Pathological Gambling- Is it an addiction? Part II

Michael Campos, Ph.D.

This is part II in Michael’s series on pathological gambling (click the preceding for part I):

The risk factors for pathological gambling

Pathological gambing (or gambling addiction)There are a number of factors that are important in pathological gambling including types and number of games played, alcohol use, and socio-demographic factors. Some research suggests that casino gambling, pull tabs, card playing outside a casino, bingo, and sports betting are associated with increased risk for gambling problems. In addition, the number of different types of games played is associated with gambling problems such that the more different types of games a person plays, the greater the risk for gambling problems. Alcohol abuse/dependence is associated with increased risk for gambling problems as well. Finally, socio-demographic factors (e.g., low socio-economic status, minority ethnicity) are associated with gambling problems even after controlling for gambling behavior.

Pathological gambling’s impact on health

Pathological gambling disorder is associated with a number of other mental and physical health problems. Major depression and anxiety are more common among pathological gamblers relative to general population samples. Substance use disorders including alcohol-, drug-, and tobacco-related disorders are also more common among individuals with pathological gambling. Medical conditions such as hypertension, chronic fatigue, heart disease, and obesity often exist among individuals with pathological gambling.

How to tell if you have a gambling problem

There are a number of screening tests that can be used to determine if you may have a problem with gambling. One set of three questions known as the NODS CLiP was developed as a quick screen to determine the need for more formal assessment. The NODS CLiP items include:

1. Have there ever been periods lasting 2 weeks or longer when you spent a lot of time thinking about your gambling experiences or planning out future gambling ventures or bets?

2. Have you ever tried to stop, cut down, or control your gambling?

3. Have you ever lied to family members, friends, or others about how much you gamble or how much money you lost on gambling?

If an individual gives a positive response (yes) to any of these items, it suggests the need for further assessment to determine whether or not they are a problem or pathological gambler.

The effectiveness of treatment for pathological gambling

The literature on the treatment of gambling problems is relatively new and many issues make it difficult to determine the effectiveness of specific components of treatment; however, data suggest that, among those who complete treatment, significant reductions in gambling behavior and gambling-related problems occur. Often times, treatment for gambling problems involves addressing co-occurring disorders such as mood, anxiety, and substance use disorders. Treating co-occurring disorders is important because these disorders may sustain gambling behavior. Family involvement in treatment is recommended in order to address the relationship problems that often occur among families with a member who has a gambling problem.

Pathological gambling may be best conceptualized as a chronic disease with a relapsing remitting course. The majority of individuals don’t seek treatment – the estimates are that only 10% of individuals do seek treatment for their gambling problems. Many times individuals with gambling problems seek treatment for other psychological or behavioral problems and gambling problems are not discovered until much later on.

To date, the most empirical evidence has been collected on the treatment of gambling problems using cognitive behavioral approaches in both individual and group formats; however, psychodynamic and purely behavioral approaches like systematic desensitization have also been employed. In addition Gambler’s Anonymous is available, it has been in existence since 1957 and is a self-help fellowship dedicated to aiding individuals to stop gambling and stay stopped.

Getting help for gambling problems?

There are a number of sources for help with gambling problems including Gambler’s Anonymous, mental health treatment providers, and addiction treatment providers.

Gamblers Anonymous (GA) is the second oldest of the twelve-step programs. It was founded in 1957 by two dually-addicted, alcoholic gamblers who were already attending AA but found themselves unable to abstain from gambling. They began meeting regularly and adapted the structure and organization of AA, as well as its literature, to compulsive gambling. Today the organization has an estimated 35,000 members and meetings in forty-nine countries.

In addition to GA, there are a number of state-funded treatment programs for gambling problems. For example, in the state of California, the Office of Problem Gambling of the California Department of Alcohol and Drug Programs offers state-funded residential, intensive outpatient, outpatient, and telephone-based brief interventions for gambling problems to individuals with gambling problems and their family members.

19 Replies to “Pathological Gambling- Is it an addiction? Part II”

  1. Michael

    “Best conceptualized as a chronic disease” – with all due respect, that is absolute nonesense! What definition of ‘disease’ are you using? What is the evidence that gambling induces brain or body deficits to the extent that action is no longer under the individual’s willful control? This is what would be needed to prove the existence of a disease. This just smacks of “well if it looks like a disease and it sounds like a disease it must be a disease”. Here is just another attempt to medicalize a behaviour.

    I asked the question in response to part 1: how is ‘loss of control’ measured in pathalogical gamblers. As you didnt answer, I pose the question again.

