The Connection between Gambling and Addiction
In America today, we have to deal with the reality that certain lawful practices can be harmful to the population. Historically, prohibitions against casinos and alcohol simply have not worked. Gambling, like alcohol consumption, is big business in America. Each year, it is estimated that gambling contributes $240 billion to the US economy and keeps more than 700,000 people in jobs. Across the world, winnings from gambling in 2015 were estimated to be around $400 billion, with one-third of that amount coming from casinos.
Since gambling isn’t likely going to be delegalized, it is incumbent upon each person in America to exercise a healthy level of self-control vis-à-vis legal activities that are addiction-forming. However, it’s clear that some individuals will develop a compulsive relationship with legal activities, such as gambling or drinking alcohol.
Prevalence of Gambling Issues
According to research, approximately 0.2-5.3 percent of adults in the world have a gambling disorder. In the US, different research studies suggest that approximately 2-3 percent of the population experience problem gambling while about 1 percent have a gambling disorder.
Gambling is a popular American pastime. Approximately 86 percent of Americans have gambled at least once in their lifetime, and about 60 percent of Americans gamble at least once in any given year. Despite the need for treatment for problem gambling and gambling disorder, services lag. For instance, in 2009, $17 billion in public funds was invested in the treatment of substance use disorders, which was 281 times more than the amount invested in gambling disorder treatment ($60.6 million). The lower public investment could owe, in part, to much of the silence surrounding gambling disorder. Even though public funding is not at the desired level, treatment is also available from private and nonprofit organizations.
An Official Disorder
A discussion of gambling disorder requires proper contextualization. The Diagnostic and Statistical Manual of Mental Disorders (DSM), a publication of the American Psychiatric Association, serves as a clinical handbook for mental health professionals. The DSM, currently in its fifth edition, categorizes all recognized mental health disorders. If the DSM does not expressly list a mental health disorder, then it is unlikely clinicians will diagnose it, and insurance companies will likely not cover its treatment. In this way, the DSM is one of the most powerful texts in all of medicine. It’s a good thing, therefore, that the DSM is not wooden. Each edition tends to expand on the last, especially in the area of recognizing different addictions.
Under the rubric of Addictive Disorders in the DSM-5, gambling disorder is the only recognized behavioral disorder. (Note: Some literature refers to gambling as a process addiction whereas the DSM uses the term behavioral disorder.) The fourth edition of the DSM included pathological gambling but did not list it in the addictive disorders chapter. Rather, that edition listed pathological gambling in the impulse-control disorder section. This relocation reflects that, from a clinical standpoint, gambling addiction presents in a similar way to substance addiction. The overlapping elements of substance use disorder and gambling disorder include:
- Their similar impacts on the brain
- The way the disorder is expressed emotionally, psychologically, and physically (for example, demonstrative behaviors, such as getting into a financial quandary to facilitate the addiction)
- Comorbidity (i.e., the co-occurrence of addictions, such as gambling disorder and depressive disorder)
- Similar treatments often used for both disorders
Technology seems to be outpacing every pocket of society, including the medical sector. The recognition of gambling disorder in the DSM begs a question: If a person gambles online, is that a gaming addiction or a gambling disorder? The DSM-5 includes internet gaming disorder in Section III, an area of the manual that is reserved for conditions that require further research.
It appears that the DSM-5 has not specifically defined the types of games that can be involved in an online gaming addiction. But researchers have noted that some individuals who play games online become so obsessive that their day-to-day functioning becomes impaired, and they may experience withdrawal when separated from gaming. As CNN reports, a man in Taiwan died as a result of cardiac failure while on a three-day online gaming binge at an internet café; he passed away at the café.
As research in the area of online gaming continues, individuals who gamble online may emerge as a group that is clinically distinct from, but related to, in-person gamblers and online gamers.
Clinical Features of Gambling Disorder
It can be difficult for a person to self-diagnose a gambling disorder, especially if it is in the mild or moderate range, or so severe that the person has lost the ability to actually gauge the severity of the gambling behavior. Also, people who gamble may defend the practice with a statement like, “How can I have a gambling disorder if gambling is legal?” From a clinical standpoint, however, there are certain symptoms that, if present, support a diagnosis of gambling disorder.
The DSM, as to be expected, provides a list of nine symptoms that can be involved. The presence of 4-5 criteria means that the patient has a mild gambling disorder, 6-7 means it’s moderate, and 8-9 means it’s severe. There is no required combination of symptoms needed to reach a diagnosis, but each should be recurrent and persistent over a 12-month period. The following is a sample of five symptoms:
- Evidence of tolerance: In order to achieve the familiar level of pleasure associated with gambling, the individual has to increase the associated risks (e.g., spend more money and possibly gamble for longer periods of time).
