Iman Parhami, MD, MPH

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A patient is brought to the emergency department by her daughter for bizarre behavior and symptoms of mania after gambling  from the casino for 48 continuous hours. 

A Case of Gambling Disorder

Nearly 4% of the population has gambling-related problems, and 6% will experience harm from gambling during their lifetime-including financial, legal, relational, and health problems.

 In addition, individuals with gambling problems have exponentially higher rates of suicide attempts and completions. One study found that 81% of pathological gamblers in treatment showed some suicidal ideation, and 30% reported one or more suicide attempts in the preceding 12 months.

DSM-5 criteria for gambling disorder represent the most common symptoms experienced by those with gambling problems. These symptoms characterize 3 heterogeneous dimensions related to gambling disorder: damage or disruption, loss of control, and dependence. The loss of control over urges and behaviors may be the central component of gambling disorders, and the inability to control gambling may be a component of a progressively worsening process in the life span of some gamblers.

Individuals who encounter gambling-related problems but who do not reach the diagnostic threshold (subthreshold gambling disorder meets only 1 to 3 criteria) are referred to as problem gamblers. For the most part, those with subthreshold gambling disorder continue to experience social, psychological, and health repercussions but to a lesser degree. They are also at increased risk for progression to gambling disorder compared with non-gamblers.

Gambling disorder is referred to as a hidden addiction because of the minimal signs and symptoms associated with this condition.

 The level of severity can also be concealed and involve multiple components. For example, a gambler who “hits rock bottom” (or one who has lost everything, including financial assets and social relationships) may have stopped gambling because of the lack of finances, but he or she may be severely depressed and suicidal because of the ongoing repercussion. Other components of severity include gambling behavior (frequency, duration, amount gambled), extent of gambling desires (cravings, urges), repercussions (eg, employment, legal, relationships), level of control, and comorbid symptoms (eg, suicidality, impulsivity, depression). These factors help predict treatment outcome and determine the appropriate treatment (ie, brief intervention, intensive outpatient, hospitalization). In research, severity is usually assessed using the total number of criteria endorsed, which can also be a quick and straightforward method in the clinical setting.

Gambling disorders are strongly associated with comorbid psychopathology. A meta-analysis of 11 population surveys found high mean prevalence for nicotine dependence (60.1%), a substance use disorder (57.5%), mood disorders (37.9%), and anxiety disorders (37.4%).

 A longitudinal 3-year study also found that any mood, anxiety, or substance use–related disorder was more likely to develop in individuals with either subthreshold gambling disorder or gambling disorder than in those who did not gamble.

Clinically, it may be helpful to assess sleep. Those with gambling problems have an increased risk of difficulty in initiating sleep, maintaining sleep, and more and early awakenings.

 Sleep disturbances can impair self-control and decision making, increase impulsivity, degrade cognition in executive functioning tasks, attenuate responses to losses, and increase expectations of gains that can affect gambling behavior.

There are no FDA-approved pharmacological treatments for gambling disorder, but several studies have evaluated the effects of medications on gambling behavior and comorbid symptoms. Grant and colleagues

 reviewed 18 double-blind placebo-controlled studies that included antidepressants, antipsychotics, mood stabilizers, glutamatergic agents, and opioid antagonists. Although the results were mixed and conclusions were limited because of the small sample sizes, opioid antagonists and glutamatergic agents (

-acetylcysteine) seemed to have the most promising results, especially for those with intense gambling urges.

A number of psychosocial strategies have shown promise in controlling aberrant gambling behavior, including self-help manuals, brief one-session interventions (motivational therapy), psychodynamic therapy, cognitive-behavioral therapy (CBT), and referrals to 12-step support groups.

 Research findings indicate that the treatment for gambling disorder not only reduces gambling behavior but can also help reduce comorbid psychiatric symptoms, such as anxiety and depression; improve quality of life; decrease psychological stress; and decrease the likelihood of comorbid psychopathology.

Jack, a 16-year-old 10th grader, is brought by his mother for evaluation of his “excessive online gaming.” Jack’s mother is concerned that her son plays casino-based “freemium” games 5 hours every day. (Freemium games are free to download but require tokens that are purchased with real money and gambled among players.) He buys approximately $30 worth of tokens every day and has spent more than $5000 on tokens in the past 6 months. He constantly argues with his parents regarding his playing time, his school work has deteriorated, and he no longer has any social interactions.

