Gambling Disorder

Aka: Gambling Disorder, Compulsive Gambling, Pathologic Gambling, Gambling Addiction

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II. Epidemiology

  1. Compulsive gamblers in U.S. estimated: 5-8 Million (severe in 2.5 Million)
  2. U.S. Gambling is legal in every state except Utah, Hawaii
  3. Gender: Male predominance (2 fold higher than women)

III. Pathophysiology

  1. Process Addiction

IV. Mechanism: Casino Psychology

  1. Constant sound of other people wining
    1. Ringing of slots, and coins clinking from machine
  2. No windows and very few clocks
    1. Timeless environment
  3. Chips exchanged for money
    1. "Not real money being thrown around"
  4. Free Alcohol
    1. Disoriented, uninhibited
  5. "Air purification"
    1. Oxygen Supplementation pumped into casino in evening
  6. Intermittent Reinforcement Schedule
    1. Occasional gambler wins and keeps them playing
  7. Sensation of expectation
    1. "Near wins": Hit 7, 7, and part of a 7
    2. No increase chance of win, but Sensation of near win

V. Risk Factors

  1. Substance Abuse (e.g. Alcohol, Nicotine, Marijuana)
  2. Gambling Family History
  3. Child Abuse or neglect
  4. Lower socioeconomic status
  5. Witness of Trauma
  6. Physical abuse
  7. Weapon carrying
  8. History of fighting
  9. Comorbid Mental illness
    1. Attention Deficit Disorder
    2. Major Depression
    3. Anxiety Disorder
    4. Bipolar Disorder
    5. Cluster B Personality Disorder
      1. Antisocial Personality
      2. Narcissistic Personality
      3. Borderline Personality Disorder
  10. Medications
    1. Dopamine Agonists (Pramipexole, Ropinirole)
    2. Dopamine modulator (Aripiprazole)
    3. Wolfschlag (2023) Pharmaceut Med 37(1):37-52 +PMID: 36611111 [PubMed]

VI. Types: Gambling

  1. Most common
    1. Casino
    2. Lottery
  2. Sports
    1. Sports Betting
    2. Daily Fantasy Sports
    3. Horse racing
  3. Other
    1. Bingo
    2. Online gambling
    3. Card rooms
    4. Charitable or social gambling

VII. Types: Gamblers

  1. Action Gamblers
    1. Often men gambling in groups around craps table
    2. Driven by
      1. Grandiosity
      2. Control
      3. Fame (on a stage)
      4. Respect
      5. Action, Excitement
    3. Winning does not matter
      1. Money is only to get gambler to action
      2. Win or lose, they keep playing
  2. Escape Gamblers
    1. Often women gambling alone at slot machines
    2. Driven by Escape
      1. Emotional distress
      2. Financial hardship
      3. Loneliness
    3. Reinforced by Sensation
      1. Stimulant
      2. Pain killer or Tranquilizer effect
        1. Escape from reality: "Zone out"
      3. Anonymous relationship with slot machine
        1. Machine used for companionship

VIII. Stages

  1. Winning Stage
    1. Gambler has success and walks home with easy profit
  2. Losing Stage
    1. Continues gambling despite losses
    2. Action or Escape reinforces gambling behavior
  3. Desperation Stage (Follows bail-out)
    1. Risk everything to support habit
  4. Suicide or Insanity

IX. Differential Diagnosis

  1. Attention Deficit Hyperactivity Disorder
    1. Associated with impulsivity, poor planning and inattention
  2. Bipolar 1 Disorder
    1. Engages in high risk behavior (esp. during manic or hypomanic episodes)
  3. Obsessive Compulsive Disorder
    1. Engages in repetitive behaviors
  4. Cluster B Personality Disorder (Antisocial Personality, Narcissistic Personality, Borderline Personality Disorder)
    1. Associated with impulsivity, risk taking and a disregard for negative consequences
  5. Substance Use Disorder
    1. Dopaminergic reward system of substance use mirrors that of Substance Use Disorder
    2. Associated with craving, tolerance, withdrawal and control loss
    3. Commonly associated with Gambling Disorders

