Henry R. Lesieur

Pathological gambling: A review of the literature (prepared for the American Psychiatric Association task force on DSM-IV committee on disorders of impulse control not elsewhere classified).

This is a review of the literature on pathological gambling prepared for the work group on disorders of impulse control, not elsewhere classified of the American Psychiatric Association. It introduces the new DSM-IV criteria as well as outlines the phases of the career of the pathological gambler. Research discussed includes that on pathological gambling and psychiatric disorders, substance abuse, family issues, children, finances, and crime. Psychoanalytic, personality, behavioral, sociological, psychologically based addiction theories, and physiological research are also summarized. Finally, treatment outcome studies are outlined.

Pathological gambling among high school students

Eight hundred and ninety-two high school students from four New Jersey high schools were given a questionnaire concerning their gambling behavior. Ninety-one percent of the students had gambled at least once in their lifetime, 86% gambled in the last year and 32% gambled at least once a week. Using an index which was validated in other research (Lesieur, Blume, & Zoppa, 1986) 5.7% of the students showed clear signs of pathological gambling. The pathological gambling signs index was found to be correlated with sex, parental gambling problems, grade average, and the extent of gambling by the student.

Studies of the 48 bp repeat polymorphism of the DRD4 gene in impulsive, compulsive, addictive behaviors: Tourette syndrome, ADHD, pathological gambling, and substance abuse.

Prior studies have reported an association between the presence of the 7 repeat allele of the 48 bp repeat polymorphism of the third cytoplasmic loop of the dopamine D4 receptor gene (DRD4) and novelty seeking behaviors, attention deficit hyperactivity disorder (ADHD), Tourette syndrome (TS), pathological gambling, and substance abuse. However, other studies have failed to replicate some of these observations. To determine whether we could replicate these associations we genotyped 737 individuals from four different groups of control subjects, and 707 index subjects from four different groups of impulsive, compulsive addictive behaviors including substance abuse, pathological gambling, TS, and ADHD. Chi-square analysis of those carrying the 7 allele versus non-7 allele carriers was not significant for any of the groups using a Bonferroni corrected alpha of.0125. However, chi-square analysis of those carrying any 5 to 8 allele versus noncarriers was significant for pathological gambling (p <.0001), ADHD (p </=.01) and the total index group (p </=.0004). When the comparison included all 7 alleles the results were significant for gamblers (p <.0001), TS (p </=.003), ADHD (p </=.003), and the total group (p </=.0002). There was a significant increase in the frequency of heterozygosity versus homozygosity for all alleles for pathological gamblers (p </=.0031) and the total index group (p </=.0015), suggesting that heterosis played a role. In the substance abuse subjects a quantitative summary variable for the severity of drug dependence, based on the Addiction Severity Index, showed that the scores varied by increasing severity across the following genotypes: 44 </= heterozygotes </= 77 </= 22. Studies of other quantitative traits indicated an important role for the 2 allele and the 22, 24, and 27 genotypes. All studies indicated that the role of the DRD4 gene in impulsive, compulsive, addictive behaviors is more complex than a sole focus on the 7 versus non-7 alleles.

The Compulsive Gambler’s Spiral of Options and Involvement

The material presented in this report is not intended as an explanation of compulsive gambling. I do not pretend to be refuting the psychoanalytic or the personality theorists. Rather, I describe the changes that take place in the career of the person turned compulsive gambler. Some of what is described here adds to the already existing knowledge of the compulsion.

Costs and Treatment of Pathological Gambling

The nature and social costs of pathological gambling are reviewed. Costs of gambling in terms of indebtedness for the gambler, costs for family members, costs for the workplace, illegal activities, and physical and psychological costs are examined. The interaction of pathological gambling with other disorders, including substance abuse, anxiety, and depression, are noted. Methods of screening pathological gamblers are summarized. Different treatment approaches and their effectiveness are reviewed, including Gamblers Anonymous and Gam-Anon, psychodynamic treatment, behavioral and cognitive approaches, and treatment based on an addiction model. Treatment for spouses is discussed. Gambling expenditure data are then examined to determine what portion of total expenditures is accounted for by problem gamblers.