- Loss of balance vis-à-vis gambling: The individual recognizes the negative consequences of gambling (e.g., financial loss, relationships in distress, or diminished work performance) but continues to gamble.
- A mental preoccupation with gambling: Thoughts of gambling are persistent and disrupt other activities, such as working and meeting family obligations (e.g., cleaning the house, picking up kids from school, going to family gatherings, etc.).
- Lying: In order to protect and continue gambling, the individual tells lies to family, friends, and/or colleagues.
- Signs of withdrawal: When removed for any appreciable period of time from gambling (e.g., during a vacation), the person shows psychological signs of withdrawal, including but not limited to restlessness or irritability.
The symptoms of gambling can be confused with a manic episode. A manic episode is not a disorder in and of itself but rather a feature of certain mental health disorders, including bipolar disorder. As an article published by Psych Central discusses, a person who is having a manic episode typically has symptoms for at least a week. The symptoms experienced can vary and may include excessive talking, agitated limbs/psychomotor dysfunction, and/or feelings of grandiosity.
In addition, the person may be uncharacteristically reckless. For example, a person may excessively shop, engage in especially bad investments, or gamble a lot. A mental health clinician can accurately assess a person’s symptoms, make the proper diagnosis, and create the appropriate treatment plan.
Substance Abuse and Gambling: Similarities in the Brain
An article published in Scientific American looks closely at how gambling works in the brain. As recently as a decade ago, a therapist would usually not have associated gambling with addiction. Gambling, as the DSM-IV reflects, was seen as a compulsive behavior but was not considered to operate in the brain in a way similar to drugs of abuse. That conceptualization saw gambling mainly as an activity to calm anxiety.
Today, the connection between gambling and addiction is accepted as a matter of course. Now that gambling has been framed in terms of an addiction, this activity is no longer thought to quell anxiousness but rather to induce pleasure. The medical and mental health communities now see gambling as a way some people experience a high, similar to how people seek a euphoric experience through drug use.
Research supports that gambling and drug use impact the reward system of the brain in similar ways. Speaking broadly here, dopamine is a main player in the brain’s reward system and responsible in part for the pleasure people feel when they engage in certain behaviors. From an evolutionary standpoint, the reward system’s utility lies in helping to keep the species alive; activities such as eating and procreative act cause dopamine to release, which makes people return to these activities and thus sustain and perpetuate life. But drugs and risky behaviors like gambling can hijack the reward system, so to speak. Even though nature didn’t anticipate drug abuse and gambling, and these are not life-affirming behaviors, the brain still rewards these behaviors with dopamine release.
But there’s one important difference between natural activities, like eating, and unnatural activities, like taking drugs: The dopamine that is released when a person uses drugs or gambles is typically far greater than the amount that enters the reward system when, for example, a person eats (in most cases). Some research suggests that certain individuals develop a behavioral addiction or substance addiction because of deficiencies in the brain’s reward system in the first place.
There is yet another important dimension to the brain vis-à-vis addictive behaviors. The connection between the brain’s reward system and the prefrontal cortex weakens when there is continually an excessive amount of dopamine in the brain. The weakening of the prefrontal cortex is linked to diminished impulse control. In short, a brain that is addicted to drugs or gambling gets rewired to make engaging in those activities even easier. The brain can go from an engine of survival to an engine of destruction.
Co-occurrence of Gambling Disorder and Other Disorders
At present, the field of addiction science postulates that mental health disorders are separate diagnosable conditions. However, some researchers theorize that individuals are actually addicted to a process and not any one behavior or drug of abuse. This means that a person will substitute one high-inducing drug or behavior for another. Whether an individual has an addictive disorder related to one or more things, or a process disorder amenable to substitutions, some individuals may have a co-occurring gambling disorder and a substance use disorder. According to various research, 10-20 percent of individuals with a substance abuse disorder also have a significant problem with gambling.
Dr. Flora Matheson, a researcher for St. Michael’s Hospital (Canada), conducted an extensive review of existing research literature pertaining to people with substance use and gambling problems. Dr. Matheson’s findings were published in 2013 in the online publication ISRN Addiction. Dr. Matheson made numerous deductions from the review, including the following:
- There is a high correlation between substance abuse and problematic gambling.
- Individuals who face both substance abuse and gambling disorder can be less responsive to treatment than individuals who only have a gambling disorder.
- It may be possible that substance abuse and gambling disorder are really one disorder, related to an underlying impulsivity; however, again, the DSM-5 moved away from characterizing gambling disorder as an impulse-control disorder.
- In many instances, both the substance use disorder and gambling disorder begin in the teen or young adult years and may stem from common influences, such as depression, delinquency, and/or sexual abuse.
- One study noted that individuals who experience substance abuse and a gambling disorder are more likely to have attempted suicide and more likely to report having a history of sexual compulsivity.
