Pathological gambling
312.31 Pathological Gambling
Diagnostic Features
The essential feature of Pathological Gambling is persistent and recurrent maladaptive gambling behavior (Criterion A) that disrupts personal, family, or vocational pursuits. The diagnosis is not made if the gambling behavior is better accounted for by a Manic Episode (Criterion B).
The individual may be preoccupied with gambling (e.g., reliving past gambling experiences, planning the next gambling venture, or thinking of ways to get money with which to gamble) (Criterion A1). Most individuals with Pathological Gambling say that they are seeking "action" (an aroused, euphoric state) or excitement even more than money. Increasingly larger bets, or greater risks, may be needed to continue to produce the desired level of excitement (Criterion A2). Individuals with Pathological Gambling often continue to gamble despite repeated efforts to control, cut back, or stop the behavior (Criterion A3). There may be restlessness or irritability when attempting to cut down or stop gambling (Criterion A4). The individual may gamble as a way of escaping from problems or to relieve a dysphoric mood (e.g., feelings of helplessness, guilt, anxiety, depression) (Criterion A5). A pattern of "chasing" one's losses may develop, with an urgent need to keep gambling (often with larger bets or the taking of greater risks) to undo a loss or series of losses. The individual may abandon his or her gambling strategy and try to win back losses all at once. Although all gamblers may chase for short periods, it is the long-term chase that is more characteristic of individuals with Pathological Gambling (Criterion A6). The individual may lie to family members, therapists, or others to conceal the extent of involvement with gambling (Criterion A7). When the individual's borrowing resources are strained, the person may resort to antisocial behavior (e.g., forgery, fraud, theft, or embezzlement) to obtain money (Criterion A8). The individual may have jeopardized or lost a significant relationship, job, or educational or career opportunity because of gambling (Criterion A9). The individual may also engage in "bailout" behavior, turning to family or others for help with a desperate financial situation that was caused by gambling (Criterion A10).
Associated Features and Disorders
Associated descriptive features and mental disorders.
Distortions in thinking (e.g., denial, superstitions, overconfidence, or a sense of power and control) may be present in individuals with Pathological Gambling. Many individuals with Pathological Gambling believe that money is both the cause of and solution to all their problems. Individuals with Pathological Gambling are frequently highly competitive, energetic, restless, and easily bored. They may be overly concerned with the approval of others and may be generous to the point of extravagance. When not gambling, they may be workaholics or "binge" workers who wait until they are up against deadlines before really working hard. They may be prone to developing general medical conditions that are associated with stress (e.g., hypertension, peptic ulcer disease, migraine). Individuals seeking treatment for Pathological Gambling have relatively high rates of suicidal ideation and suicide attempts. Studies of men with Pathological Gambling suggest that a history of inattentive and hyperactive symptoms in childhood may be a risk factor for development of Pathological Gambling later in life. Increased rates of Mood Disorders, Attention-Deficit/Hyperactivity Disorder, Substance Abuse or Substance Dependence, other Impulse-Control Disorders, and Antisocial, Narcissistic, and Borderline Personality Disorders have been reported in individuals with Pathological Gambling.
Associated laboratory findings.
There are no laboratory findings that are diagnostic of Pathological Gambling. However, a variety of laboratory findings have been reported to be abnormal in males with Pathological Gambling compared with control subjects. These include measures of neurotransmitters and their metabolites in cerebrospinal fluid and urine, and response to neuroendocrine challenges, implicating abnormalities in a variety of neurotransmitter systems, including the serotonin, norepinephrine, and dopamine systems. Abnormalities in platelet monoamine oxidase activity have also been reported in males with Pathological Gambling. Individuals with Pathological Gambling may display high levels of impulsivity on neuropsychological tests.
Specific Culture and Gender Features
There are cultural variations in the prevalence and type of gambling activities (e.g., pai go, cockfights, horse racing, the stock market). Approximately one-third of individuals with Pathological Gambling are females, but in different geographic areas and cultures, gender ratio can vary considerably. Females with the disorder are more apt to be depressed and to gamble as an escape. Females are underrepresented in treatment programs for gambling and represent only 2%-4% of the population of Gamblers Anonymous. This may be a function of the greater stigma attached to female gamblers.
Prevalence
The prevalence of Pathological Gambling is influenced by both the availability of gambling and the duration of availability such that with the increasing availability of legalized gambling, there is an increase in the prevalence of Pathological Gambling. Community studies estimate the lifetime prevalence of Pathological Gambling to range from 0.4% to 3.4% in adults, although prevalence rates in some areas (e.g., Puerto Rico, Australia) have been reported to be as high as 7%. Higher prevalence rates, ranging from 2.8% to 8%, have been reported in adolescents and college students. The prevalence of Pathological Gambling may be increased in treatment-seeking individuals with a Substance Use Disorder.
Course
Pathological Gambling typically begins in early adolescence in males and later in life in females. Although a few individuals are "hooked" with their very first bet, for most the course is more insidious. There may be years of social gambling followed by an abrupt onset that may be precipitated by greater exposure to gambling or by a stressor. The gambling pattern may be regular or episodic, and the course of the disorder is typically chronic. There is generally a progression in the frequency of gambling, the amount wagered, and the preoccupation with gambling and obtaining money with which to gamble. The urge to gamble and gambling activity generally increase during periods of stress or depression.
Familial Pattern
Pathological Gambling and Alcohol Dependence are both more common among the parents of individuals with Pathological Gambling than among the general population.
Differential Diagnosis
Pathological Gambling must be distinguished from social gambling and professional gambling. Social gambling typically occurs with friends or colleagues and lasts for a limited period of time, with predetermined acceptable losses. In professional gambling, risks are limited and discipline is central. Some individuals can experience problems associated with their gambling (e.g., short-term chasing behavior and loss of control) that do not meet the full criteria for Pathological Gambling.
Loss of judgment and excessive gambling may occur during a Manic Episode. An additional diagnosis of Pathological Gambling should only be given if the gambling behavior is not better accounted for by the Manic Episode (e.g., a history of maladaptive gambling behavior at times other than during a Manic Episode). Alternatively, an individual with Pathological Gambling may exhibit behavior during a gambling binge that resembles a Manic Episode. However, once the individual is away from the gambling, these manic-like features dissipate. Problems with gambling may occur in individuals with Antisocial Personality Disorder; if criteria are met for both disorders, both can be diagnosed.
Diagnostic criteria for 312.31 Pathological Gambling
- Persistent and recurrent maladaptive gambling behavior as indicated by five (or more) of the following:
- is preoccupied with gambling (e.g., 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 repeated unsuccessful efforts to control, cut back, or stop gambling
- is restless or irritable when attempting to cut down or stop gambling
- gambles as a way of escaping from problems or of relieving a dysphoric mood (e.g., feelings of helplessness, guilt, anxiety, depression)
- after losing money gambling, often returns another day to get even ("chasing" one's losses)
- lies to family members, therapist, or others to conceal the extent of involvement with gambling
- has committed illegal acts such as forgery, fraud, theft, or embezzlement to finance gambling
- has jeopardized or lost a significant relationship, job, or educational or career opportunity because of gambling
- relies on others to provide money to relieve a desperate financial situation caused by gambling
- The gambling behavior is not better accounted for by a Manic Episode.