Jack admits that he lies to his parents about the extent of his playing-he sometimes plays more than 10 hours a day. He has a hard time stopping and usually plays until he loses all his tokens. He uses his mother’s credit card to buy tokens without permission. He is proud of his online accomplishments and enjoys the winning and competition with real adults. Although he now has no desire to interact with peers outside of school, he had enjoyed participating in a recreational sports league in the past.

Jack does not appear to suffer from any other disorder. He has never had problems with alcohol or drugs, and he has never seen a mental health professional or received psychotropics. His childhood and development have been without incident. Last year, his mother returned to work and Jack started taking care of his 7-year-old sister after school (during which he games the most).

During the initial session, gaming patterns and repercussions are discussed (financial, educational, and developmental). Recommendations are made that include changing passwords to the app store and limiting Internet access to supervised sessions, and Jack’s access to his mother’s credit card is cut off. After-school activities for both children are also highly encouraged, possibly restarting recreational sports competitions for Jack. Potential positive reinforcement methods for complying with clean Internet play are also discussed. The family is referred to a family therapist to continue working on family dynamics.

A 19-year-old college sophomore is referred by student health for evaluation of his gambling problems. Michael’s gambling has become pathological in the past year: he either bets on sports online or spends about 6 hours at a local casino daily. Although he does not work, he lost $50,000 in the past year, using money from his sports scholarship and financial aid. His mother has bailed him out multiple times by paying his credit card bills. He still has a credit card debt and owes money to his friends, which totals $25,000. He usually chases his losses, has strong cravings to gamble during the day, and experiences anxiety trying to find money to use for gambling. The time he spends on academics and team practices has become significantly reduced.

His primary care physician (PCP) prescribed stimulants after a diagnosis of ADHD in middle school, which Michael took until 12th grade. He has never seen a mental health professional or taken any psychotropic medication. He started binge drinking at college parties (probably twice a month, enough to black out); in addition, he smokes one blunt of marijuana every week.

Michael started gambling recreationally with friends in middle school, but he acknowledges that his problem controlling gambling started last year. Although he is disheartened by his gambling problem (and its repercussions), he is not depressed, still enjoys hobbies (which he indicates is gambling), and has fun with his girlfriend. He seems intelli-gent and brags about knowing the poker odds. He is seeking treatment because he wants to control his gambling (make only smart bets or play the good hands). His biggest problem is “losing a few bets in a row and going on tilt!”

During the first session, gambling patterns and repercussions are discussed, which he had initially minimized (ie, the possibility of losing his scholarship and being kicked off the team). He agrees to restart treatment with a stimulant, to include his mother in the next session via phone, and to go to Gamblers Anonymous. He agrees to continue CBT at the student health center to work on his aberrant alcohol use.

During the second session (3 weeks later), he reports that he has restarted the stimulant, which helps his impulsivity and studying habits. He has completed 8 sessions of CBT at the student center. He went to a Gamblers Anonymous meeting but did not agree with their tenet for abstinence. His mother agrees to stop bailing him out, control his credit cards and scholarship checks, and provide a limited allowance.

For the next few months, his gambling decreases (both in duration and frequency), but he places larger bets and loses more. Since his mother stopped bailing him out, he borrows money from a loan shark. He is kicked off the team and his scholarship is terminated. He decides to contact a state-funded mental health professional for more regular therapy sessions. He also agrees to ask the loan shark for a repayment plan.

By the fifth session (4 months after his initial presentation), he has stopped gambling and has a part-time job. He is making regular payments to his loan shark, studying more, drinking less alcohol, and playing more sports recreationally. He still enjoys gambling but now is aware of the repercussions. He is more focused on raising his grade point average and returning to the sports team.

James, a depressed 40-year-old poker player, is referred by his wife. He was laid off from work 8 months earlier. Since then he plays poker for 8 hours a day at a nearby casino. He gambles “out of boredom” and enjoys the social atmosphere. Although he is well-off financially, he has lost more than $200,000 in the past year. He now plays at higher-limit tables and chases his bets. He lies to his wife regarding his gambling and is on the brink of getting a divorce. He started playing poker as a teenager and had weekly poker games with his colleagues at work.

He lacks motivation, has stopped taking care of himself, and has gained 30 pounds in the past year. He has a hard time falling asleep and at times is restless in the mornings. James has had 3 episodes of depression in the past; he has been taking aripiprazole, citalopram, and bupropion (prescribed by his PCP) for the past 6 months. There is no his-tory suggestive of mania, hypomania, suicidality, or aberrant substance use.