- One study found that people who engage in substance abuse and have a gambling disorder tend to also partake in risky sexual behaviors.
- One study noted that gambling may potentially reinforce drug use, or as treatment for drug use occurs, the gambling may increase as a substitution for a drug high.
- One study observed that people with both disorders were more likely to use drugs before or during gambling to potentiate the high of winning or cope with the pain of losing.
The findings of these various studies highlight the complexity of symptoms that can be involved in one diagnosis, let alone a dual diagnosis. When a person enters rehab, the opening consultation (often called intake) typically occurs right away. At this point, medical assessments can be made (potentially based on blood work and medical records) and a comprehensive interview is conducted. Intake gets the ball rolling toward a diagnosis, which in turn guides the addiction team in the creation of treatment plan tailored to the individual client’s specific needs.
If it is determined that a person has a dual diagnosis, and the rehab center provides treatment that can accommodate a dual diagnosis, then treatment can be provided under one roof. If a dual diagnosis is made and the treatment center cannot accommodate it, a referral will typically be made. In some instances, a rehab center can coordinate with a local psychiatrist to provide care in tandem. While treatment plan specifics vary from person to person and rehab to rehab, there is a universal consensus in the addiction treatment community that co-occurring disorders must be treated simultaneously.
Cognitive Behavioral Therapy for Gambling Disorder
Treatment for addiction is supported by two main pillars: medications and therapy. At present, the US Food and Drug Administration has not approved any medications for the treatment of an addiction to gambling. Individuals with a gambling disorder have been shown to respond to therapy; as mentioned, often the same methods of therapy that are used to treat substance use disorders are effective to treat gambling disorder.
Therapy for gambling disorder occurs after a person has undergone detox (i.e., a number of days of abstinence from gambling). Cognitive Behavioral Therapy (CBT) has been shown to be an effective treatment for individuals in recovery from a gambling disorder.
CBT techniques are designed to teach people in recovery to have an awareness of their addictive behaviors and therefore to be able to intercept and change them. CBT sessions often occur during a stay at a rehab center and as part of aftercare after structured treatment ends. The following are some of the approaches that CBT can take to help a person with a gambling disorder:
- Revisit a gambling episode and break it down into its component parts: the trigger, the feelings around the gambling, and the evaluation of the ensuing consequences, both negative and positive (i.e., conducting functional analysis).
- Brainstorm ways to handle gambling cravings or triggers that do not involve gambling. Time is spent in sessions coming up with alternatives, such as calling a friend or sponsor, taking a walk, or engaging in a pleasurable but healthy activity.
- Discuss interpersonal problems and other stressors that can build up to act as a trigger to gamble. The therapist can work with the recovering client to develop ways to handle such difficulties in a way that maximizes self-worth and the recovering person’s commitment to the recovery process.
- Address irrational thoughts that can undermine the recovery process. For instance, some individuals may irrationally think that the only way to have fun is to gamble.
- Do homework assignments that will help the recovering individual to deepen insights and lessons learned while in sessions.
- Discuss the future with reference to what triggers could potentially arise and strategies to handle them.
CBT not only focuses on gambling behavior, but also helps recovering individuals to develop the life skills necessary to build a new, addiction-free life.
To prevent a relapse, a person can work to avoid triggers but is also best advised to develop interests in areas that are not conducive to gambling. To provide a metaphor, people who have back pain may focus on treating the affected back muscles. But the more effective approach is to work on healing those muscles while building up core strength in the stomach and in other muscle areas. People in recovery who engage in healthy activities and have a network of sober individuals can fortify themselves against relapse while at the same time enjoying life.
Like substance abuse, gambling abuse can strip away the most important layers of a person’s life – family, friends, health, and career. But a gambling disorder is a treatable condition. The world is replete with stories of people who have overcome a gambling disorder. Treatment for a gambling disorder can provide a person with benefits: the ability to recognize a serious problem, address it, and in the process acquire a canon of knowledge and various tools for healthy living.
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 “Diagnostic and Statistical Manual of Mental Disorders (DSM).” (n.d.). American Psychiatric Association. Accessed May 22, 2016.
 “Substance-Related and Addictive Disorders.” (2013). American Psychiatric Association. Accessed May 22, 2016.
 “Internet Gaming Addiction.” (May 2013). American Psychiatric Association. Accessed May 22, 2016.
 Hunt, K. (January 19, 2015). “Man dies in Taiwan after 3-day online gaming binge.” CNN. Accessed May 22, 2016.
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 “Links made between problem gambling and substance abuse, and lack of treatment options.” (September 4, 2013). Science Daily. Accessed May 22, 2016.
 Okuda, M., et al. (December 2009). “Cognitive Behavioral Therapy for Pathological Gambling: Cultural Considerations.” The American Journal of Psychiatry. Accessed May 22, 2016.
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