The Evolution of Gambling Disorder

Gambling disorder is now listed under the category of “substance use disorder” in the DSM-5 as the first behavioral addiction (APA, 2013). In the latest edition of the manual, the connection between gambling disorder and substance use disorder (SUD) was well established, though not without some disagreement. According to Potenza, “The designation of gambling disorder is justified as an addiction because it includes the core elements of substance addictions; including continued engagement in a behavior despite adverse consequences, diminished self-control over engagement in a behavior, an appetitive urge or craving state before such engagement, and compulsive engagement” (2008).

The DSM-5 is the full circle of the medicalization of problem gambling—now the standard-bearer of psychological diagnoses says there is sufficient evidence to classify gambling disorder as a brain disorder (APA, 2013). In other words, the behavior of gambling causes changes in how the brain functions while gambling and alters the normal functioning of several neurotransmitters in a similar manner to substances. Grant and colleagues note that “Diminished control is a core defining concept of psychoactive substance dependence addiction. Gambling that becomes excessive can be similarly classified” (Grant, Potenza, Weinstein, & Gorelick, 2010).

Another factor that caused the reclassification of gambling disorder was the change in the functioning of the brain. Neurobiological processes show diminished activity in the prefrontal cortex and heightened dopamine activity in the limbic system of the brain. This means that gambling disorder is driven for reasons of excitement or escape in the limbic system, and decreased activity in the prefrontal cortex means a decreased ability to think about consequences, rational thinking, or logical thinking that guides behavior according to values and self-control. There are other factors that lead to the change in thinking about gambling disorder, but as Grant et al. expresses, “Growing evidence suggests that behavioral addictions resemble substance addictions” (Grant et al., 2010).

In the DSM-5, criteria no longer determine that people may gamble as a means of escape, but that they gamble when feeling distressed (APA, 2013). Gamblers feel some level of distress—it could be stress, depression, anxiety, or other disorders—or they are experiencing some level of ego-dystonic mood. In this case, gambling can serve as a means of correcting the mood to a more normalized state of feeling. However, in time the gambling behavior becomes a new source of ego-dystonic stress and can no longer serve the previous goal. Grant and colleagues affirm this notion, stating, “In time, continued gambling becomes less pleasurable and more of a habit or compulsion” (Grant et al., 2010). When gambling serves as a defense mechanism, it will serve the purpose of creating an ego-syntonic state or at least an escape from the pressures and stresses that life may bring. Like all defense mechanisms, they work until they do not, leaving gamblers with another set of problems and the previous list of issues that are still unresolved and/or untreated.

Gambling disorder is now listed under the category of “substance use disorder” in the DSM-5 as the first behavioral addiction (APA, 2013).

A key factor in the gambling disorder diagnosis is that it will seldom be a stand-alone diagnosis. In the era of the DSM-III, the leading co-occurring disorders were: major depressive episodes, SUD, a personality disorder, and anxiety disorders (Lesieur & Rosenthal, 1991). The National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) revealed that 73.2 percent of respondents had an alcohol use disorder, 38.1 percent had a drug use disorder, 60.4 percent had nicotine dependence, 49.6 percent had a mood disorder, 41.3 percent had an anxiety disorder, and 60.8 percent had a personality disorder (NIAAA, 2002). Another factor of concern with gambling-disordered individuals is the high rate of suicidal ideation and attempts. Different studies report suicide attempts ranging from 15 to 25 percent and suicidal ideation as high as 50 to 75 percent (Custer & Custer, 1978). Ledgerwood and Petry (2004) report several research samples ranging from 47 to 93 percent of treatment-seeking gamblers with lifetime rates of suicidal ideation and 4 to 36 percent of suicide attempts among six different studies. Besides other psychological disorders, there are many accompanying factors that lead to increases in gambling, such as gambling while using drugs or alcohol; the death of a spouse or close relative; divorce or family problems; physical illness or disability; and job loss.

It is also noted that gamblers may have multiple addictive tendencies like sex addictions, overspending, and eating disorders (Lesieur, 1988). Gambling and depression is often akin to the chicken or the egg scenario: did gambling produce the major depression or was gambling a means of relieving the depressed state? It can be safely said that both factors are true, and no matter which comes first it will be common for gamblers to experience states of depression. Lesieur stated, “Gambling-related problems create tremendous stress, which increases as the pathological gambler becomes more involved in gambling and uses options for financing it” (1979). Walker noted that “Depression is frequently associated with heavy gambling,” and that in some cases the depression preceded the gambling as a means of coping with a long-term condition (1992). In other cases, such as McCormick’s theory, gambling is associated with learned helplessness and depression—again in these cases, gambling serves as a means of dealing with a preexisting condition (McCormick & Taber, 1988).

