She sits near her mother reading
about the Vietnam war, and I lie under
a grape arbor in early Tuscan spring,
violets and anemones opened to the sun,
last summer's lavender dusty green in the rocks,
silver olives shimmering on terraces below.
Across the brown patchwork plain, a river curls
cobalt blue, ancient Sienna in the distance,
and cypress trees everywhere,
	exclamations toward heaven.

For years mother and daughter shared
a private landscape whose breeze
I've listened to like Italian: half-understanding,
a bit disoriented, but delighted by the melody.
Now I watch distance spread between them
like cloud and shadow on the valley floor,
a daughter emerging from the old country
no longer willing to speak the native tongue.

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By definition, gambling is the process of placing something of value (usually money) at risk in the hopes of gaining something of greater value (Potenza et al., 2001). It is a human behavior that has persisted for millennia; some of humanity's earliest historical accounts document gambling as a practice of ancient civilizations (France, 1902; Potenza and Charney, 2001).

Over the past several decades, there has been a rapid proliferation of legalized gambling across the United States, creating a markedly different environment from only a generation ago (National Gambling Impact Study Commission [NGISC], 1999). State-run lotteries were reintroduced in 1964, and legal changes, such as those encompassed in the Indian Gaming Regulatory Act of 1988, have resulted in gambling becoming a big business, grossing an estimated $50 billion annually. As compared with 25 years ago, today more people  report having gambled at some point in their lives: 86% of the general adult population in 1998 as compared with 68% in 1975 (NGISC, 1999, as cited in Potenza et al., 2001). With the introduction and expansion of newer types of gambling (e.g., Internet and video gambling) the landscape is likely to change further.

Prevalence RatesAlthough most people have gambled, only a relatively small proportion develops problems with gambling (Potenza et al., 2001). Results from a meta-analysis of studies performed over the past several decades in North America yielded past year and lifetime prevalence rate estimates for pathological gambling of 1.14% and 1.60%, respectively (Shaffer et al., 1999). An additional 2.80% and 3.85% were estimated to have experienced problem gambling over the past-year or lifetime, respectively. The study data also suggest that the rates of problem gambling and pathological gambling have risen in conjunction with the increased availability of legalized gambling.

The annual cost to society attributable to problem and pathological gambling in the United States has been estimated at $5 billion annually (NGISC, 1999). However, this figure is likely an underestimate of the true expense due to costs that are difficult to eliminate and thus often go unaccounted. For example, when the cost related to the elevated rates of divorce as a result of problem gambling were calculated, only the resulting legal fees were used to represent the costs incurred and the often devastating effects on family members were not taken into consideration (NGISC, 1999). 

Together, these data suggest that pathological gambling is as or is more common than several other major psychiatric disorders (e.g., schizophrenia or bipolar disorder) and represents a significant cost to society. As such, there exists a need for increased efforts in prevention, treatment and research in order to advance current clinical practice.

Pathological gambling and substance dependence share many features, including similarities in diagnostic features, clinical courses and high rates of comorbidity. 

  Given these similarities, it has been proposed that pathological gambling may be conceptualized as an addiction without the drug. In order to gain a better understanding of the etiology and pathophysiology of pathological gambling and its relationship to drug dependence, rigorous study needs to be applied to pathological gambling as it has been to drug dependence.

Craving represents a highly clinically relevant internal state as it often immediately precedes engagement in a self-destructive addictive behavior and is consequently a target of both behavioral and pharmacological treatments. A craving or appetitive urge state is also common to both drug dependence and pathological gambling.

Wexler and colleagues (2001) recently conducted a functional magnetic resonance imaging-based study of cocaine cravings in individuals with cocaine dependence. 

  The protocol involved the exposure of healthy controls and cocaine-dependent subjects to three different types of videotaped scenarios (cocaine-related, happy and sad) during brain imaging tests. The paradigm allowed for the identification of brain activities that were specific to viewing of cocaine-related scenarios in cocaine-dependent subjects; that is, the pattern of activity was not seen in cocaine-dependent subjects viewing happy or sad scenarios or control subjects viewing the drug- or emotion-related videos. The results of the study demonstrated differences in limbic and frontal brain regions during drug-cue exposure in cocaine-dependent subjects and suggested the existence of more generalized dysregulation in neural circuits thought to mediate affective responses. 

We have currently modified the paradigm used by Wexler and colleagues in order to study the responses of subjects with pathological gambling disorders to emotional and gambling cues. Comparison of similarities and differences in the neural responses of individuals with pathological gambling disorders to patients with a drug dependence will help not only to better define the underlying neurobiology of pathological gambling, but also to clarify its relationship to drug use disorders. For many years, relatively few investigations into the neurobiology of pathological gambling have been performed. Pathological gambling represents a significant public health concern. An improved understanding of the basic biological processes contributing to the disorder will likely facilitate advances in the prevention and treatment efforts related to not only pathological gambling, but also for other disorders characterized by features of impaired impulse control.

France C (1902), The gambling impulse. Am J Psychology 13:364-407.

NGISC (1999), National Gambling Impact Study Commission: Final Report. Available at: www.ngisc.gov/reports/fullrpt.html. Accessed Aug. 21, 2001.

Potenza MN, Charney DS (2001), Pathological gambling: a current perspective. Semin Clin Neuropsychiatry 6(3):153-154.

Potenza MN, Kosten TR, Rounsaville BJ (2001), Pathological gambling. JAMA 286(2):141-144.

Shaffer HJ, Hall MN, Vander Bilt J (1999), Estimating the prevalence of disordered gambling behavior in the United States and Canada: a research synthesis. Am J Public Health 89(9):1369-1376.

Wexler BE, Gottschalk CH, Fulbright RK et al. (2001), Functional magnetic resonance imaging of cocaine craving. Am J Psychiatry 158(1):86-95.

Psychiatric Times Vol 17 No 9

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Pathological Gambling: A Present Problem From the Past