Pathological Gambling and Other Behavioral Addictions

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Several disorders, particularly those formally categorized in the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) as impulse control disorders (ICDs) not elsewhere classified, have been described as "behavioral" addictions (American Psychiatric Association, 2000). The ICDs include pathological gambling (PG), kleptomania, intermittent explosive disorder, trichotillomania, and pyromania, and diagnostic criteria for compulsive computer use, compulsive sexual behavior, and compulsive buying (CB) have been proposed. Although there exists some controversy regarding the most precise categorization of these disorders, mounting evidence supports phe-nomenological, clinical, epidemiological, and biological links between behavioral and drug addictions. As such, it seems increasingly important that individuals involved in the prevention and treatment of substance use disorders (SUDs) have a current understanding of ICDs and the potential for future research findings to guide prevention and treatment efforts for addictions in general.

PG represents the most thoroughly investigated ICD; consequently, this chapter largely focuses on PG, the relationship of PG to SUDs, and current treatment options for PG. We will also review two other ICDs (kleptomania and CB) that, despite having been less studied than other psychiatric disorders, have been receiving increasing attention from clinicians and researchers.


Behavioral and drug addictions share common core qualities: (1) repetitive or compulsive engagement in a behavior despite adverse consequences; (2) diminished control over the problematic behavior; (3) an appetitive urge or craving state prior to engagement in the problematic behavior; and (4) a hedonic quality during the performance of the problematic behavior. These features have led to a description of ICDs as "addictions without the drug."

Clinical similarities between ICDs and SUDs are best reflected in the diagnostic criteria for PG. Criteria for PG (Table 13.1) share common features with those for SUDs (American Psychiatric Association, 2000), including aspects of tolerance, withdrawal, repeated unsuccessful attempts to cut back or stop, and impairment in major areas of life functioning (Blanco, Moreyra, Nunes, Saiz-Ruiz, & Ibanez, 2001). Epidemiological data also support a relationship between PG and SUDs, with high rates of co-occurrence in each direction (Potenza, Fiellin, Heninger, Rounsaville, & Mazure, 2002). Phenomenological

TABLE 13.1. Diagnostic Criteria for Pathological Gambling

A. Persistent and recurrent maladaptive gambling behavior as indicated by five (or more) of the following:

(1) 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)

(2) needs to gamble with increasing amounts of money in order to achieve the desired excitement

(3) has repeated unsuccessful efforts to control, cut back, or stop gambling

(4) is restless or irritable when attempting to cut down or stop gambling

(5) gambles as a way of escaping from problems or of relieving a dysphoric mood (e.g., feelings of helplessness, guilt, anxiety, depression)

(6) after losing money gambling, often returns another day to get even ("chasing" one's losses)

(7) lies to family members, therapist, or others to conceal the extent of involvement with gambling

(8) has committed illegal acts such as forgery, fraud, theft, or embezzlement to finance gambling

(9) has jeopardized or lost a significant relationship, job, or educational or career opportunity because of gambling

(10) relies on others to provide money to relieve a desperate financial situation caused by gambling

B. The gambling behavior is not better accounted for by a Manic Episode

Note From American Psychiatric Association (2000, p. 674). Copyright 2000 by the American Psychiatric Association. Reprinted by permission.

data further support a relationship between behavioral and drug addictions: For example, high rates of PG and SUDs have been reported during adolescence and young adulthood (Chambers & Potenza, 2003); the telescoping phenomenon (reflecting the rapid rate of progression from initial to problematic behavioral engagement in women as compared with men) initially described for alcoholism has been applied to PG (Potenza et al., 2001); and similar typologies to those defining groups with alcoholism have been proposed for PG (Lesieur, 2000; Potenza, Steinberg, McLaughlin, Rounsaville, & O'Malley, 2000). Emerging biological data, such as those identifying common genetic contributions to alcohol use and gambling disorders (Slutske et al., 2000) and common brain activity changes underlying gambling urges and cocaine cravings (Potenza et al., 2002), provide further support for a shared relationship between PG and SUDs.


Although much data from diverse sources support a close relationship between PG and SUDs, other non-mutually-exclusive proposed models for ICDs include categorizations as obsessive-compulsive spectrum (Potenza & Hollander, 2002) and affective spectrum (McElroy et al., 1996) disorders. The range of medication classes (serotonin reuptake inhibitors [SRIs], mood stabilizers, opioid antagonists) investigated in the treatment of ICDs reflects the different categorizations.