X. Diagnosis: DSM5

  1. Persistent and recurrent problematic gambling leading to Clinically SignificantImpairment and distress
  2. Not better explained by alternative diagnosis (esp. Mania)
  3. Demonstrates >=4 of the following findings in a 12 month period
    1. Needs to gamble with increasing amounts of money to achieve desired excitement
    2. Restless or irritable when trying to cut down or stop gambling
    3. Repeated unsuccessful efforts to control, cut back or stop gambling
    4. Preoccupied with gambling
      1. Persistent thoughts of reliving past gambling experiences
      2. Handicapping or planning the next venture
      3. Thinking of ways to acquire money for gambling
    5. Often gambles when distressed (e.g. helpless, guilty, anxious or depressed)
    6. After losing money gambling, returns in a subsequent day to "get even" ("chasing losses")
    7. Lies to conceal the extent of involvement in gambling
    8. Jeopardized or lost a significant relationship or job, or educational or career opportunity due to gambling
    9. Relies on others to provide money to relieve financial situations caused by gambling
  4. Timing
    1. Episodic
      1. Meets diagnostic criteria at more than one time point
      2. Symptoms subside for at least several months between periods of Gambling Disorder
    2. Persistent
      1. Continuous symptoms that meet diagnostic criteria for multiple years
  5. Remission
    1. Early remission
      1. Follows meeting full criteria for Gambling Disorder
      2. None of the criteria for Gambling Disorder have been met for at least 3 months (but <12 months)
    2. Sustained remission
      1. Follows meeting full criteria for Gambling Disorder
      2. None of the criteria for Gambling Disorder have been met for at least 12 months
  6. Severity
    1. Mild: 4-5 criteria met
    2. Moderate: 6-7 criteria met
    3. Severe: 8-9 criteria met
  7. References
    1. (2022) DSM5, APA

XI. Complications

  1. As with other addictions, willing to sacrifice
    1. Relationships (and divorce)
    2. Savings (and bankruptcy, welfare dependency)
    3. Law (arrest and incarceration)
  2. Willing to do anything to support habit
    1. Bank robbery
    2. Kidnapping
  3. Suicide
    1. Gambling Addiction has the highest Suicide rate of any addiction

XII. Management

  1. Agree on pragmatic goals with the patient
    1. Complete abstinence is unlikely to be achieved
    2. Reduce severity and frequency of gambling
    3. Diminish the impact of gambling on the patient and their environment
  2. Medications
    1. Discontinue medications (or decrease dose) of medications known to increase risk of Gambling Disorder
      1. Dopamine Agonists (Pramipexole, Ropinirole)
      2. Dopamine modulator (Aripiprazole)
    2. Medications found effective for short-term use to reduce gambling symptom severity (not FDA approved)
      1. Opioid Antagonists (Naltrexone, Nalmefene)
      2. Atypical Antipsychotic (Olanzapine)
  3. Psychotherapy
    1. Cognitive Behavioral Therapy (CBT)
      1. Reduces gambling severity and associated financial losses for up to 12 months
    2. Motivational Interviewing
      1. May reduce gambling behavior
    3. Other measures
      1. Establish responsible gambling patterns
      2. Develop financial literacy (e.g. budgeting, managing debt)
      3. Enroll in local government self-exclusion programs (if available)
        1. Patient is excluded from gambling marketing materials (e.g. casino)
      4. Identify gambling triggers
        1. Inventory of Gambling Situations
          1. https://kmb.camh.ca/ggtu/igs

XIII. Resources

  1. Gamblers Anonymous
    1. https://gamblersanonymous.org/
  2. National Counsel on Problem Gambling
    1. https://www.ncpgambling.org/
  3. What is Gambling Disorder (APA)
    1. https://www.psychiatry.org/patients-families/gambling-disorder/what-is-gambling-disorder

XIV. References

  1. Cowlishaw (2012) Cochrane Database Syst Rev 11(11):CD008937 +PMID: 23152266 [PubMed]
  2. Dowling (2022) Cochrane Database Syst Rev 9(9):CD008936 +PMID: 36130734 [PubMed]
  3. Kaminski (2026) Am Fam Physician 113(6): 536-41 [PubMed]
  4. Ribeiro (2021) BMC Psychiatry 21(1):105 +PMID: 33596853 [PubMed]

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