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Treatments for Gambling Disorder

Table of Contents

Pathological Gambling Classification

Malicious gambling behavior has been researched, evaluated, and classified for more than three decades. With the field of research ever-expanding, it should come as no surprise that the diagnosis has changed based on empirical evidence from ongoing research and a growing body of literature.

Pathological Gambling’s classification in the Diagnostic and Statistical Manual of Mental Disorders’ (DSM-III) has evolved over the years, as expected since the third edition was released in 1980. The original criteria and subsequent revisions were amended in each edition by committees of experts based on numerous factors, including literature reviews and the experts’ clinical experience and expertise.

Diagnostic criteria for Pathological Gambling were first introduced in 1980 in DSM-III (American Psychiatric Association 1980), only to be revised in 1987 for DSM-III-R (American Psychiatric Association 1987) and, yet again, in 1994 for DSM-IV (American Psychiatric Association 1994). The most recent iteration of the criteria is in the DSM-5 (American Psychiatric Association, 2013).

The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) replaced the DSM-IV diagnosis of Pathological Gambling with the term Gambling Disorder.

Within this article, we’ll look at the revised criteria for diagnosis under DSM-5, the suggested steps to be taken to treat Gambling Disorder as well as the umbrella term, Problem Gambling.

Pathological Gambling Explained

For the sake of clarity, it’s imperative to note that Problem Gambling is the updated terminology for Gambling Addiction, whereas Gambling Disorder replaces the term Pathological Gambling. It’s vital to separate these two diagnoses, as they are distinctly different from one another. At times these terms have been used interchangeably, albeit erroneously.

Problem Gambling

The umbrella term Problem Gambling refers to excessive gambling that constitutes subthreshold symptoms. Despite the criteria set out for the diagnosis of Pathological Gambling in previous editions of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III and DSM-IV), most clinicians and researchers have recognized the existence of subclinical symptoms of Pathological Gambling (DSM-IV).

Subclinical pathological gamblers, commonly known as problem gamblers, have been defined as having difficulties brought about by their gambling but did not fulfill the Pathological Gambling diagnosis criteria. Other terms that describe this group are ‘at-risk,’ ‘level 2’, and ‘probable pathological.’

Korn and Shaffer suggested that gambling occurred along a continuum and conceptualized a continuum model that ranges from levels 0 to 3. As described in the continuum model, level 0 represents no gambling, level 1 represents non-problem gambling, level 2 represents at-risk gambling, while level 3 represents diagnosable Pathological Gambling.

Problem Gambling is estimated to affect up to 5% of the general population, 2,6 million in the USA alone, a significantly higher percentage than the general population diagnosed with Pathological Gambling (DSM-IV) that accounts for an approximated 1% of the community based on extensive research.

Pathological Gambling = Gambling Disorder

Historically, individuals suffering from Pathological Gambling were known as addicts. The word’s etymological roots can be traced back to the early Roman Republic (5th – mid 3rd cent. BCE), with the term commonly associated with debt. Addiction in reference to alcohol and drug dependence is considered a relatively recent phenomenon, with the word’s medical connotation only appearing in the early 19th century.

The release of DSM-III in 1980 saw the first official recognition of Pathological Gambling and defined the term as a disorder. Pathological Gambling was characterized by; a continuation of the behavior despite adverse consequences, a preoccupation with gambling and obtaining money with which to gamble, irrational thinking, and continuous or periodic loss of control over gambling. The definition’s similarities to alcohol and substance dependence were strikingly similar. The similarities included criteria that included the emphasis on loss of control, preoccupation, disregard for consequences, and progression.

In recent years, professionals questioned the inclusion of Pathological Gambling as an impulse-control disorder, citing essential differences between the classification and symptoms associated with Pathological Gambling. Shaffer and Korn’s review; Gambling and Related Mental Disorders: A Public Health Analysis (2002), observed that individuals with impulse control disorders such as Trichotillomania (compulsive hair-pulling), Intermittent Explosive Disorder, Kleptomania, and Pyromania experienced overwhelming impulses to act and frequently reported a sense of relief following the act. In contrast, individuals diagnosed with Pathological Gambling found the deed enjoyable. They would only begin to feel distressed once their gameplay had come to an end or if they had incurred financial loss.  

Furthermore, clinicians noted that the individuals diagnosed with Pathological Gambling experienced cravings, developed tolerance (larger high-risk bets needed to be placed to reach the desired level of excitement), and exhibited withdrawal symptoms. In addition to these symptoms, some gamblers also reported that they felt a ‘rush’ during periods of anticipated gambling, including the onset of sweaty palms, rapid heartbeat, and nausea.

