Gambling

Question 1

Criteria for diagnosis

Answer 1

Frequently preoccupied with gambling (eg, preoccupied with reliving past gambling experiences, handicapping or planning the next venture, or thinking of ways to get money with which to gamble)

●Needs to gamble with increasing amounts of money in order to achieve the desired excitement

●Has made repeated unsuccessful efforts to limit, cut back, or stop gambling

●Is restless or irritable when attempting to cut down or stop gambling

●Often gambles as a way of escaping from problems or relieving dysphoric moods (eg, feelings of helplessness, guilt, anxiety, or depression)

●After gambling and losing money, often gambles another day to get even (“chasing” after one’s losses)

●Lies to family members, therapist, or others to conceal the extent of gambling

●Has jeopardized or lost a significant relationship (eg, spouse), job, or educational or career opportunity because of gambling

●Relies on others to provide money to relieve a desperate financial situation caused by gambling

In addition, the gambling behavior is not better accounted for by a manic episode

Question 2

Demographic groups associated with higher rates

Answer 2

Such factors include:

●Age. Gambling is common among children and adolescents
In one survey of 21,297 8th through 12th grade students in public and private schools in Vermont, 53 percent reported gambling in the past 12 months, and 7 percent reported problems attributable to gambling [14]. Senior citizens may also have an increased risk. In one survey of attendees at a senior center in the US, approximately 10 percent were problem or pathological gamblers, with greater prevalence among males [15].

●Gender. The prevalence of pathologic and problem gambling in men is two to three times higher than in women [2,16]. However, the progression of the disorder appears to be faster in women [17]. Women who entered an outpatient treatment program for gambling were found more often to be single than their male counterparts, and started gambling significantly later than men

Other risk factors include:

●Adults in mental health treatment [1]

●Nicotine or substance abuse: alcohol, marijuana, inhalants, illegal steroids [1]

●African American [2,16].

●Positive family history [18,19].

●Childhood abuse and child neglect [20,21]

●Lower socioeconomic status [2,16]

●Witnessing trauma or being a victim of physical attack [21]

●Carrying a weapon or being involved in a fight [1]

●Seatbelt nonuse [1]

Question 3

debate about whether pathologic gambling is a nonsubstance abuse-related disorder or an impulse control disorder

Answer 3

Support for the hypothesis that the pathogenesis of gambling disorder is related to impulse control disorders comes from studies that found changes in serotonin metabolites in both pathologic gamblers and patients with impulse control disorders [23,25]. Men who are pathologic gamblers also experience abnormal responses to challenges with serotonergic ligands.

●A relationship between pathologic gambling and substance abuse is suggested by similarities between the two disorders, including symptoms of tolerance, withdrawal, anticipatory craving, and a chronic relapsing course [23,24]. Common genetic vulnerability for pathologic gambling and alcohol abuse also has been reported among twins [18]. Finally, studies of decision making have found that compared with healthy controls, people with substance use disorders more frequently choose large immediate rewards when presented with gambling tasks despite larger intermittent punishments

Question 4

genetic contribution

Answer 4

Genes are as important in causing gambling disorder in women as they are in men. A twin study that included 867 monozygotic twin pairs and 1008 dizygotic twin pairs found that genetic influences accounted for 49 percent of the variation in liability for pathologic gambling, and that there was no evidence of sex differences

Question 5

screening tool for gambling

Answer 5

The South Oaks Gambling Screen (SOGS) is the only extensively used, validated screening tool for the identification of pathologic gamblers. It is a 20 item scale that includes weighted items to determine if the patient is hiding evidence of gambling, spending more time or money gambling than intended, arguing with family members over gambling, and borrowing money from a variety of sources to gamble or to pay gambling debts.

Question 6

Comorbid psychiatric disorders

Answer 6

High rates of depressive, bipolar, psychotic, anxiety, personality, and substance abuse disorders (including alcohol and tobacco), as well as attention deficit hyperactivity disorder, are seen in patients with gambling disorder and problem gambling

At some point during their lives, major depressive disorder is likely to occur in 76 percent of pathologic gamblers, with recurrent depressive episodes likely to occur in 28 percent

Patterns of gambling are different for substance abusers compared to non-users. A nationally representative sample found that substance-abusing gamblers had a younger age of onset of gambling, and were more likely to engage in heavier gambling with greater risk

Question 7

Treatment options

Answer 7

1. Psychotherapy
   The use of behavioral and, in particular, cognitive-behavioral therapies for patients with pathologic gambling is supported by randomized trials with some methodologic flaws. We suggest psychological treatment be included in a treatment plan for all patients with problem gambling. Unfortunately, patients are often reluctant to seek psychological help, and one-half of patients referred to mental health services fail to follow through on the referral.
2. Gamblers anonymous
3. Pharmacotherapy-> when directed at co-morbid conditions. SSRI’s, naltrexone
4. Enlisting family members to assist in encouraging the pathologic gambler to follow through on treatment recommendations.
5. Treating the patient for comorbid conditions of major affective disorders and substance abuse, as well as intervening to reduce the risk of suicide.
6. Providing the gambler and family members with support resources

Question 8

PUBLIC HEALTH APPROACH

Answer 8

A public health approach to control problem gambling has been proposed, based on the lessons learned from addressing tobacco availability and addiction:

● Decrease available gambling locations and lottery venues
● Ban advertising for gambling activities
● Keep lottery tickets out-of-sight
● Plain package gambling products, and add warning label with risk of problem gambling
● Enforce the legal age for gambling
● Regulate or ban instant play/reward games (immediate gratification may exacerbate gambling behavior)
● Decrease the number of video lottery terminals
● Consider a moratorium on building new casinos

Question 9

CBT approach overview to gambling

Answer 9

1. Self-monitoring e.g. diary of time, money, mood etc.
2. Psycho-education based on CBT principles.
3. Goal setting using graded desensitisation, imaginal and then live exposure.
4. Managing urges to gamble with discussion of triggers/cues.
5. Challenging irrational cognitive beliefs.
6. Problem solving skills inc. limits on money carried, time spent on gambling.
7. Social and coping skills inc. relaxation, physical activity, meditation etc.
8. Relapse prevention to cope with high risk situations.
9. Involvement and communication with others e.g. financial counselling, GP, assistance with studies