Problem gambling

Problem gambling, or ludomania, is an urge to continuously gamble despite harmful negative consequences or a desire to stop. Problem gambling often is defined by whether harm is experienced by the gambler or others, rather than by the gambler's behavior. Severe problem gambling may be diagnosed as clinical pathological gambling if the gambler meets certain criteria. Pathological gambling is a common disorder that is associated with both social and family costs. The condition is classified as an impulse control disorder, with sufferers exhibiting many similarities to those who have substance addictions. Although the term gambling addiction is used in the recovery movement, pathological gambling is considered by the American Psychiatric Association to be an impulse control disorder rather than an addiction. However, for the DSM 5.0 Pathological Gambling is being considered as an Addictive Disorder as opposed to an impulse-control disorder.

Definition
Research by governments in Australia led to a universal definition for that country which appears to be the only research-based definition not to use diagnostic criteria: "Problem gambling is characterized by many difficulties in limiting money and/or time spent on gambling which leads to adverse consequences for the gambler, others, or for the community." The University of Maryland Medical Center defines pathological gambling as "being unable to resist impulses to gamble, which can lead to severe personal or social consequences."

Most other definitions of problem gambling can usually be simplified to any gambling that causes harm to the gambler or someone else in any way; however, these definitions are usually coupled with descriptions of the type of harm or the use of diagnostic criteria. According to DSM-IV, pathological gambling is now defined as separate from a manic episode. Only when the gambling occurs independent of other impulsive, mood, or thought disorders is it considered its own diagnosis. In order to be diagnosed, an individual must have at least five of the following symptoms:


 * 1) Preoccupation.  The subject has frequent thoughts about gambling experiences, whether past, future, or fantasy.
 * 2) Tolerance.  As with drug tolerance, the subject requires larger or more frequent wagers to experience the same "rush".
 * 3) Withdrawal.  Restlessness or irritability associated with attempts to cease or reduce gambling.
 * 4) Escape.  The subject gambles to improve mood or escape problems.
 * 5) Chasing.  The subject tries to win back gambling losses with more gambling.
 * 6) Lying.  The subject tries to hide the extent of his or her gambling by lying to family, friends, or therapists.
 * 7) Loss of control.  The person has unsuccessfully attempted to reduce gambling.
 * 8) Illegal acts.  The person has broken the law in order to obtain gambling money or recover gambling losses. This may include acts of theft, embezzlement, fraud, or forgery.
 * 9) Risked significant relationship.  The person gambles despite risking or losing a relationship, job, or other significant opportunity.
 * 10) Bailout. The person turns to family, friends, or another third party for financial assistance as a result of gambling.

Biological basis
According to the Illinois Institute for Addiction Recovery, evidence indicates that pathological gambling is an addiction similar to chemical addiction. It has been seen that some pathological gamblers have lower levels of norepinephrine than normal gamblers. According to a study conducted by Alec Roy, formerly at the National Institute on Alcohol Abuse and Alcoholism, norepinephrine is secreted under stress, arousal, or thrill, so pathological gamblers gamble to make up for their under-dosage.

Further to this, according to a report from the Harvard Medical School Division on Addictions there was an experiment constructed where test subjects were presented with situations where they could win, lose, or break even in a casino-like environment. Subjects' reactions were measured using fMRI, a neuro-imaging technique very similar to MRI. And according to Hans Breiter, M.D., co-director of the motivation and Emotion Neuroscience Centre at the Massachusetts General Hospital, "Monetary reward in a gambling-like experiment produces brain activation very similar to that observed in a cocaine addict receiving an infusion of cocaine." However, studies have compared gamblers to substance-dependent addicts, concluding that addicted gamblers display more physical symptoms during withdrawal.

Deficiencies in serotonin might also contribute to compulsive behavior, including a gambling addictions.

Controversy over biomedical model
Some medical authors suggest that the biomedical model of “problem gambling” may be unhelpful because it focuses only on individuals. These authors point out that social factors are a far more important determinant of gambling behaviour than brain chemicals and they suggest that a social model may be more useful in understanding the issue. For example, an apparent increase in “problem gambling” in the UK may be better understood as a consequence of changes in legislation which came into force in 2007 and enabled casinos, bookmakers, and online betting sites to advertise on TV and radio for the first time in the UK and which eased restrictions on the opening of betting shops and online gambling sites.

Gambler's fallacy
The gambler's fallacy is the erroneous belief that a win in a game of pure chance is "due" after a string of losses. While it is logically correct to say that more trials of a probabilistic event increase the likelihood of the event occurring at least once, earlier games are independent of and have no influence over subsequent games.