The DSM-5 workgroup suggested that Pathological Gambling be moved from the Impulse Control Disorders Not Elsewhere Classified to Substance-Related and Addictive Disorders. The reclassification is based on growing scientific literature on Pathological Gambling that revealed similarities with substance use disorders.

Many clinicians and researchers have fervently asserted that individuals diagnosed with Pathological Gambling closely resembled alcoholic and drug addicts in terms of destructive behavior, problematic finances, and psychological issues.

Dr. Charles O’Brien, chair of the Substance-Related Disorders Work Group for DSM-5, disclosed that neurochemical tests, as well as brain imaging studies, have made a “strong case that [gambling] activates the reward system in much the same way that a drug does.”

Before the release of DSM-5, biological studies found that pathological gamblers and substance users shared several neurobiological features identified by genetic, biochemical, and functional neuroimaging studies. Parallels between gambling and substance use disorders were observed in the neurotransmitter systems, including dopamine, serotonin, and gamma-aminobutyric acid.

Documentation indicates that individuals diagnosed with Pathological Gambling have reported that they experience cravings and highs in response to gambling stimulus. Comorbidity with other addiction was also frequently observed, as was the fact that this particular behavior was often present in family history.

Despite being categorized as an impulse control disorder, Pathological Gambling was similar to other addictive behaviors. The collective evidence is based on similarities in diagnosis and assessment, the presence of one or more additional conditions often co-occurring with a primary condition (comorbidity), neurobiological overlap, and treatment practices to substance use disorders. It was found that the diagnostic criteria of Pathological Gambling closely correlate with the criteria associated with substance abuse and dependence as opposed to other impulse control disorders.

Pathological Gambling was defined as a progressive disorder up until the release of DSM-5 in 2013. The DSM-5 renamed and reclassified Pathological Gambling from impulse control disorders to substance-related and addictive disorders.

How to Identify if You suffer from Gambling Disorder

Unlike the DSM-IV, which did not provide a time period for Pathological Gambling symptoms, the DSM-5 requires that individuals display four or more of the nine symptoms listed in the criteria within a 12-month period to be diagnosed with Gambling Disorder.

As such, an individual who exhibited two symptoms in the past year and two symptoms years ago would not qualify for a Gambling Disorder diagnosis.

Diagnosis of Gambling Disorder Requires at Least Four of the Following Symptoms:

  1. Preoccupation. An individual is often preoccupied with gambling experiences – this includes frequent thoughts about gambling such as planning the next gambling experience, strategizing ways to fund gambling behavior, and reliving past gambling experiences.
  2. Withdrawal. An individual experiences restlessness or irritability associated with attempts to reduce or cease gambling.
  3. Tolerance. As with drug tolerance, an individual requires larger or more frequent wagers to achieve the desired excitement equated with a ‘rush.’
  4. Escape. An individual resorts to gambling when feeling distressed.
  5. Chasing. An individual frequently attempts to win back gambling losses with more gambling. Chasing one’s losses as a long-term behavior as opposed to short-term behavior is characteristic of Gambling Disorder.
  6. Lying. An individual tries to hide the extent of their gambling activity or gambling-related consequences by lying to family, friends, therapist, etc.
  7. Loss of control. An individual has repeatedly and unsuccessfully attempted to reduce, limit, or cease gambling.
  8. Risked a significant relationship. An individual has risked or lost a meaningful relationship, job, or educational/career opportunity because of gambling
  9. Bailout. The individual depends on family, friends, or another third party to alleviate desperate financial situations caused by gambling.

It’s important to note that if an individual exhibits 1 to 3 of the symptoms, they are considered to indicate subthreshold Gambling Disorder, thus indicating Problem Gambling.

Gambling Disorder can be represented as either episodic or persistent and is quantitatively rated as mild (4–5 criteria met), moderate (6–7 criteria met), or severe (8–9 criteria met) according to the number of symptoms exhibited.

If manic episodes better accounts for the nine symptoms above, then the DSM-5 states that Gambling Disorder is deemed invalid.

The Elimination of Illegal Acts as a Criterion

A DSM-5 revision that hasn’t been explained thus far is the elimination of the criterion, “has committed illegal acts such as forgery, fraud, theft, or embezzlement to finance gambling.”

The decision to remove the abovementioned criterion was based on empirical data from two studies (Strong and Kahler 2007; Zimmerman et al. 2006) that found low the prevalence for this particular criterion to be particularly low. Furthermore, the studies revealed that the criterion was infrequently endorsed, even when there was a lack of other criteria, signifying that it does not add to diagnostic integrity.

