Problem gambling

Problem gambling (ludomania) is an urge to gamble despite harmful negative consequences or a desire to stop. Problem gambling often is defined by whether harm is experienced by the gambler or others, rather than by the gambler's behavior. Severe problem gambling may be diagnosed as clinical pathological gambling if the gambler meets certain criteria. Although the term gambling addiction is common in the recovery movement pathological gambling is considered to be an impulse control disorder and is therefore not considered by the American Psychological Association to be an addiction.

Definition
Research by governments in Australia led to a universal definition for that country which appears to be the only research based definition not to use diagnostic criteria.


 * Problem gambling is characterized by many difficulties in limiting money and/or time spent on gambling which leads to adverse consequences for the gambler, others, or for the community.

Most other definitions of problem gambling can usually be simplified to any gambling that causes harm to the gambler or someone else in any way. However, these definitions are usually coupled with descriptions of the type of harm or the use of diagnostic criteria. According to DSM-IV, Pathological gambling is now defined as separate from a manic episode. Only when the gambling occurs independent of other impulsive, mood, or thought disorders is it considered its own diagnosis. In order to be diagnosed, an individual must have at least 5 (or more) of the following symptoms:


 * 1) Preoccupation. The subject has frequent thoughts about gambling experiences, whether past, future, or fantasy.
 * 2) Tolerance. As with drug tolerance, the subject requires larger or more frequent wagers to experience the same "rush".
 * 3) Withdrawal. Restlessness or irritability associated with attempts to cease or reduce gambling.
 * 4) Escape. The subject gambles to improve mood or escape problems.
 * 5) Chasing. The subject tries to win back gambling losses with more gambling.
 * 6) Lying. The subject tries to hide the extent of his or her gambling by lying to family, friends, or therapists.
 * 7) Loss of control. The person has unsuccessfully attempted to reduce gambling.
 * 8) Illegal acts. The person has broken the law in order to obtain gambling money or recover gambling losses. This may include acts of theft, embezzlement, fraud, or forgery.
 * 9) Risked significant relationship. The person gambles despite risking or losing a relationship, job, or other significant opportunity.
 * 10) Bailout. The person turns to family, friends, or another third party for financial assistance as a result of gambling.

As with many disorders, the DSM-IV definition of pathological gambling is widely accepted and used as a basis for research and clinical practice internationally.

Biological basis
According to the Illinois Institute for Addiction Recovery, recent evidence indicates that pathological gambling is an addiction similar to chemical addiction. It has been seen that some pathological gamblers have lower levels of norepinephrine than normal gamblers.

According to a study conducted by Alec Roy, M.D. formerly at the National Institute on Alcohol Abuse and Alcoholism, norepinephrine is secreted under stress, arousal, or thrill, so pathological gamblers gamble to make up for their under-dosage.

Further to this, according to a report from the Harvard Medical School Division on Addictions there was an experiment constructed where test subjects were presented with situations where they could win, lose or break even in a casino-like environment. Subjects' reactions were measured using fMRI, a neuro-imaging technique very similar to MRI. And according to Hans Breiter, MD, co-director of the motivation and Emotion Neuroscience Centre at the Massachusetts General Hospital, "Monetary reward in a gambling-like experiment produces brain activation very similar to that observed in a cocaine addict receiving an infusion of cocaine."

Deficiencies in serotonin might also contribute to compulsive behavior, including a gambling addiction.

Relation to other problems
Pathological gambling is similar to many other impulse control disorders such as kleptomania, pyromania, and trichotillomania. Other mental diseases that also exhibit impulse control disorder include such mental disorders as antisocial personality disorder, or schizophrenia.

According to evidence from both community- and clinic-based studies, individuals who have pathological gambling are highly likely to exhibit other psychiatric problems at the same time, including substance use disorders, mood and anxiety disorders, or personality disorders.

As debts build up people turn to other sources of money such as theft, or the sale of drugs. A lot of this pressure comes from bookies or loan sharks that people rely on for capital to gamble with.

Compulsive gambling is often very detrimental to personal relationships. In a 1991 study of relationships of American men, it was found that 10% of compulsive gamblers had been married three or more times. Only 2% of men who did not gamble were married more than twice.

Abuse is also common in homes where pathological gambling is present. Growing up in such a situation leads to improper emotional development and increased risk of falling prey to problem gambling behavior.

Suicide rate
A gambler who does not receive treatment for pathological gambling when in his or her desperation phase may contemplate suicide. Problem gambling is often associated with increased suicidal ideation and attempts compared to the general population.

Early onset of problem gambling increases the lifetime risk of suicide. However, gambling-related suicide attempts are usually made by older people with problem gambling. Both comorbid substance use and comorbid mental disorders increase the risk of suicide in people with problem gambling.