During the first session with James and his wife, his recent gambling winnings/losses are reviewed, including bank statements that his wife brings in. He is surprised at the total amount of losses. He loves poker, but he does not want a divorce. He agrees to give all his bank cards to his wife, ban himself from local casinos, and work on saving his marriage. The couple are given a self-help workbook and listings for Gamblers Anonymous and Gam-Anon, and proper sleep hygiene is emphasized. The couple are also referred to the state-funded gambling provider network to receive therapy to work on their relationship.

Mirtazapine is started to help with depression, and aripiprazole is tapered. (Case report findings suggest a potential correlation between aripiprazole and excessive gambling, which is similar to the association between dopamine replacement therapy for Parkinson disease and gambling.9)

By the next session, James has stopped gambling because he no longer has easy access to money. He has also started attending Gamblers Anonymous several times a week and enjoys their camaraderie. He appreciates how attending Gamblers Anonymous has helped diminish his strong urges to play poker.

By the fourth session (third month), he has completed his rÃ©sumÃ© and started exercising again. His sleep is improved, he regularly attends meetings of Gamblers Anonymous, and he has a sponsor in addition to making a commitment to the group. He is also in the process of completing 12 sessions with the marriage and family therapist. He misses playing poker, but realizes how abstaining has improved his relation-ship with his wife.

Jackie, a 34-year-old nurse, is referred by her coworker for gambling at work. Compelled by her colleague, Jackie came to the addiction clinic to receive help for her uncontrollable need to gamble at work. She plays online slots on her phone for about 6 hours during her night shifts; after work, she usually tries to win back her losses at the local casino. Although she has lost $50,000 in the past 6 months, with an annual salary of $150,000, she does not have any financial difficulties and is still well regarded at work.

Six months earlier, Jackie called off her wedding after discovering her fiancÃ©’s infidelity. Since that time, gambling has been a great escape for her, specifically helping with ruminations. She is sad, has almost daily crying spells, lacks motivation to care for herself, has problems falling asleep and sustaining sleep, and has some thoughts that she may be better off dead. She is also irritable, easily snapping at colleagues and difficult patients at work. She drinks several glasses of wine every day to “help her nerves.”

Jackie describes some history suggestive of hypomania (not sleeping for a few days, very energetic, happy, impulsively shopping, gambling, and having sex). She carries diagnoses of bipolar disorder, depression, borderline personality disorder, and ADHD. When she was 17, she had a psychiatric hospitalization after breaking up with her boyfriend; she had suicidal ideations and self-injurious behavior (cutting). Jackie saw a therapist for 3 years, went to an accelerated nursing school, and currently works full-time at the hospital. She sees a psychiatrist (about twice a year), who prescribes quetiapine extended-release. Her PCP also prescribes trazodone, fluoxetine, methylphenidate (twice daily), clonazepam (3 times daily), and zolpidem.

During the first session, Jackie is ambivalent about treatment for her gambling, but she does want help for her insomnia, irritability, and anxiety. She agrees to consolidate her prescriptions to one prescriber to optimize medications. She receives psychoeducation regarding the importance of sleep hygiene, especially the effects of smoking, alcohol, stimulants, and shift work. The repercussions of her gambling are also discussed, and she is given a self-help workbook with listings for Gamblers Anonymous meetings. She agrees to taper off most of her medications and to start lamotrigine.

During the second session (10 days later), she reports that her gambling at work has decreased significantly because she was being monitored by her colleagues, but her gambling outside of work has increased. She also started melatonin and diphenhydramine on her own to help with insomnia. Her passive suicidal ideations are stronger, because she thinks that she is not doing anything productive with her life. She does not have a specific plan to hurt herself; she believes that suicide is immoral; and she does not want to voluntarily admit herself to an intensive outpatient program, a residential treatment program, or an inpatient unit.

Jackie continues to be irritable and to have poor self-care and low self-esteem. She enjoys talking during the session and wants to come more often. She has not been to any Gamblers Anonymous meetings because she does not believe that she has a gambling problem. Medications continue to be optimized, and the benefits of sleep hygiene are reinforced. She is also referred to a state-funded therapist to help with her gambling problems.

During her third and fourth sessions (weekly), she reports that the new medication regimen is finally working and she feels less irritable. She has not gambled at work during the past week and feels good, and she has started working more shifts (about 90 hours per week). Consequently, she is usually exhausted af-ter work and does not have the energy to go gambling.

At the seventh session (about 10 weeks after intake), Jackie reports that her work shifts have become more irregular. She works subsequent day and night shifts, and then has a few days off. During her most recent off days, she accepted an invitation for free accommodations and a spa package at a casino/hotel. In those 3 days, she lost $30,000 and gambled for 40 hours. She maxed out her credit cards and emptied her savings account. She finally agrees that she has a gambling problem. She plans to remove herself from the casino’s mailing list, ban herself from the local casinos, close her online casino gambling accounts, schedule an appointment with the state-funded therapist, and ask her brother to start controlling her finances.