In addition to the reduction of criteria, there was also a reduction of the threshold for diagnosis from five to four criteria based on three studies across the world, namely USA (Stinchfield 2003), Canada (Stinchfield et al. 2005), and Spain (Jimenez-Murcia et al. 2009). The studies collectively found that not only was there a reduction in false negatives, but the classification accuracy was modestly improved. Another study conducted in France confirmed that the revised DSM-5 criteria outperformed the criteria set out in DSM-IV.

The Illegal Acts Criterion Faced Numerous Problems

The illegal acts criterion can be open to potential misunderstanding by interviewees; as a result thereof, it’s likely to be the most underreported criterion.

An example of such confusion is a problem gambler writing bad checks. The individual may not consider this illegal or a criminal act, especially if they intend to deposit the money into their account later to cover the bad check. The act is also disregarded as illegal if the individual did not suffer any consequences such as arrest.

The illegal acts criterion requires extensive clarification and investigative questioning for the criterion to be relevant during a diagnostic interview. To establish if an act such a writing bad checks satisfies the criterion of illegal acts would need additional probing.

Furthermore, some individuals may refuse to report illegal acts in a diagnostic interview or clinical assessment based on the possible legal consequences or criminal implications. Reports indicate that individuals who do not disclose criminal acts during initial diagnostic interviews later disclose during treatments that they engaged in illegal acts as a means to fund gambling or pay gambling debts.

Underreporting of criminal acts invariably contribute to the criterion’s low prevalence rates. An investigation into these factors informed the elimination of this stand-alone criterion in DSM-5.

Researchers have also demonstrated that illegal activity that is dependent on gambling is associated with a set of gambling symptoms much greater in severity.

Treatments

Studies have indicated that approximately a third of individuals diagnosed with Gambling Disorder will recover without the need for treatment. Other individuals will likely turn to treatment options to regain control. These treatment options include self-help and peer support, brief and motivational interventions, and cognitive-behavioral therapy.

Research suggests that individuals diagnosed with Gambling Disorder will benefit from gambling treatments predominantly based on treatments developed for alcohol and drug addiction.

The common interventions are listed below:

12-Step Recovery Program

Gamblers Anonymous is modeled after Alcoholics Anonymous and shares the 12-step philosophy pioneered by the AA. Gamblers Anonymous also shares many of the AA principles, including an abstinence-only orientation, adoption of the disease model of addiction, and the approach of addiction as a chronic illness.

Gambling Anonymous seems to benefit individuals with severe addiction, although abstinence orientation in treatment may dissuade some individuals. Studies show that treatment outcomes are enhanced when Gambling Anonymous involvement is pursued alongside professional treatment, with many professional treatments encouraging Gamblers Anonymous involvement as a recommended component.

Self-Help

Self-help treatments offer many benefits not found in professionally delivered treatments or 12-step meetings, such as accessibility, cost savings, convenience, and privacy.  

Evaluations have discovered that self-help literature for problem gambling has proven to beneficial for individuals diagnosed with Gambling Disorder, in comparison to those that have not pursued any form of treatment. However, trials suggest that therapist interaction is essential for a useful self-help bibliography for diagnosed individuals.

Motivational Interventions

This particular treatment includes any clinical strategy designed to eliciting behavior change. It includes brief intervention, client assessment, counseling, or multiple sessions. Motivational interventions are ideal for individuals diagnosed with Gambling Disorder who are ambivalent about a shift in behavior or treatment.

Studies have demonstrated that individuals who completed single-session (~75 minutes) motivational interventions have effectively reduced gambling frequency and the amount of money wagered. The effects have been noted to persist up to a year after the session.

Cognitive and/or Behavioral Therapies

Professionally delivered, manual-guided Cognitive and/or Behavioral Therapies have proven to provide optimal results compared to Gamblers Anonymous or self-help bibliotherapy in individuals diagnosed with Gambling Disorder.

Studies have indicated that psychiatric symptoms are responsive to and improve during Cognitive and/or Behavioral Therapies. Research has suggested that the format (group vs. individual therapy) has no direct bearing on treatment results. It appears that most treatments are beneficial and that the treatment format depends on the individual’s preferences and needs.

Conclusion

This article discussed critical topics about Pathological Gambling and Gambling Disorder, not forgetting the subthreshold classification of Problem Gambling. The revised criteria and classification of DSM-5 were detailed, and the identification and treatments of Gambling Disorder. The article also touched on the rationale of removing one of the requirements found in DSM-IV and the similarities that Gambling Disorder has with alcohol and drug addictions.