Pathological Gambling: Update on Assessment and Treatment

Surveys show that approximately 60% of the general population has gambled within the past 12 months.¹ The majority of people who gamble do so socially and do not incur lasting adverse consequences or harm. Beyond this, approximately 1% to 2% of the population currently meets criteria for pathological gambling.² This prevalence is similar to that of schizophrenia and bipolar disorder, yet pathological gambling often goes unrecognized by most health care providers.

Screening and treatment for pathological gambling—otherwise known as compulsive gambling, gambling addiction, or disordered gambling—is not generally taught in medical school, during psychiatry residency, or during training for mental health or substance abuse counselors. As a result, clinicians may not recognize the signs and symptoms of pathological gambling and may lack the training and experience to provide state-of-the-art treatment.

Diagnostic issues

DSM-IV lists pathological gambling in the section on impulse control disorders. There is an ongoing debate as to where to include pathological gambling in DSM-V. One viewpoint is to include pathological gambling as an addictive disorder because both conditions share core features—namely, loss of control in the face of adverse consequences.³ Another possibility is to view pathological gambling as an obsessive-compulsive spectrum disorder because of the shared symptoms of preoccupation; tension; and repetitive, almost ritualistic behaviors.⁴ Finally, pathological gambling may be viewed as a stand-alone impulse control disorder with unique characteristics, disease course, and pathophysiology.

According to current DSM-IV criteria, pathological gambling is characterized by continued gambling despite harmful consequences. Some of the cardinal symptoms include preoccupation with gambling, tolerance (need to increase the size of bets), loss of control, inability to cut down, and lost opportunities as a result of gambling. Criteria that are specific to pathological gambling include chasing losses, committing illegal acts to finance gambling, and having others pay gambling debts.

Problem gamblers are considered those who meet 1 or more of the diagnostic criteria for pathological gambling but less than 5. This is similar to substance abuse in that the gamblers’ lives are being harmed by gambling, but full criteria are not satisfied.

Most clinicians can recognize signs and symptoms of gambling addiction, but screening is not routine. There are several validated, simple screens for pathological gambling (Table 1) that can be used in different languages, as well as a quick 2-question (Lie-Bet) tool that can be used.⁵ Frequent screening for pathological gambling is recommended. Patients in substance abuse treatment settings have been known to switch addictions during the recovery process.

Most pathological gamblers do not present with a chief complaint of “being addicted to gambling.” Research has shown that only 10% of pathological gamblers present for treatment.⁶ Presenting symptoms can be vague and might include commonly seen problems, such as insomnia, stress, depression, anxiety, or interpersonal problems. Since pathological gambling is a hidden addiction that cannot be detected by physical examination, the use of screening tools is essential.

Clinical characteristics

The course of pathological gambling can vary from a chronic relapsing condition to one with a short time course.⁷ Vulnerable groups include males; persons with comorbid psychiatric disorders, especially substance abuse, attention-deficit/hyperactivity disorder, and antisocial personality disorder; the elderly; adolescents; the disabled; and those with low socioeconomic status.^8,9 Pathological gambling has been shown to be a condition with high genetic transmission and heritability.¹⁰ It is unclear what is being genetically inherited, although the trait for risk-taking preference, absence of loss aversion, or sensitivity to immediate rewards may be responsible.

The consequences of pathological gambling vary with each case and can range from financial loss, divorce, substance abuse, domestic violence, lost time/productivity, and illegal activity. Suicidal ideation is common in pathological gamblers, affecting nearly 25% of this population.¹¹ In addition, the medical consequences of pathological gambling are also being recognized—insomnia, sleep deprivation, lack of exercise, stress-related illnesses, and decreased attention to self-care have all been seen clinically in pathological gamblers.

Recently, attention has been drawn to the association between Parkinson disease, use of dopamine(Drug information on dopamine) agonists, and pathological gambling. Although definitive scientific causality has not been established, there is compelling evidence to suggest that pathological gambling behaviors that were not previously evident may develop in a subset of individuals with Parkinson disease who are taking dopamine agonists.^12-14 This association implicates a role for the dopamine reward pathway in the development of the disease and informs clinicians of the need to screen for pathological gambling in this population.

Treatment approaches

No single treatment approach has been shown to be most beneficial for pathological gamblers. Most gambling treatment programs recommend an integrated biopsychosocial perspective that involves as many collateral participants as possible. The current body of research evidence is stronger for psychotherapeutic approaches than for pharmacological approaches.

Psychotherapeutic approaches. Evidence-based psychotherapies for pathological gambling include cognitive-behavioral therapies (CBT), brief interventions, motivational enhancement, and 12-step support groups.