Conceptualization of ICDs within an obsessive-compulsive spectrum is based on common features of repetitive thoughts and behaviors (Potenza & Hollander, 2002). Although clinical aspects, such as ritualistic behaviors, are shared between obsessive-compulsive disorder (OCD) and ICDs, other aspects seem different (e.g., the ego-syntonic nature of gambling in PG and the ego-dystonic nature of compulsions in OCD). Although some evidence support high rates of co-occurring OCD and ICDs (McElroy, Hudson, Pope, Keck, & Aizley, 1992), multiple studies do not report an association (Grant & Kim, 2001, 2002a; Potenza et al., 2002). Personality features of individuals with ICDs (impulsive, reward and sensation seeking) differ from those with OCD (harm avoidant) (Kim & Grant, 2001). Biological differences also exist; for example, whereas increased activity in corticobasal ganglionic-thalamic circuitry has been described during symptom provocation studies of OCD, relatively decreased activity in these brain regions was observed in cue elicitation studies in PG (Potenza et al., 2003). Family history and large-scale epidemiological studies have also not demonstrated associations between PG and OCD (Potenza et al., 2002). Thus, there is less evidence linking PG to OCD than to SUDs.

The association of ICDs with mood disorders has led to their grouping as an affective spectrum disorder (McElroy et al., 1996). Many people with ICDs report that the pleasurable yet problematic behaviors alleviate negative emotional states. Because the behaviors are risky and self-destructive, the question has been raised whether ICDs reflect subclinical mania or cyclothymia. The elevated rates of co-occurrence between ICDs and depression, and bipolar disorder support their inclusion within an affective spectrum, as do early reports of treatment response to SRIs, mood stabilizers, and electroconvulsive therapy (McElroy, Hudson, Pope, Keck, &White, 1991; McElroy et al., 1996). However, as has been suggested with SUDs, depression in ICDs may be distinct from primary or uncomplicated depression; for example, depression in ICDs may represent a response to shame and embarrassment (Grant & Kim, 2002a). In addition, rates of co-occurrence of ICDs and bipolar disorder may not be as high as initially thought (Grant & Kim, 2001, 2002a), and the response to SRIs not as robust as initially anticipated (McElroy et al., 1991). Nonetheless, brain imaging studies have found common regional brain activity differences distinguishing bipolar subjects from controls, and PG subjects from controls, during a cognitive task involving attention and response inhibition (Potenza et al., 2003). For these reasons, the relationship between ICDs and mood disorders requires clarification, particularly because appropriate classification has implications for treatment development.


Arguably the best data on the prevalence of ICDs exist for PG. A recent metaanalysis of 120 published studies and a national prevalence study estimate that the lifetime prevalence of serious gambling (meeting DSM criteria for PG) among adults ranges from 0.9 to 1.6% (National Opinion Research Center, 1999; Shaffer, Hall, Vander Bilt, 1999), with past-year rates for adults ranging from 0.6 to 1.1% (National Opinion Research Center, 1999; Shaffer & Hall, 1996).

Rates of problem gambling, a less severe form of disordered gambling than PG, not presently defined in the DSM, have been estimated at an additional 35% of the general adult population. As with SUDs, higher rates of problem gambling and PG have been reported in males, particularly during adolescence and young adulthood.

Although the precise prevalence of kleptomania remains unknown, a preliminary estimate of 0.6% has been reported (Goldman, 1991). Furthermore, there is emerging evidence that kleptomania may be more common than initially throught (Grant, Potenza, Levine, & Kim, in press). Estimates of the lifetime prevalence of compulsive buying have ranged from 1.1 to 5.9% (Christenson et al., 1994; McElroy, Keck, Pope, Smith, & Strakowski, 1994).


A growing body of literature implicates multiple neurotransmitter systems (e.g., serotonergic, dopaminergic, noradrenergic, opioidergic), as well as familial and inherited factors, in the pathophysiology of ICDs (Potenza & Hollander, 2002).

The most consistent findings involve the serotonin (5-hydroxyindole or 5-HT) system, believed to underlie impulse control (Potenza & Hollander, 2002). Evidence for serotonergic involvement in ICDs comes in part from studies of platelet monoamine oxidase B (MAO-B) activity, which correlates with cerebrospinal fluid (CSF) levels of 5-hydroxyindoleacetic acid (5-HIAA, a metabolite of 5-HT) and is considered a peripheral marker of 5-HT function (Potenza & Hollander, 2002). Low CSF 5-HIAA levels have been found to correlate with high levels of impulsivity and sensation seeking (Potenza & Hollander, 2002). Pharmacological challenge studies that measure hormonal response after administration of serotonergic drugs also provide evidence for se-rotonergic dysfunction in ICDs (Potenza & Hollander, 2002).