During the next 6 months (about 15 sessions), she stops gambling. She completes 10 sessions of gambling treatment with the state therapist and decides to continue the therapy out-of-pocket. Her sleep has improved, and her irritability and anxiety have decreased. Jackie also has started working only regular day shifts and has started exercising and socializing with old friends.

Mrs Kim, a 60-year-old manic gambler, is brought to the emergency department by her daughter for bizarre behavior. For the past month, Mrs Kim has been gambling more than usual and today she returned from the casino after gambling for 48 continuous hours. She had maxed out her credit cards and emptied her savings account. A family friend saw her at the casino acting provocatively toward random strangers. Apparently, she has not slept for the past 3 days. Her family has never seen her act this way.

Mrs Kim has no psychiatric history other than complaining of boredom and lack of motivation to her PCP last month, who prescribed an antidepressant.

Gambling has been a significant part of her life for years; she has been going to the local casino at least once a week for the past 16 years and playing for 5 to 8 hours each time. Before this past incident, she has never gambled more money than she could afford or chased her bets. She has also never experienced gambling-related repercussions.

On evaluation, Mrs Kim is restless but alert and oriented. She is talkative with rapid speech. She reports that she feels “amazing”; her affect is labile-she cries when discussing her deceased husband and then suddenly starts making jokes. She is fixated on leaving the hospital and returning to Thailand to see her deceased mother (whom she believes is still alive).

She is admitted to the inpatient unit after a negative medical workup. Medication-induced bipolar and related disorder are suspected. Her antidepressant is discontinued and a low-dose antipsychotic is started. Fourteen days later, she is discharged: her delusions and manic symptoms have resolved, including her urges to gamble uncontrollably.

These fictional case vignettes represent samples of individuals with gambling problems that any practicing psychiatrist may encounter. Although each patient suffered gambling-related problems, treatments were unique and personalized. It is also not uncommon to include significant others to help control finances, professionals (eg, accountants, lawyers), and health care workers (eg, counselors, therapists) in treatment plans. Specifically, free resources are available and can be used as part of the treatment plan, including self-help manuals and referrals to state-funded provider treatments and 12-step support groups (

Dr Parhami, is a PGY 3 Psychiatry Resident at the Delaware Psychiatry Residency Program, New Castle. He has completed a postdoctoral research fellowship at UCLA and will start a Child and Adolescent Psychiatry Fellowship at Johns Hopkins, Baltimore, in July. Dr Fong is Associate Psychiatry Professor, Co-Director of the UCLA Gambling Studies Program, Director of the UCLA Addiction Medicine Clinic, and Program Director for the UCLA Addiction Psychiatry Fellowship. Dr Parhami reports no conflicts of interest concerning the subject matter of this article; Dr Fong has received funding from the California Office of Problem Gambling.

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 Ladouceur R. Gambling: the hidden addiction. 

 Parhami I, Mojtabai R, Rosenthal RJ, et al. Gambling and the onset of comorbid mental disorders: a longitudinal study evaluating severity and specific symptoms. 

 Parhami I, Siani A, Rosenthal RJ, Fong TW. Pathological gambling, problem gambling and sleep complaints: an analysis of the National Comorbidity Survey: Replication (NCS-R). 

 Grant JE, Odlaug BL, Schreiber LR. Pharmacological treatments in pathological gambling. 

 Hodgins DC, Stea JN, Grant JE. Gambling disorders. 

 Fink A, Parhami I, Rosenthal RJ, et al. How transparent is behavioral intervention research on pathological gambling and other gambling-related disorders? A systematic literature review. 

 Gaboriau L, Victorri-Vigneau C, GÃ©rardin M, et al. Aripiprazole: a new risk factor for pathological gambling? A report of 8 case reports. 

 National Center for Responsible Gaming. Brief Biosocial Gambling Screen. 

http://www.ncrg.org/resources/brief-biosocial-gambling-screen.

http://www.gamblersanonymous.org/ga/locations

 California Department of Public Health. Freedom From Problem Gambling. 

http://problemgambling.securespsites.com/ccpgwebsite/help-available/publications.aspx

Articles

The loss of control over urges and behaviors may be the central component of gambling disorders, but there is so much more to consider. Individuals with these problems have exponentially higher rates of suicide attempts and completions. 

Author | Iman Parhami, MD, MPH

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