Clinical Assessment and Management of Pathological Gambling

Pathological gambling (PG) is characterized by persistent and recurrent maladaptive patterns of gambling behavior (eg, a preoccupation with gambling, the inability to control gambling behavior, lying to loved ones, illegal acts, and impaired social and occupational functioning).¹ With past-year prevalence rates similar to those of schizophrenia and bipolar disorder,² it is apparent that PG has become a significant public health issue. The aim of this article, therefore, is to introduce clinicians to the assessment and treatment of PG with the hope that early interventions will reduce the considerable personal and social costs associated with the disorder.

PG usually begins in adolescence or early adulthood; males tend to exhibit symptoms associated with the disorder at an earlier age.³ Although there is some debate about the course of PG, when it is left untreated it appears to be a chronic, relapsing condition for many individuals.^4,5

As in substance use disorders, PG appears to develop more quickly in females than in males after they begin to gamble—a phenomenon originally observed in alcohol(Drug information on alcohol) dependence termed "telescoping."⁶ Women who are pathological gamblers tend to have problems with nonstrategic forms of gambling, such as slot machines and bingo; men tend to have problems with strategic forms, such as sports and card gambling.⁷ Both females and males who are pathological gamblers report that advertisements are common triggers of their gambling urges, and females are more likely to report that feeling bored or lonely may trigger an urge.⁸

Studies have consistently found that co-occurring conditions, such as depression, substance use disorders, and anxiety disorders, are common in individuals who are pathological gamblers (Figure 1).^9-13 These co-occurring disorders may provide clues about the most effective treatment options for PG and should be treated simultaneously.

PG often goes unrecognized because patients are hesitant to disclose information about their behavior unless specifically asked.¹⁴ Given the personal and social impact of untreated PG, clinicians need to routinely screen for the disorder, perform a thorough assessment of the behavior and co-occurring conditions, and treat the disorder.

DIAGNOSIS
The first and most important step to treating a disorder is to diagnose it properly. Studies have found that most individuals who are pathological gamblers do not voluntarily discuss the issue with clinicians.¹⁴ Many are ashamed of the problematic behaviors associated with PG and therefore may not self-report. When asked about gambling, however, most patients are willing to talk about the disorder. The diagnosis of PG is usually straightforward and can be done by asking patients if they feel they cannot control their gambling or if they are preoccupied with gambling.Sample questions clinicians can use to begin a discussion about gambling can be found in Table 1.

An affirmative answer can be followed with questions to determine the degree of impairment (social, financial, familial, or occupational) and distress that this behavior is causing. It must also be ascertained whether the gambling behavior can be attributed to bipolar disorder. Simple self-reports and clinician-administered screenings, as well as diagnostic measures, are available (eg, South Oaks Gambling Screen, Early Intervention Gambling Health Test).¹⁵

TREATMENT
Because of the limitations of current research, it is unclear which treatment approach may be most beneficial for a particular pathological gambler. What is known, however, is that no single treatment has been shown to be clear- ly more effective than others. Until greater knowledge of the pathophysiology is available, there is not enough evidence to make definitive treatment recommendations.

An assessment of clinical presentation, comorbidity, and family history, however, may provide useful clues to treatment interventions. Subtyping of PG based on clinical similarities to other disorders (eg, substance use disorders) or existence of co-occurring conditions (eg, bipolar disorder), or due to core features of the behavior (eg, cravings) may be useful when deciding on treatment interventions. A suggested clinical approach is presented in Figure 2.

Although both pharmacological and psychosocial interventions have shown early promise for PG, no comparative studies have been performed. Should an individual with PG begin with medication, therapy, or both? In addition, are there differences in individuals who are pathological gamblers that may indicate a preferential response to a particular intervention? Research addressing these issues is lacking.