A 2010 Australian hospital study found that 17% of suicidal patients admitted to the Alfred Hospital's emergency department were problem gamblers.

Prevalence
A study by the United Kingdom Gambling Commission, the "British Gambling Prevalence Survey 2007", found that approximately 0.6% of the adult population had problem gambling issues, the same percentage as in 1999. The highest prevalence of problem gambling was found among those who participated in spread betting (14.7%), fixed odds betting terminals (11.2%) and betting exchanges (9.8%).

Available research seems to indicate that problem gambling is an internal tendency, and that problem gamblers will tend to risk money on whatever game is available, rather than a particular game being available inducing problem gambling in otherwise "normal" individuals. However, research also indicates that problem gamblers tend to risk money on fast-paced games. Thus a problem gambler is much more likely to lose a lot of money on roulette or slot machines, where rounds end quickly and there is a constant temptation to play again or increase bets, as opposed to a state lottery where the gambler must wait until the next drawing to see results.

Dopamine agonists, in particular pramipexole (Mirapex), have been implicated in the development of compulsive gambling and other excessive behavior patterns (e.g., PMID 16009751).

Assessment
The most common instrument used to screen for "probable pathological gambling" behavior is the South Oaks Gambling Screen (SOGS) developed by Lesieur and Blume (1987) at the South Oaks Hospital in New York City. This screen is undoubtedly the most cited instrument in psychological research literature. In recent years the use of SOGS has declined due to a number of criticisms including that it over-estimates false positives.

The DSM-IV diagnostic criteria presented as a checklist is an alternative to SOGS, it focuses on the psychological motivations underpinning problem gambling and was developed by the American Psychiatric Association. It consists of ten diagnostic criteria. One screening measure based upon the DSM-IV criteria is the National Opinion Research Center DSM Screen for Gambling Problems (NODS). This measure is currently used frequently. The Canadian Problem Gambling Inventory (CPGI) is another newer assessment measure. The Problem Gambling Severity Index (PGSI) is composed of nine items from the longer CPGI. The PGSI focuses on the harms and consequences associated with problem gambling.

Treatment
Most treatment for problem gambling involves counselling, step-based programs, self-help, peer-support, medication, or a combination of these. However, no one treatment is considered to be most efficacious and no medications have been approved for the treatment of pathological gambling by the US Food and Drug Administration (FDA).

Gamblers Anonymous (GA) is a commonly used treatment for gambling problems. Modeled after Alcoholics Anonymous, GA uses a 12-step model that emphasizes a mutual-support approach.

One form of counseling, cognitive behavioral therapy (CBT) has been shown to reduce symptoms and gambling-related urges. This type of therapy focuses on the identification of gambling-related thought processes, mood and cognitive distortions that increase one’s vulnerability to out-of-control gambling. Additionally, CBT approaches frequently utilize skill-building techniques geared toward relapse prevention, assertiveness and gambling refusal, problem solving and reinforcement of gambling-inconsistent activities and interests.

As to behavioral treatment, some recent research supports the use of both activity scheduling and desentization in the treatment of gambling problems In general behavior analytic research in this area is growing

There is evidence that the SSRI paroxetine is efficient in the treatment of pathological gambling. Additionally, for patients suffering from both pathological gambling and a comorbid bipolar spectrum condition, sustained release lithium has shown efficacy in a preliminary trial. The opiate antagonist drug nalmefene has also been trialled quite successfully for the treatment of compulsive gambling.

Voluntary exclusion
Some casinos and state lottery programs offer a Self/Voluntary Exclusion program. When a person signs up for one of these programs, they are effectivley banned from the casino, and will be arrested upon entry; in the case of a state lottery program, they are not permitted to cash out winnings, thereby removing the positive incentive to gamble. Once a person signs up for a Self Exclusion program, the ban may or may not be permanent. However, it must be stated that the actual execution of the program is more difficult than it would appear in theory, because it involves security finding the people and then removing them. There have been lawsuits because people have still been able to gamble in a casino after signing up for the programs.

Step-based programs
One step-based program for gambling issues is Gamblers Anonymous. Gamblers Anonymous uses a 12-step program adapted from Alcoholics Anonymous and also places an emphasis on peer support.

Other step-based programs are specific to gambling and generic to healing addiction, creating financial health, and improving mental wellness. Commercial alternatives, designed for clinical intervention using the best of health science and applied education practices have been used as patient centered tools for intervention since 2007. They include measured efficacy and resulting recovery metrics.

Peer support
A growing method of treatment is peer support. With the advancement of online gambling, many gamblers experiencing issues use various online peer-support groups to aid their recovery. This protects their anonymity whilst allowing to attempt to self-recover often without having to disclose their issues to loved ones.

Self help
Research into self-help for problem gamblers has shown benefits.