Introduction
Gambling is a multi-billion dollar industry that continues to grow each year, and while a recreational activity for many, it can become problematic for individuals with a gambling disorder. Approximately 2-3% of the population experience problems with disordered gambling, yet historically it was not formally recognized as a mental health condition. According to the American Psychiatric Association (2013), pathological gambling was added to the Diagnostic and Statistical Manual of Mental Disorders (DSM) as an impulse control disorder in 1980. The revision of the DSM-5 in 2013 reclassified gambling disorder as an addictive disorder and changed some of the diagnostic criteria. Despite being recognized as a public health issue, the stigma surrounding gambling addiction often prevents individuals from seeking help. The purpose of this paper is to explore problem and disordered gambling, specifically focusing on the evolving classification, diagnostic criteria and models of addiction as it relates to gambling behavior. This paper will also discuss prevalence rates, populations at increased risk, comorbidities, and treatment options. By increasing understanding of gambling as a disorder, it is hoped this will reduce stigma and improve accessibility of treatment resources for individuals struggling with a gambling problem.
Literature Review
Classification
The inclusion of pathological gambling in the DSM has legitimized gambling addiction as a recognized mental health condition. The evolving classification provides insight into ongoing debate regarding underlying mechanisms. In the DSM-III and DSM-IV, pathological gambling was categorized as an impulse control disorder due to impulsive, uncontrolled gambling behavior despite negative consequences (American Psychiatric Association, 2013). In developing criteria for the DSM-5, the workgroup concluded gambling disorder involved the cognitive, emotional and physiological signs of addiction rather than simply lack of self-control (American Psychiatric Association, 2013). As such, the diagnostic criteria were revised and gambling disorder was moved under the addictive disorders section representing gambling’s neurobiological basis mirroring substance use disorders (American Psychiatric Association, 2013). This re-classification is consistent with current drug addiction models which emphasize both the compulsive drug-seeking and reward/reinforcement mechanisms in the brain (American Psychiatric Association, 2013). Similarly, neuroimaging studies show similarities in brain activity and biochemical responses in the reward pathways when someone is gambling compared to using other addictive substances (Fede, 2016). Overall the evolving DSM classification reflects shifting understanding of gambling’s underlying mechanisms moving from a behavioral model of impulse control to recognizing cognitive and physiological components consistent with addiction.
Diagnostic Criteria
The DSM-5 criteria for gambling disorder were updated from the DSM-IV criteria for pathological gambling. Some key changes include: renaming from “pathological” to “gambling disorder”, reducing the threshold from five or more criteria in a twelve month period to four or more criteria, and changing or removing some of the individual criteria (American Psychiatric Association, 2013). For example, the criterion “committing illegal acts such as forgery, fraud, theft or embezzlement to finance gambling” was removed in response to concerns it was too extreme yet was not essential for diagnosing a gambling problem (American Psychiatric Association, 2013). Instead, “reliance on others to provide money to relieve a desperate financial situation caused by gambling” was added which may occur earlier in the progression of a gambling problem (American Psychiatric Association, 2013). Other revisions like changing “preoccupation with gambling” to “often preoccupied with gambling” were done to reduce ambiguity and improve reliability and validity of the diagnosis (American Psychiatric Association, 2013). Overall, the changes are intended to capture a wider range of difficulties from mild to severe gambling behaviors and make the diagnosis more applicable in clinical practice.
Prevalence and Demographics
Gambling participation and problems tend to vary between countries based on availability and cultural attitudes towards gambling activities. Estimates indicate approximately 2-3% of the adult population in Western countries experience gambling problems (Calado & Griffiths, 2016). Specifically, lifetime prevalence of pathological gambling ranges from 0.5-3.8% in countries with legalized gambling, versus 0.2-0.6% in countries with less access (Calado & Griffiths, 2016). Certain populations face elevated risk including males compared to females, young adults ages 18-24, individuals with comorbid psychiatric disorders or substance use issues, and some ethnic minorities (Calado & Griffiths, 2016; Slutske et al., 2015). For example, the rate of problem gambling is estimated to be 2.5% among Native Americans versus 1.9% for non-natives (Fede, 2016). Cultural and attitudinal factors may contribute to variation observed between certain demographic groups. Overall, most research indicates approximately 1-3% of the general population experience some level of disordered gambling depending on measurement tools and jurisdiction characteristics (Calado & Griffiths, 2016). Disordered gambling negatively impacts individuals, families and communities disproportionately given its relatively low prevalence.