Problem gamblers, problem substance users, and dual-problem individuals: an epidemiological study

OBJECTIVES This study compared problem gamblers, problem substance users, dual-problem individuals, and persons without these problems in the general population. METHODS On the basis of computer-assisted telephone interviews of a random sample of Texas adults (n = 6308) standard instruments were used to gauge substance use and gambling problems in the general population. RESULTS Compared with those having a substance use or gambling problem only, dual-problem individuals were more likely to be young, never-married men, without conventional religious affiliations. There was more dysfunctionality (as evidenced by treatment-seeking and problems with the law) among dual-problem respondents than among those troubled exclusively by gambling or substance use problems. CONCLUSIONS Screening and treatment for gambling problems should be offered in drug treatment and criminal justice arenas.

Epidemiological surveys of pathological gambling: critique and suggestions for modification

Epidemiological studies of problem and pathological gambling were examined for their accuracy. Fundamental flaws and biases were found in these surveys. These include problems with survey instruments; nonresponses and refusal bias; the exclusion of institutionalized populations; exclusion of other groups; and failure to protect against denial on the part of the respondent when others are present near the telephone. Based on the issues discussed, one can reasonably be expected to assume that most epidemiological surveys seriously underestimate the extent of problem and pathological gambling. Alternative strategies for addressing these issues are discussed. These strategies include the use of field interviews, surveys of institutionalized populations, frequent player surveys and significant other surveys. The value and potential problems of these approaches are also discussed.

Pathological Gambling: Roots, Phases, and Treatment

The medical model of pathological gambling is coming to dominate the public image of the problem gambler. The new image is replacing the previous one of sinner or criminal. This article traces the roots, causes, and phases of pathological gambling. The sociocultural roots of pathological gambling are seen as distinct from gambling itself. The work of sociologists, psychologists, psychiatrists, and others is summarized herein, and different types of pathological gamblers are examined. Three phases of the career of the pathological gambler are outlined: the adventurous, or winning phase; the losing phase; and the desperation phase. The gamblers career progresses with increasing problems in all spheres of life, including relations with family members and friends, gambling associates, employment, and finances. Eventually the gambler has reduced life options, which include suicide, imprisonment, running away, and seeking help. Two major sources of help, Gamblers Anonymous and professional counseling, are examined, and their prospects and difficulties are revealed. Projections are made for future developments in the area of pathological gambling.

Pathological gambling among methadone patients

This paper examines the correlates of problem gambling among a population of 220 methadone patients receiving treatment in the New York metropolitan area. Like most methadone patients, respondents were primarily adult males, ethnically mixed, of limited educational accomplishment and had long experiences with intravenous drug use. More than two-thirds of subjects had been convicted of one or more criminal offences. Analysis of the data showed seven percent of respondents to be probable pathological gamblers according to the South Oaks Gambling Screen (SOGS), indicating a high rate of gambling problems among this treatment population. Consistent with past studies, problem gamblers are more likely to be men, with histories of alcohol abuse, and with extensive criminal participation dating back to their teenage years. The data also suggested that problem gamblers who were also drug dependent were more likely to show greater evidence of social dysfunctionality compared to those who were exclusively substance abusers. More dually addicted respondents reported higher levels of recent heroin use, greater unemployment, and more reported hallucinations. Probable pathological gamblers who were substance abusers were also more likely to report being in conflict with their close friends. A multiple regression analysis suggested this to be the closest linked correlate to being a pathological gambler. Evidently, pathological gamblers create antipathy towards themselves as their compulsion to gamble is expressed; this in turn, may drive them toward further gambling, as they respond to this perceived opposition. These last preliminary findings will require further confirmation in future research.

Gambling among Methadone Patients

In this paper we assess participation in various forms of gambling activities and establish the prevalence of pathological gambling in a sample of patients (N = 117) enrolled in a large methadone maintenance treatment program in New York City. Respondents were interviewed with a protocol that incorporates the South Oaks Gambling Screen. We found that gambling was a common part of the regular activities of many patients, that 15% of the patients had some problem with gambling, and that an additional 16% were probable pathological gamblers. The implications of our findings are discussed.