    I am not denying the negative consequences of gambling; I myself answered ‘yes’ to each of the three questions above. But if we’re talking about causation and ‘loss of control’, you need to describe four things:

    1) The proportion of gamblers with a certain brain deficit
    2) The proportion of gamblers without this brain deficit
    3) The proportion of the genreal population with this deficit
    4) The proportion of the general population without this deficit.

    Until then, please dont invoke the word ‘disease’ when describing a behaviour. At most, you are justified in saying ‘disease-like’, which suggests it is a hypothesis being tested. Calling it a disease says to the reader that this has been proven. We both know it hasnt.

    1. Let’s not tell people what they can or can’t do Christopher. Also, let’s not be disrespectuful even with “all due respect” as a precursor. Trust me when I tell you that scores of people would call your inability to distinguish between complete loss of control and probabilistic control loss, or the idea that brain function (like ADHD associated issues for instance) can bring about reduced behavioral control, nonsense as well. We can make this discussion very unpleasant if we let our opinions get in the way of civil debate.

  2. Where did I tell anyone what they can or cannot do?. Ive re-read my post and cant ee what youre referring to. I also cant see ant instances of disrespect or opinion. Calling a statement ‘nonsense’ isnt disrespectuful, just as calling a statement ‘sensible’ isnt respectful. Moving on…

    I have only asked Dr Campos a question: what is the evidence that gambling is a chronic disease. I assume that because he is saying it is then will be able to cite evidence that it is. I hope he will answer. Am I wrong to ask this question?

    I assume that Dr Campos has evidence that gambling causes reduced brain function, that this reduced function compels further gambling, and that he knows the proportions of the general population with this reduced function who do and do not gamble, and the proportions of the general population who do not have this reduced function and who do and do not gamble. I understand this to be the procedure by which diseases are typically defined, but personally, I am ignorant of this evidence so I hope Dr Campos will describe at least some of it to me.

    For the hypothesis “gambling reduces brain function which causes further gambling” to be falsified, one must answer these questions (unless one doesnt want to falsify it, of course).

    I would continue to ask Dr Campos to refrain from calling gambling a disease until he can answer these questions to himself. Otherwise, Ill just pick a behaviour at random and start calling it a disease. Maybe doing work at university – I think about it all the time and I plan work in advance, I have tried to control, stop or cut down on how much I work, and I have lied to friends and family about how much I work. Maybe I have a disease. Maybe its not that I choose to not stop working; maybe, as a result of years of work, my ability to control how much I work has been considerably impaired. The next time my girlfriend moans about me coming home late from work Ill say “Honey, I literally couldnt stop myself from working”.

  3. Hello Dr. Campos,

    Great summary and review of a difficult topic. “Soft” or behavioral addictions have many features in common with substance dependence but have this far eluded concrete characterization.

    As with all of the addictions there seems to be (and you say) no bright line that is crossed into disease-land. Our semantics are clunky when we describe a chronic problem versus an intermittent and evanescent clinical course. To call any of these problems a disease (including chemical dependency) is fine to a first approximation but does not really get us any further down the road.

    Better than saying demonically possessed or mentally ill, I suppose, but a lot of groupthink around getting some respect for the complexity of addiction. Disease or not disease is not the question.

    In point of fact, risk-taking behavior as such must serve a specific purpose for the human animal. Without risks we would have starved and been eaten thousands of years ago as a species. We have evolved by and for the purpose of taking chances. It is quite possible that “pathological” gambling in another social milieu isn’t all that pathological.

    1. Some great points Dr. Giles. I don’t personally work with gambling addiction but rather with substance abuse; do you think that there are instances of gambling, or other behaviors, that perhaps transcend the social milieu limitation or would any location along the continuum of behavior be equally likely to be perceived as “normal” under different environmental conditions?

  4. Dr Giles

    What an excellent sentence – “quite possible that “pathological” gambling in another social milieu isn’t all that pathological”. Beautifully put. Your description of addiction is nuanced and your restraint to label addiction as “this” or “that” is admirable. I wish others would also take a step back once in a while rather than be so keen to pin their colours to the mast.

    On the point you allude to about ‘is a behaviour universally abnormal or just abnormal in the context?’, it saddens me that so many people call themselves gambling ‘addicts’ despite never having had a single neurobiological assessment. Imagine describing symptoms to your doctor and your doctor says, “yep you’ve got cancer, we’ll start you on chemotherapy tomorrow”. You’d likely say “Em, doc, dont you want to take a blood sample, a tissue sample, anything?” And you are right; people survey and take risks all the time. That bad things happen to us as a result of taking these risks does not mean that the decision to take them was pathalogical.