Gambling Models and Cognitive Processes
There are two main theoretical perspectives that have been developed to explain pathological gambling – the biopsychological/disease model and the behavioral model (Fede, 2016). The biopsychological model, informed by research on chemical dependence, views problem gambling as a progressive medical and neurological disorder influenced by genetic predisposition, biological and neurochemical processes (Castrén et al., 2014). Functional neuroimaging research supports biological underpinnings, showing gamblers experience reward/dopamine system activation during gambling similarly to drug triggers for addiction (Castrén et al., 2014). A purely biological explanation is incomplete as gambling behavior also involves social and contextual factors. The alternative behavioral model theorizes problem gambling develops through classical and operant conditioning where reward and reinforcement strengthen gambling behaviors (Fede, 2016). Maladaptive thoughts and cognitive distortions also contribute through erroneous perceptions of control, skill and luck which perpetuate the illusion gambling outcomes are predictable or “due” (Fede, 2016). Several cognitive processes consistently found to be characteristic of problem gamblers include: erroneous perceptions of control, unrealistic optimism and confirmation bias, gambling fallacies such as the gambler’s fallacy, excessive focus on wins versus losses, and the cognitive “schema of greed” (Fede, 2016; Spurrier & Blaszczynski, 2014). Emerging integrative models attempt to explain problem gambling as an interaction between biological predispositions, and cognitive-behavioral factors influenced by social learning and conditioning processes over time (Fede, 2016).
Gambling Comorbidity
Problem gambling is strongly associated with an increased risk for co-occurring psychiatric and substance use disorders. Research estimates as many as 60-80% of pathological gamblers meet diagnostic criteria for at least one other mental illness, predominantly mood, anxiety or substance use disorders (Cowlishaw et al., 2016). Specifically, disordered gamblers are at higher risk for: major depression, bipolar disorder, generalized anxiety disorder, panic disorder, social anxiety disorder, alcohol use disorder, drug dependence as well as nicotine dependence at two to three times the rate of the general population (Cowlishaw et al., 2016; Slutske et al., 2015). Problem gamblers are also prone to other impulse control and behavioral addictions such as compulsive shopping, eating disorders and sex addiction at elevated rates (Cowlishaw et al., 2016). Research indicates causal directions of these relationships remain unclear – while comorbidity may result from shared vulnerability factors, evidence also suggests gambling problems precede and predict development of other disorders in some cases (Cowlishaw et al., 2016; Slutske et al., 2015). Overall, comorbidity complicates treatment as multiple interacting conditions need addressing simultaneously using integrated approaches tailored for dual diagnosis. Failure to treat co-occurring disorders jeopardizes gambling recovery outcomes.
Treatment
A range of effective treatment options exist for problem and disordered gambling including cognitive behavioral therapy, motivational interviewing, 12-step programs, medical therapies and combined approaches (Fede, 2016). Significant barriers often prevent or delay treatment seeking including stigma, lack of problem awareness, denial, cost and poor service availability (Reith et al., 2019). Studies evaluating self-exclusion programs have found they can be protective against future gambling behavior for some individuals over 6-12 month follow up periods (Sharpe et al., 2019). Cognitive behavioral therapy specifically addressing cognitive distortions and modifying maladaptive beliefs about gambling has shown efficacy in reducing symptoms and disordered gambling behaviors (Fede, 2016). Combined cognitive and behavioral counseling models using exposure and response techniques that help gamblers learn new coping mechanisms tend to yield the best outcomes (Fede, 2016). Self-help peer support groups modeled after 12-step programs like Gamblers Anonymous can also assist recovery through emphasizing acceptance of addiction and reliance on a higher power (Fede, 2016). Pharmacological options currently being researched for gambling disorder include opioid antagonists, anticonvulsants and selective serotonin reuptake inhibitors, though more long term randomized control trials are still needed (Fede, 2016; Grant et al., 2014). Overall, early screening, harm minimization approaches, and a multidimensional treatment approach tailored for each individual’s needs are crucial given the severity of consequences, complexity of factors involved and high rates of comorbidity in problem gambling populations. Reducing barriers to care through education, awareness programs and gambling policies aim to promote early help-seeking before consequences escalate.
Conclusion
Problem and disordered gambling represent a serious public health issue involving significant medical, psychological and societal costs. While historically viewed as a self-control issue, research has demonstrated gambling disorder involves cognitive, biological and behavioral addiction processes. Revised diagnostic criteria in the DSM-5 reclassifying gambling disorder as an addictive disorder recognizes conceptualization has evolved due to advancing scientific knowledge. Disordered gambling disproportionately impacts certain populations and is
Andrew Stroud