Leigh Falls Holman, Ph.D.

, LPCS, RPTS, NCC Process Addictions Chair, International Association of Addiction & Offender Counselors

COMPULSIVE GAMBLING

What is Gambling?
To play games of chance for money or other rewards (Cambridge International Dictionary, 1996). Any activity that has an uncertain outcome and involves risking something of value with the hope of increasing ones wealth, status, or

security (Chamberlain, 2004, p. 129).

312.31 (F63.0) Gambling Disorder (DSM 5, p. 585-589)

Clinically significant impairment or distress 4 or more criteria in 12 month period More money to achieve desired excitement (tolerance) Restless or irritable when tries to cut down/stop (withdrawal) Cant control behavior (compulsion) Preoccupied with gambling (obsession) Gambles when feeling distressed (emotion regulation) Lies to conceal extent of gambling Impaired functioning Relies on others to provide money to continue gambling Not better explained by a manic episode

Gambling Disorder Specifiers

Episodic or Persistent Remission: Early: 3-12 months Sustained: Over 1 year Severity Level Mild: 4/5 Criteria (less in treatment) Moderate: 6/7 criteria Severe: 8/9 criteria

Gambling Disorder Diagnostic Features

Distorted Thinking:

Denial Superstitions Sense of power & control over the outcome of chance events Overconfidence

Some are impulsive, competitive, energetic, restless, and

easily bored (p. 587). May be overly concerned with the approval of others and may be generous to the point of extravagance when winning. Others may be depressed and lonely, and they gamble when feeling helpless, guilty, or depressed. About 50% in treatment have suicidal ideation & about 17% have attempted suicide.

Gambling Disorder: Prevalence

Prevalence

Last 12 months .2%-.3% of the general population Lifetime prevalence rate gender & ethnicity

Males: Females: African Am Whites Hispanics

.6% .2% .9% .4% .3%

More common among young & mid-life Risk & Prognostic Factors:
Temperament Genetic Course Modifiers

Gambling Disorder: Development & Course

Earlier onset: More common with males Often begin with family & friends Associated with impulsivity & substance abuse HS & college students who have the disorder may grow out of it Younger prefer sports betting

Older: Machine/bingo gambling more likely Females: mid-late adult onset is typical more rapid development in females more likely than males to have depression, bipolar, & anxiety

Low rate of treatment seeking in general <10%, but more older onset females present for treatment than other populations Frequency gambling can be more associated with the type of gambling than the severity of gambling. (scratch ticket vs. casino) Amount of money isnt necessarily an indicator of a gambling problem.

GD: Functional Consequences

Poor general health & utilize medical services at a high rates
Tachycardia & angina more common in GD

population even when other substance use disorders are controlled for.

Jeopardize or loss of important relationships

Repeated lying to cover up the extent of gambling

My request money used for gambling or to

pay off gambling debts

GD: Differential Diagnosis & Comorbidity

Differential Diagnosis:

Non-disordered gambling Manic Episode Personality Disorders Other Medical Conditions (e.g. Parkinsons meds) Substance us disorders Depressive disorders Anxiety disorders Personality disorders

Comorbidity

Gambling: The Paradox

The goal is to win more than you lose.
The reality is that the odds are always in favor

of the house. Gamblers believe that they can beat the odds.

Problem Gambling
Gambling behavior that causes disruptions in any major

area of a persons life (National Council on Problem Gambling, 2000). The compulsion of gambling increasingly takes over an individuals resources (time, money, energy etc.) and intrapsychic life (thoughts & dreams). Of the 60%-80% of adolescents & adults who gamble, 5%7% develop a gambling problem (Chamberlain, 2004). Volberg (1996) problem gamblers were significantly more likely to be male, under 30, non-Caucasian, and single, reported starting gambling as teens/pre-teens, and were at higher risk for committing criminal offenses to finance their gambling or cover losses. Associated with mental health issues like anxiety & depression, including suicidality, substance abuse, criminal activity, problematic relationships.

Trends in Gambling
Welte, Barnes, Wieczorek, Tidwell, & Parker

(1975, 2002):
1975: men 13 % more likely to participate in

gambling 2002: gap is only 4% (2002, p. 335) Increase among the elderly & lower SES groups growth of gambling opportunities throughout the society has been associated with the profile of the gambling population shifting to become more female, older, and less white (2002, p. 337).

Trends in Gambling
Increase in youth gambling:
Raised on internet gaming and video games More casino space is now dedicated to video versions of

traditional games of chance (i.e. poker, blackjack) The gaming industry expects that youth will easily transition from video and internet games to gambling.

National Center for Responsible Gaming, 1999:

Research indicates that early involvement in gambling may be a

risk factor for developing a gambling problem later in life.

Shaffer & Hall, 1996:

7500 adolescents 13-20 y/o Between 9.9% and 14.2% experiencing/at risk for developing

serious gambling problems

Trends in Gambling
Government supported & encouraged lotteries
Increase number of casinos located

throughout the country Internet gambling Judged by dollars spent, gambling is now more popular in America than baseball, the movies, and Disneyland combined (OBrien, 1998, p. 4).