As an example, there is a 63.3% chance that a Vegas-style slot machine with a 1:100 likelihood of paying out each pull will have paid out once or more after 100 pulls. There is a 39.5% chance that this same machine will have paid out at least once after 50 pulls. A problem gambler that is susceptible to the gambler's fallacy would believe that, if after 50 pulls the slot machine has not paid out, there is a 63.3% likelihood that the machine will pay out within the next 50 pulls, because there is a 63.3% chance of the machine paying out within any particular block of 100 trials. In reality, the likelihood that the machine will pay out in the next 50 pulls is still 39.5%.

The oversight made here is that independent probabilistic events do not actually influence one another. Gamblers are equating a posteriori probability with a priori probability. Gamblers believe that if there is a certain likelihood of a probabilistic event occurring after a certain number of trials, then as the number of past failures increases, the likelihood of the event occurring in future trials increases. The reality of the situation is that once a particular trial has been deemed a failure, we know a posteriori that there is a 0% chance of that event occurring, even if a priori there is a 1% chance of the event occurring. Within a particular set of 100 pulls, after 50 pulls we are no longer in a block of 100 1:100 events, but a block of 50 0:100 events and 50 1:100 events.

Relation to other problems
Pathological gambling is similar to many other impulse control disorders such as kleptomania, pyromania, and trichotillomania. Other mental diseases that also exhibit impulse control disorder include such mental disorders as antisocial personality disorder, or schizophrenia.

According to evidence from both community- and clinic-based studies, individuals who have pathological gambling are highly likely to exhibit other psychiatric problems at the same time, including substance use disorders, mood and anxiety disorders, or personality disorders.

Pathological gambling shows several similarities with substance abuse. There is a partial overlap in diagnostic criteria; pathological gamblers are also likely to abuse alcohol and other drugs. The telescoping phenomenon reflects the rapid development from initial to problematic behavior in women compared with men. This phenomenon was initially described for alcoholism, but it has also been applied to pathological gambling. Also biological data provide a support for a relationship between pathological gambling and substance abuse.

As debts build up people turn to other sources of money such as theft, or the sale of drugs. Much of this pressure comes from bookies or loan sharks on whom people rely for gambling capital.

In a 1995 survey of 184 Gamblers Anonymous members in Illinois, Illinois State Professor Henry Lesieur found that 56 percent admitted to some illegal act to obtain money to gamble. Fifty-eight percent admitted they wrote bad checks, while 44 percent said they stole or embezzled money from their employer.

Compulsive gambling can affect personal relationships. In a 1991 study of relationships of American men, it was found that 10% of compulsive gamblers had been married more than twice. Only 2% of men who did not gamble were married more than twice.

Suicide rate
A gambler who does not receive treatment for pathological gambling when in his or her desperation phase may contemplate suicide. Problem gambling is often associated with increased suicidal ideation and attempts compared to the general population.

Early onset of problem gambling increases the lifetime risk of suicide. However, gambling-related suicide attempts are usually made by older people with problem gambling. Both comorbid substance use and comorbid mental disorders increase the risk of suicide in people with problem gambling.

A 2010 Australian hospital study found that 17% of suicidal patients admitted to the Alfred Hospital's emergency department were problem gamblers.

In the United States, a report by the National Council on Problem Gambling showed approximately one in five pathological gamblers attempts suicide. The Council also said suicide rates among pathological gamblers are higher than any other addictive disorder.

Dr. David Phillips, a sociologist from University of California-San Diego found "visitors to and residents of gaming communities experience significantly elevated suicide levels." According to him, Las Vegas, the largest gaming market in the United States, "displays the highest levels of suicide in the nation, both for residents of Las Vegas and for visitors to that setting." In Atlantic City, the second-largest gaming market, he found "abnormally high suicide levels for visitors and residents appeared only after gambling casinos were opened."

Europe
In Europe, the rate of problem gambling is typically 0.5 to 3 percent. The "British Gambling Prevalence Survey 2007", conducted by the United Kingdom Gambling Commission, found approximately 0.6 percent of the adult population had problem gambling issues—the same percentage as in 1999. The highest prevalence of problem gambling was found among those who participated in spread betting (14.7%), fixed odds betting terminals (11.2%) and betting exchanges (9.8%). In Norway, a December 2007 study showed the amount of present problem gamblers was 0.7 percent.

North America
In the United States, the percentage of pathological gamblers was 0.6 percent, and the percentage of problem gamblers was 2.3 percent in 2008. Studies commissioned by the National Gambling Impact Study Commission has shown the prevalence rate ranges from 0.1 percent to 0.6 percent. Nevada has the highest percentage of pathological gambling; a 2002 report estimated 2.2 to 3.6 percent of Nevada residents over the age of 18 could be called problem gamblers. Also, 2.7 to 4.3 percent could be called probable pathological gamblers.