    But people dont seem to see the same need for physical tests be conducted to be diagnosed as an alcoholic or pathalogical gambler. I suspect many are just happy to finally put a name to what they’ve been going through, irrespective of whether or not it is accurate. People who have problems with their gambling just want an answer to what their problem is, and addiction/pathology/disease are convenient answers.

    I look forward to more of your contributions Dr Giles.

    1. I too agree that Dr. Giles comment was very worthwhile, not the least due to its restraint and respectful addition to the conversation. The notion that mental health disorders can be assessed using biological testing is a worthwhile one although to think that it would have to depend on those [tests] seems to suggest that all mental health disorders have a biological substrate. I personally would likely agree with this, although establishing norms is going to be the true challenge. Hopefully one day we will be able to align individuals along some true continuum of functioning within different domain based on such objective measures.
      In my circles, the biological, including genetic, estimates of the contribution to addiction itself are normally estimated around 40%-60% depending on substance and more. That leaves quite a bit of the equation up to environmental contributions and more. Indeed, as I’d pointed our in a recent talk here in LA, I could care less about the “disease” label. I think it did some good initial in terms of removing some of the judgment, but clinical labels are there for the benefit of treatment, not as an end.
      Risk-taking certainly played, and has been acknowledged to play, a significant role in allowing for advancement of species. The way I see it, some people take risk-taking to a point that is harmful to their existence, and regardless of what term you apply to their behavior, many of them need help to realign their lives. While there is little doubt that social contexts affect perception, I think it is safe to say that while some “pathological” behavior of any kind is objectively harmful to the individual who is engaging in it.

    2. “some people take risk-taking to a point that is harmful to their existence, and regardless of what term you apply to their behavior, many of them need help to realign their lives”… like boxers, rally drivers, mountain climbers, tightrope walkers and lets face it, the military!

      These people take risks which threaten their existence. No one makes them do these things. Do these people need to realign their lives? If soldiers die, does that mean that their decision to fight was ‘pathalogical’?

      Im not having a pop at anyone here, my question is not where do we draw the line between normal and abnormal behaviour, but instead should a line be drawn? To say that people need help to realign their lives suggests to me that there is a right and wrong way of living and that corrupted biological systems are the cause of the wrong ways of living. Thats a hell of a suggestion!

      Drug use and gambling often lead to negative consequences, but does this mean these activities are abnormal or pathalogical? I dont think so. Just as soldiers fighting a lost cause or mountain climbers trekking up Everest, drug use doesnt make sense to a lot of us. But not being normal to us doesnt qualify them as abnormal in the grand scheme.

      Again, not having a pop at anyone, just my two cents.

      1. I would suggest that if there are boxers, rally drivers, mountain climbers, tightrope walkers, and soldiers who have repeatedly faced negative consequences due to their activities, have had to give up other things in their life they care about, and find themselves needing continuously greater and greater exposure to more and more risky behaviors and/or have repeatedly tried to stop and found they fail that they might consider their behavior unhealthy. I understand that this stand could be a biased one and I would be willing to consider if evidence to the contrary could be shown to me.

        The question isn’t only o risking lives, were that the only criteria then I would suggest that addiction would be defined very differently. All of the above criteria are part of the definition and until we change the definition they should all be considered. I definitely agree that the notion of should we place a right or wrong label on these behavior is correct, but often times these individuals are the ones themselves asking for help, in which case I think the question of a label is moot – they want to stop but find themselves unable, which is where addiction treatment comes in. Not everyone is referred into treatment.

  5. Thanks Dr Jaffe

    I would think that these criteria describe most soldiers – they get shot at but get up the next morning and go out to get shot at again, they given up things they care about in life (wives, husbands, children) to go get shot at, and they have considered leaving the military but feel compelled by a sense of duty to go on second and third tours despite their loved ones asking them to leave the military or expressing concern about what they are doing. But we dont call them “battle addicts”, we call them “heroes”. Are these people addicted to gambling with their lives in similar ways to those who gamble with their livelihoods in casinos and online?

    Its an interesting example. I would also think that the same diagnostic criteria you cite would apply to someone who goes on hunger strike for political reasons, no?

    Maybe the topic of a future piece on A3? Addiction to morality?