Dopaminergic systems influencing rewarding and reinforcing behaviors have also been implicated in ICDs. "Reward deficiency syndrome," a hypothesized hypodopaminergic state involving multiple genes and environmental stimuli that puts an individual at high risk for multiple addictive, impulsive, and compulsive behaviors, is one proposed mechanism (Blum et al., 2000). Alterations in dopaminergic pathways have been proposed as underlying the seeking of rewards (gambling, drugs) that trigger the release of dopamine and produce feelings of pleasure (Blum et al., 2000).

Noradrenergic systems, believed to underlie arousal, excitement, and sensation seeking, have been implicated in impulsive behaviors (Potenza & Hollander, 2002). Anticipation of or engagement in seemingly impulsive behaviors can activate the autonomic nervous system. Correlations between scores on the extroversion scale of the Eysenck Personality Questionnaire and markers of noradrenergic functioning (e.g., CSF or plasma 3-methoxy-4-hydroxyphenyl-glycol [MHPG] levels, urinary outputs of norepinephrine and its major metabolites) suggest a disturbance in central noradrenergic system functioning in PG (Roy, De Jong, & Linnoila, 1989).

The mu opioid system is believed to underlie urge regulation through the processing of reward, pleasure, and pain, at least in part via modulation of dopamine neurons in mesolimbic pathway through gamma-aminobutyric acid (GABA) interneurons (Potenza & Hollander, 2002). Opioidergic involvement in ICDs comes from studies of naltrexone, a mu opioid receptor antagonist with efficacy in reducing the urges in ICDs (Grant & Kim, 2002b; Kim, Grant, Adson, & Shin, 2001).

PATHOLOGICAL GAMBLING Clinical Characteristics

PG shares many features with SUDS. Gambling usually begins in childhood or adolescence, with males tending to start at an earlier age (Chambers & Potenza, 2003; Grant & Kim, 2001). Higher rates of PG are observed in men, with a telescoping phenomenon observed in females (Potenza, Steinberg, et al., 2001). PG has been described as a chronic, relapsing condition (Potenza, Kosten, & Rounsaville, 2001). High rates of PG in adolescents and young adults suggest a similar natural history to that observed with SUDs (Chambers & Potenza, 2003).

Other gender-related differences in PG have been described. Female as compared with male pathological gamblers tend to have problems with non-strategic forms of gambling, such as slot machines and bingo, whereas men are more likely than women to have problems with strategic forms, such as sports and card gambling (Potenza, Steinberg, et al., 2001). As is the case of SUDS and specific substances, the extent to which problems with specific forms of gambling might relate to prevention and treatment efforts requires further investigation. Both female and male gamblers report that advertisements are a common trigger of their urges to gamble, although females are more likely to report that feeling bored or lonely may also trigger their urges to gambling (Grant & Kim, 2001; Ladd & Petry, 2002).

As with SUDs, financial and marital problems are common (Grant & Kim, 2001) and often include illegal behaviors, such as stealing, embezzlement, and writing bad checks (Grant & Kim, 2001; Potenza et al., 2000). Cognitive features have also been reported as common between PG and SUDs; for example, both groups have been found to have high rates of temporal discounting of rewards and to perform disadvantageously on decision-making tasks (Bechara, 2003).

Co-Occurring Disorders

Studies consistently find that patients with PG have high rates of lifetime mood (60-76%), anxiety (16-40%), and personality (87%) disorders, particularly antisocial personality disorder (Black & Moyer, 1998; Crockford & el-Guebaly, 1998). Elevated rates of CB, compulsive sexual behavior, and intermittent explosive disorder have also been found (Black & Moyer, 1998).

High rates of co-occurrence have been reported for SUDs (including nicotine dependence) and PG, with the highest odds ratios generally observed between gambling and alcohol use disorders (Cunningham-Williams, Cottier, Compton, & Spitznagel, 1998; Welte, Barnes, Wieczorek, Tidwell, & Parker, 2001). A Canadian epidemiological survey estimated that the relative risk for an alcohol use disorder is increased 3.8-fold when disordered gambling is present (Grant, Kushner, & Kim, 2002), and odds ratios ranging from 3.3 to 23.1 have been reported between PG and alcohol abuse/dependence in U.S. population-based studies (Cunningham-Williams et al., 1998; Welte et al., 2001).

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