According to a 1997 meta-analysis by Harvard Medical School's Division on Addictions, 1.1 percent of the adult population of the United States and Canada could be called pathological gamblers. A 1996 study estimated 1.2 to 1.9 percent of adults in Canada are pathological. In Ontario, a 2006 report showed 2.6 percent of residents experienced "moderate gambling problems" and 0.8 percent had "severe gambling problems". In Quebec, an estimated 0.8 percent of the adult population were pathological gamblers in 2002.

Australia
Both casinos and poker machines in pubs and clubs facilitate problem gambling in Australia. The building of new hotels and casinos has been described as "one of the most active construction markets in Australia"; for example, AUD$860 million was allocated to rebuild and expand the Star complex in Sydney.

A 2010 study, conducted in the Northern Territory by researchers from the Australian National University (ANU) and Southern Cross University (SCU), found that the proximity of a person's residence to a gambling venue is significant in terms of prevalence. Harmful gambling in the study was prevalent among those living within 100 metres of any gambling venue, and was over 50% higher than among those living ten kilometres from a venue. The study's data stated:

Specifically, people who lived 100 metres from their favourite venue visited an estimated average of 3.4 times per month. This compared to an average of 2.8 times per month for people living one kilometre away, and 2.2 times per month for people living ten kilometres away.

Assessment
The most common instrument used to screen for "probable pathological gambling" behavior is the South Oaks Gambling Screen (SOGS) developed by Lesieur and Blume (1987) at the South Oaks Hospital in New York City. This screen is undoubtedly the most cited instrument in psychological research literature. In recent years the use of SOGS has declined due to a number of criticisms, including that it overestimates false positives.

The DSM-IV diagnostic criteria presented as a checklist is an alternative to SOGS, it focuses on the psychological motivations underpinning problem gambling and was developed by the American Psychiatric Association. It consists of ten diagnostic criteria. One frequently used screening measure based upon the DSM-IV criteria is the National Opinion Research Center DSM Screen for Gambling Problems (NODS). The Canadian Problem Gambling Inventory (CPGI) is another newer assessment measure. The Problem Gambling Severity Index (PGSI) is composed of nine items from the longer CPGI. The PGSI focuses on the harms and consequences associated with problem gambling.

Treatment
Most treatment for problem gambling involves counseling, step-based programs, self-help, peer-support, medication, or a combination of these. However, no one treatment is considered to be most efficacious and no medications have been approved for the treatment of pathological gambling by the US Food and Drug Administration (FDA).

Gamblers Anonymous (GA) is a commonly used treatment for gambling problems. Modeled after Alcoholics Anonymous, GA uses a 12-step model that emphasizes a mutual-support approach.

One form of counseling, cognitive behavioral therapy (CBT) has been shown to reduce symptoms and gambling-related urges. This type of therapy focuses on the identification of gambling-related thought processes, mood and cognitive distortions that increase one’s vulnerability to out-of-control gambling. Additionally, CBT approaches frequently utilize skill-building techniques geared toward relapse prevention, assertiveness and gambling refusal, problem solving and reinforcement of gambling-inconsistent activities and interests.

As to behavioral treatment, some recent research supports the use of both activity scheduling and desensitization in the treatment of gambling problems. In general, behavior analytic research in this area is growing

There is evidence that the SSRI paroxetine is efficient in the treatment of pathological gambling. Additionally, for patients suffering from both pathological gambling and a comorbid bipolar spectrum condition, sustained release lithium has shown efficacy in a preliminary trial. The opiate antagonist drug nalmefene has also been trialled quite successfully for the treatment of compulsive gambling.

Step-based programs
One step-based program for gambling issues is Gamblers Anonymous. Gamblers Anonymous uses a 12-step program adapted from Alcoholics Anonymous and also places an emphasis on peer support.

Other step-based programs are specific to gambling and generic to healing addiction, creating financial health, and improving mental wellness. Commercial alternatives that are designed for clinical intervention using the best of health science and applied education practices, have been used as patient centered tools for intervention since 2007. They include measured efficacy and resulting recovery metrics.

Motivational interviewing
Motivational interviewing is one of the treatment of compulsive gambling. The motivational interviewing's basic goal is promoting readiness to change through thinking and resolving mixed feelings. Avoiding aggressive confrontation, argument, labeling, blaming, and direct persuasion, the interviewer supplies empathy and advice to compulsive gamblers define their goal. Also the important point is promoting freedom of choice and encouraging confidence in the ability to change.

Peer support
A growing method of treatment is peer support. With the advancement of online gambling, many gamblers experiencing issues use various online peer-support groups to aid their recovery. This protects their anonymity while allowing them to attempt recovery on their own, often without having to disclose their issues to loved ones.

Self-help
Research into self-help for problem gamblers has shown benefits. A study by Dr. Wendy Slutske of the University of Missouri concluded one-third of pathological gamblers overcome it by natural recovery.