Psychiatric Comorbidity Associated With Pathological Gambling
Psychiatric Comorbidity Associated With Pathological Gambling
Gambling has become a major recreational activity in the United States. Formerly confined to a few states such as Nevada and New Jersey, legal gambling opportunities have exploded across the nation in the past 2 decades. Some form of legalized gambling now exists in all but 2 states: 37 have lotteries, and 27 have casino gambling. Recent estimates indicate that 70% to 90% of North Americans have engaged in some form of gambling.1 Between 1974 and 1997, gambling expenditures more than doubled as a percentage of personal income.
Although disordered gambling has been recognized for centuries, criteria for pathological gambling (PG) were first specified in 1980 in DSM-III. Although categorized as an impulse control disorder (ICD), the current criteria are patterned after those used for substance dependencies and emphasize the features of tolerance and withdrawal, both of which have been described in persons with PG and in those with substance dependence.2 Ten specific maladaptive behaviors are enumerated, and 5 or more are required for the diagnosis.
EPIDEMIOLOGY OF PG
Although most persons gamble responsibly, approximately 5.5% of those in the general population are problematic gamblers.3 PG—the most severe form of problematic gambling—affects 1% to 2% of the adult general population. These figures suggest that more than 2 million Americans suffer from PG; roughly twice that many have gambling-related difficulties but do not meet DSM-IV criteria.4,5 There is evidence that the prevalence of PG is increasing along with the ever-expanding availability of gambling venues.6-8
One-quarter to one-third of all persons with PG are women, but the gap is narrowing.9 (See the case vignette.) Women tend to begin gambling later in life, often in their early 30s, compared with men who start in their late teens or early 20s. Women tend to have a more rapid progression to PG.10,11
Special populations at risk for PG include adults with mental health or substance use disorders, persons who have been incarcerated, African Americans, and persons of lower socioeconomic status.12 However, the typical profile of a treatment-seeking gambler is one who is white, middle-aged, married, and employed, with a relatively low level of education.
Research has not empirically validated proposed subtypes, but the most widely discussed scheme is the distinction between “escape-seekers” and “sensation-seekers.”12,13 Escape-seekers are often older persons who gamble out of boredom or depression or to fill time, and they may choose passive forms of gambling, such as slot machines, lotteries, and scratch tickets. Sensation-seekers tend to be younger and prefer card games or table games, sports betting, or other gambling that involves some elements of skill and suspense.
PUBLIC HEALTH CONSEQUENCES OF PG
PG is increasingly being recognized as a major public health problem. The greater attention focused on PG was spurred in part by a commission formed by President Clinton that documented its negative impact on individuals and society.4 PG is estimated to cost society approximately $5 billion per year and an additional $40 billion in lifetime costs for reduced productivity, social services, and creditor losses.4 The disorder impairs quality of life,14 and is associated with comorbid psychiatric disorders, psychosocial impairment, and suicide.15,16 Family-related problems include financial distress, child and spousal abuse, and separation and divorce.17
Psychiatric comorbidity is the rule, not the exception, for persons with PG. Clinicians who assess and treat these individuals benefit from understanding the scope and direction of these associations. In addition to evaluating the person’s gambling behavior and its considerable impact on their lives, clinicians need to thoroughly assess current and lifetime psychiatric comorbidity. The following case vignette illustrates how PG and depression can intertwine.18
Mary, a 42-year-old accountant, had gambled recreationally for years. She had a history of depressive disorder and had brief contacts with a mental health center because of depression and marital discord. At age 38, she became hooked on casino slot machines. Her interest in gambling gradually escalated and, within a year, Mary was gambling during most business days.
To acquire funds to fuel her gambling, she created a fake company to which she transferred more than $300,000 from her accounting firm. The embezzlement was eventually detected and Mary was arrested. She became severely depressed and suicidal in the wake of the arrest and public humiliation and attempted a drug overdose. After a brief hospital stay, Mary entered counseling and was treated with paroxetine. In a plea bargain, she agreed to perform 400 hours of community service.
ASSESSING PSYCHIATRIC COMORBIDITY
The psychiatric history should be carefully explored because many persons with PG will meet criteria for comorbid psychiatric disorders (eg, alcohol dependence, major depression, anxiety disorder, personality disorder, or another disorder of impulse control). The presence of comorbid disorders may also suggest particular medication treatment strategies or psychotherapeutic approaches. For example, the depressed person who is a pathological gambler will benefit from antidepressant medication and cognitive-behavioral therapy. This dual approach may reduce the gambling behavior—particularly when the behavior had been prompted by the patient’s need to escape.
Inquire about past psychiatric treatment, including medications used, hospitalizations, and psychotherapy. Bipolar disorder should be ruled out as the cause of the disorder because some persons with PG may gamble excessively when manic. Typically, the patient’s unrestrained spending corresponds to episodes of mania that are accompanied by euphoric mood; grandiosity; unrealistic plans; and often a giddy, overly bright affect.
The pattern of gambling seen in the person with PG lacks the periodicity seen with bipolar patients, and points to an ongoing preoccupation.
The patient’s history of physical illness, surgeries, drug allergies, and medical treatment can help rule out medical causes that may be causing symptoms (eg, mass lesions) or may identify conditions that may contraindicate the use of certain medications prescribed to treat the disorder.
RESEARCH FINDINGS ON COMORBIDITY
Most comorbidity research in PG has been hampered by biased ascertainment, small samples, and unsystematic assessments. Yet both community- and clinic-based studies suggest that substance use disorders, mood and anxiety disorders, and personality disorders are highly prevalent in persons with PG.18,19
Substance use disorders
Substance misuse has a clear relationship with PG. The National Opinion Research Center study found that the rate of alcohol or drug abuse was nearly 7 times higher in persons with PG than in nongamblers or in recreational gamblers.4
Surveys from specific geographical areas support these findings: rates of alcohol and dependence were at least 4 times higher among persons identified as having a gambling disorder than among those without a gambling disorder.9,20-22 In a nationally representative sample, almost three-quarters (73.2%) of persons with PG had an alcohol use disorder as well.23 There is some evidence that PG predicts the subsequent onset of substance misuse.24
Gerstein and colleagues4 found that 8.1% of persons with PG and 16.8% of persons with problem gambling (ie, those who met 3 or 4 DSM-IV criteria for PG), reported illicit drug use in the past year. These figures compared with 4.2% in recreational gamblers and 2% in nongamblers. Bland and coworkers21 also found that the prevalence of illegal drug abuse and dependence among individuals with PG was about 4 times higher than among nongamblers. In a 1998 general population study, 15.5% of persons with PG evidenced illegal drug use disorders, compared with 7.8% of recreational gamblers and 3.5% of nongamblers.9 In a national survey, the lifetime prevalence rate for any drug use disorder was 38.1% among PG respondents.23 Conversely, from 9% to 16% of substance abusers are probable pathological gamblers.25,26
A number of differences emerge from looking at treatment-seeking persons with a history of substance misuse and at pathological gamblers who have no history of substance misuse. Those with such a history report greater psychiatric distress, more frequent gambling, and more years of disordered gambling; they were also more likely to be receiving mental health care treatment.27