Commonalities between Pharmacological Addictions and Gaming (McCown & Chamberlain, 2000, p. 17)
Symptoms of Behavior
Cravings Denial of problems severity or existence Disruption of families Effects on specific neurotransmitters High relapse rate Loss of control Lying to support use/activity Preoccupation with use/activity Progressive disorder Tolerance developed Used as a means of escaping problems Withdrawal symptoms common

Alcohol & Other Drugs

Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes

Compulsive Gambling
Yes Yes Yes Unknown Yes Yes Yes Yes Yes Yes Yes Yes

Common Elements
Pre-occupation
Tolerance Denial Progression Withdrawal

3 Cs of Compulsive Gambling
Compulsive Activity
Loss of Control Continued Use Despite Adverse Consequences

Compulsive Activity
Stein, Hollander, & Liebowitz (1993) define compulsive gambling as a conflict between a gamblers stated intention, such as to not gamble, or to not gamble more than X amount, and the actual behavior, which violates the intention. May experience fugue-like states where they find themselves engaging in unplanned, spontaneous gambling activity (Chamberlain, 2004, p. 135). Triggers: internal & external

Loss of Control
The Chase (1984) the more they lose the more they

gamble chasing losses Double Down: double each bet they make following a loss with the intention of winning the bet that will eliminate the loss. Downward spiral of loss of more than intended and continuing to gamble to try to win back the losses. Gambling binges frequently end in exhaustion, disoriented, & an overwhelming sense of despair and depression that is unavoidable. Reports of being overpowered by the impulse to gamble Increasing pervasiveness of gambling in a persons life to the point that all activities center around gambling.

Continued Use Despite Adverse Consequences

Mental health consequences include anxiety, depression, substance abuse, loss of a sense of self, loss of hope, feelings of shame & embarrassment, fear of consequences, suicidal ideation & attempts. Financial consequences, job loss Relationship issues: abandonment of family members; wives of compulsive gamblers are 4 times more likely to commit suicide than the general population (Lesieur, 1993); miss family commitments; iritability, defensiveness, verbal and physical violence. The risk for self-destructive behavior is higher [in gambling] than with any other addiction (Chamberlain, 2004). The longer they are able to hide the gambling, the more problematic it becomes. There are no obvious signs of intoxication, like substance dependence. Gambling is non-linear in its consequences (may have a win as they are going through a downward spiral, where substance addiction consequences generally progressively get worse.)

Patterns of Compulsive Gambling

Gamblers seek different emotional

experiences through their gambling activity:

Escape Gamblers: Gambling becomes a trance-like

escape
Action Gamblers: Gambling becomes a powerful

stimulant

Escape Gamblers
Predisposing Factors:
Physical, emotional, or sexual abuse Poor relationships Losses

Values:
Denial of gambling as a problem Maintain family trust is important

Gambling Habits:

Onset later in life Faster progression of compulsive behavior Seeking to escape from loneliness or boredom Begins as a social activity and entertainment Participates mainly in games of chance Fewer big-win experiences

Escape Gamblers

Emotional Consequences:

Becomes emotionally dependent on gambling Preoccupied with gambling Depression Secretive about excess gambling Guilt about both financial losses and failure to meet standards of behavior Guild over lost time with family Shame related to dishonesty Fears of being revealed and disgraced

Financial Consequences:

Loss of household money Credit card problems Use of money from family savings or accounts Sale of valued family possessions
Denial that gambling is a problem Frequently doesnt want to stop gambling Partner may not intervene Family less supportive in getting help Child care Male dominated treatment and recovery services

Recovery Issues:

Action Gamblers
Predisposing factors:
Family of origin Personality characteristics

Introduction to Gambling:

Introduced by friends or family Begins betting at an early age Occasional gambling Experimenting with new types of gambling Developing a relationship with gambling Deviant behavior Precipitating or traumatic event Experiences a big win

Action Gamblers
Winning Phase:
Frequent winning Fantasizing about winning Increases amount of money bet & time spent

gambling Lies about gambling Brags about winning

Action Gamblers
Losing Phase:
Chases losses
Loses time from work or school Cannot stop gambling Begins to accumulate debts Relationship with family & friends impacted Ferquently borrows money Drops nongambling activities Becomes irritable, restless, depressed

Action Gamblers
Desperation Phase:
Unable to pay debts Sells possessions or family valuables Increases drug/alcohol use Thoughts of committing crimes to finance gambling

Loss of job or drops out of school

Withdraws from family & friends Blames others Shame, guilt, despair

Thoughts of or attempts at suicide

Emotional, physical, financial breakdown.

Action Gamblers
Often begins when a recreational gambler wins big. Predominantly male, view gambling as a skill to be learned & as a desirable way to make a living without the drudgery of employment Experience an unequaled rush of sensation; feel powerful & special, adrenaline rush; enjoy recognition & status Tend to play games requiring skill like black jack, craps, or poker; or a handicapping sporting event (like racing).

Action Gamblers
Often describe a system they have Generally much more competitive personalities Like to be perceived as a high-roller, respected & admired, viewed as talented and skilled Stimulated by overcoming the odds even purposely take irrational risks to provide more stimulation that comes from digging out of a hole