  6. Hi All.

    First of all, thank you for taking the time to read and think about the write up on pathological gambling.

    I think the issue of what behavior is functional in a given environment is an interesting one. I accept the idea that risk-taking is part of human nature. I think that where risk-taking becomes problematic is when consequences and environmental feedback are not taken into account in determining future behavior.

    I think this lack of regulation of behavior based on environmental feedback is one factor at the core of addiction and I think this is present in pathological gambling. This, however, is my opinion.

    There may be different reasons why environmental feedback and consequences are not taken into account, but the end result is that, for those with gambling disorders, in the current social environment in which they find themselves, their gambling behavior is problematic.

  7. Hi Michael,

    If the disorder is defined by persisiting with the behaviour in spite of negative consequences, can I ask: What if the gambler wins? What if he repeatedly makes a fortune? The consequence is different but the behaviour is the same, so, in your view, is successful gambling also a disorder?

    Thanks

    1. Christopher, given the first part of your comment (“persisiting with the behaviour in spite of negative consequences”) I fail to see where the negative consequences are in the scenario you present?

  8. Thats kind of the point. Imagine two guys bet their monthly food budget on a horse for three months in a row. One guy wins each time, one guy loses each time. They are both doing the exact same behaviour with the exception that one guy chooses horse A and the other chooses horse B. The guy who loses his food budget three months in a row would be said to be showing addictive behaviour whereas the winner’s behaviour is perfectly rationale – he is winning so why not keep going. The issue isnt addiction, the issue is skill or luck! If you think about it, the difference between the winner who we call normal and the loser whom we say is behaving pathalogically could come down to a horse being a millisecond slower or faster or a horse that trips and falls! That is absurd.

    The consequences of a behaviour say nothing about why the behaviour was done in the first place, and surely we are seeking to know what is causing disordered behaviour. The example above shows how inferring the abnormality of behaviour by observing its consequences is absurd; we’re talking about a millisecond separating a millionaire from a gambling addict. If this is the case, the loser doesnt need treatment, he needs to pick more winning horses!

    1. ‘The consequences of a behaviour say nothing about why the behaviour was done in the first place, and surely we are seeking to know what is causing disordered behaviour”

      I would have to completely disagree here – Behavior should be chosen based on its outcome and the people we are focusing on as having a problem are those who do not respond as expected to the consequences of their behavior. If behavior happened in a vacuum then this might be appropriate, but it doesn’t. You behave, things happen, and you react – that is the course of life. The difference between those two people has nothing to do with the horse but rather with their reaction to the horse’s behavior.

      As usual, you present extreme cases “we’re talking about a millisecond separating a millionaire from a gambling addict” which is a great example of an individualistic fallacy – just because you can dream up, or point out, an example that does not conform to a set of rules does not mean that the rule – that people who continue to gamble away their rent and end up in trouble because of it are pathologically gambling – isn’t true. Addiction is defined by the outcomes of the behavior not by the behavior itself.

  9. First of all, this isnt an extreme case; a millisecond, a point, a goal, an inch, this is what the majority of bets come down to. This is the rule because this is what the people I work with (problem gamblers) tell me is the rule.

    “Addiction is defined by the outcomes of behaviour, not by the behaviour itself”.

    Ok, so I pick a horse (I behave), the horse loses (things happen), and I think my next horse will win so put on another bet (I react). Chances are I would have put on this second bet regardless of whether or not the first horse had won. Just because one bet loses why should I think that the next one will also lose and so not place a bet? If you appreciate the statistical independence of two races, you realise that a previous loss cannot affect the result of another race. So I could argue that if every expert in the world says a horse is going to win and I dont bet on this horse, my decision to not bet, to not make money, is pathaological.

    Im not sticking up for gamblers here, its just unfortunate that their motives for gambling are being called pathalogical when in fact a great deal of reasoning has gone into their bets.

  10. Hi Christopher,

    Although it seems statistically possible that someone could win more than lose, it is highly improbable. The house always has an edge and if you play over time, the house will always come out ahead.

    A second thing to consider is the time and energy invested in gambling. The monetary costs are not the only costs of gambling problems. Relationships suffer, work suffers, health suffers so the money should not be the only concern.

  11. One more comment:

    It has been my experience that individuals with gambling problems report that even when they do win, they end up playing until they give back whatever money they won.

  12. its really a game of losing or winning,
    but why thus that if your in the state of winning your putting much higher bet, and if you lose it you’ll just think, i made a bad decision, why they can’t quit the game if they already win alot!?

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