 and modeled on Alcoholics Anonymous (AA) (Table 20.13-2). It is accessible, at least in large cities, and is an effective treatment for gambling in some patients. GA is a method of inspirational group therapy that involves public confession, peer pressure, and the presence of reformed gamblers (as with sponsors in AA) available to help members resist the impulse to gamble. The dropout rate from GA is high, however. In some cases, hospitalization may help by removing patients from their environments. Insightoriented psychotherapy should not be sought until patients have been away from gambling for 3 months. At this point, patients who are pathological gamblers may become excellent candidates for this form of psychotherapy. Family therapy is often valuable. Cognitive-behavioral therapy (e.g., relaxation techniques combined with visualization of gambling avoidance) has had some success. Table 20.13-2 Twelve Steps of Gambler’s Anonymous

Psychopharmacological treatment, once largely unsuccessful, now plays a significant role in the management of pathological gamblers. Effective agents include antidepressants, notably selective serotonin reuptake inhibitors (SSRIs) and bupropion (Wellbutrin, Zyban); mood stabilizers, including sustained-release lithium (Eskalith) and antiepileptics such as topiramate (Topamax); atypical antipsychotics; and opioid agents such as naltrexone (ReVia). In many patients it is difficult to determine whether an antidepressant or mood stabilizer alleviates gambling cravings directly or via treatment of a comorbid condition, particularly depressive or bipolar disorders. REFERENCES Ashley LL, Boehlke KK. Pathological gambling: A general overview. J Psychoactive Drugs. 2012;44:27. Bosco D, Plastino M, Colica C, Bosco F, Arianna S, Vecchio A, Galati F, Cristiano D, Consoli A, Consoli D. Opioid antagonist naltrexone for the treatment of pathological gambling in parkinson disease. Clin Neuropharm. 2012;35:118. Cunningham-Williams RM, Gattis MN, Dore PM, Shi P, Spitznagel EL. Towards DSM-V: Considering other withdrawal-like symptoms of pathological gambling disorder. Int J Methods Psychiatr Res. 2009;18:13. Greenberg HR. Pathological gambling. In: Sadock BJ, Sadock VA, Ruiz P, eds. Kaplan & Sadock’s Comprehensive Textbook of Psychiatry. 9th ed. Philadelphia: Lippincott Williams & Wilkins; 2009:2661. Hodgins DC. Reliability and validity of the Sheehan Disability Scale modified for pathological gambling. BMC Psychiatry. 2013;13:177. Hodgins DC, Fick GH, Murray R, Cunningham JA. Internet-based interventions for disordered gamblers: Study protocol for a randomized controlled trial of online self-directed cognitive-behavioural motivational therapy. BMC p ublic h ealth. 2013;13:10. Kessler RC, Hwang I, LaBrie R, Petuhova M, Sampson NA, Winters KC, Shaffer HJ. DSM-IV pathological gambling in the National Comorbidity Survey Replication. Psychological Med. 2008;38:1351. Leeman RF, Potenza MN. Similarities and differences between pathological gambling and substance use disorders: a focus

on impulsivity and compulsivity. Psychopharmacology. 2012;219:469. Odlaug BL, Marsh PJ, Kim SW, Grant JE. Strategic vs nonstrategic gambling: Characteristics of pathological gamblers based on gambling preference. Ann Clin Psychiatry. 2011;3:105. Oleski J, Cox BJ, Clara I, Hills A. Pathological gambling and the structure of common mental disorders. J Nerv Ment Dis. 2011;199:956. Petry NM. Discounting of probabilistic rewards is associated with gambling abstinence in treatment-seeking pathological gamblers. J Abnorm Psychol. 2012;121:151. Shaffer HJ, Martin R. Disordered gambling: Etiology, trajectory, and clinical considerations. Annu Rev Clin Psychol. 2011;7:483. Toneatto T, Brands B, Selby P. A randomized, double-blind, placebo-controlled trial of naltrexone in the treatment of concurrent alcohol use disorder and pathological gambling. Am J Addict. 2009;18:219. Wilson D, da Silva Lobo DS, Tavares H, Gentil V, Vallada H. Family-based association analysis of serotonin genes in pathological gambling disorder: Evidence of vulnerability risk in the 5HT-2A receptor gene. J Mol Neurosci MN. 2013;49(3):550–553. Wynn J, Hudyma A, Hauptman E, Houston TN, Faragher JM. Treatment of problem gambling: development, status, and future. Drugs and Alcohol Today. 2014;14(1):6.