All the research previously discussed seeks to give some explanation of how gambling disorder develops. The pathways model (Blaszczynski & Nower, 2002) begins with the idea that all people begin gambling in a manner that does not immediately lead to a diagnosis. Gamblers are behaviorally and self-conditioned to gamble more than they intended or can control. B. F. Skinner’s learning theory (1953) explains how almost anyone can participate in a behavior to the point of becoming dysfunctional. Ferentzy and Turner note that “It provided a model that would suggest that an ordinary person (e.g., nonpsychopathic) could become addicted to a drug or behavior through a combination of positive and negative reinforcement” (2013). Yet, there is always a bit of mystery as to why gambling serves as a satisfying retreat from stress or problems. According to Ferentzy and Turner, “The pathways model is a good general explanation of how pathological gambling develops or becomes more severe. However, no theory explains why gambling serves as a means or outlet for so many unresolved psychological issues” (2013). Other pathways include the factor of being emotionally vulnerable with issues such as mood disturbance, depression, and anxiety. Another pathway that can create gambling disorder is antisocial impulsivity, which includes such disorders as attention-deficit/hyperactivity disorder (ADHD) and antisocial behavior.

Despite such evidence, the destruction of finances and family relationships as well as all other dynamics of gambling are not to be minimized. One study of Gambler’s Anonymous members from 1997 reported significant financial losses: “The mean gambling loss over a ‘lifetime’ was $98,491.00, while the median loss was $45,000.00. Losses over the last twelve months of the gambling career ranged from $100 to $240,000.00” (Thompson, Gazel, & Rickman, 1997). Other studies report, “The median loss was between $50,000 and $100,000, while the mean loss was $112,400” (Thompson, 2015). The cost of problem gambling can be traced to increases in social and legal arenas, including higher rates of debt; bankruptcies; illegal activities like embezzlement; employment problems; child welfare; and the costs of treatment. Thompson and Schwer listed the total cost of each case of problem gambling to be $19,711 (2005). Thompson explained that “If America has 200 million adults, and 1.14 percent are severe or pathological gamblers, that means that these 2.28 million people are imposing costs (x 100.53) of nearly 23 billion on their fellow citizens” (2015).

References

• American Psychiatric Association (APA). (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.
• Blaszczynski, A., & Nower, L. (2002). A pathways model of problem and pathological gambling. Addiction, 97(5), 487–99.
• Custer, R. L., & Custer, L. F. (1978). Characteristics of the recovering compulsive gambler: A survey of 150 members of gamblers anonymous. Paper presented at the Fourth Annual Conference on Gambling on December 17–19, 1978 in Reno, Nevada.
• Ferentzy, P., & Turner, N. E. (2013). The history of problem gambling: Temperance, substance abuse, medicine, and metaphors. New York, NY: Springer.
• Grant, J. E, Potenza, M. N., Weinstein, A., Gorelick, D. A. (2010). Introduction to behavioral addictions. American Journal of Drug and Alcohol Abuse, 36(5), 233–41.
• Ledgerwood, D. M., & Petry, N. M. (2004). Gambling and suicidality in treatment-seeking pathological gamblers. The Journal of Nervous and Mental Disease, 192(10), 711–4.
• Lesieur, H. R. (1979). The compulsive gambler’s spiral of options and involvement. Psychiatry, 42(1), 79–87
• Lesieur, H. R. (1988). The female pathological gambler. In W. R. Eadington (Ed.), Gambling research: Proceedings of the Seventh International Conference on Gambling and Risk Taking (pp. 230–58). Reno, NV: University of Nevada.
• Lesieur, H. R., & Rosenthal, R. J. (1991). Pathological gambling: A review of the literature (prepared for the American Psychiatric Association Task Force on DSM-IV Committee on Disorders of Impulse Control not elsewhere classified). Journal of Gambling Studies, 7(1), 5–39.
• McCormick, R. A., & Taber, J. I. (1988). Attributional style in pathological gamblers in treatment. Journal of Abnormal Psychology, 97(3), 368–70.
• National Institute on Alcohol Abuse and Alcoholism (NIAAA). (2002). 2001–2002 National Epidemiologic Survey on Alcohol and Related Conditions. Rockville, MD: Author.
• Potenza, M. N. (2008). The neurobiology of pathological gambling and drug addiction: An overview and new findings. Philosophical Transactions B, 363(1507), 3181–9.
• Skinner, B. F. (1953). Science and human behavior. New York, NY: Macmillan.
• Thompson, W. N. (2015). Gambling in America: An encyclopedia of history, issues, and society (2nd ed.). Santa Barbara, CA: ABC-CLIO.
• Thompson, W. N., Gazel, R., & Rickman, D. S. (1997). Social and legal costs of compulsive gambling. Gambling Law Review, 1(1), 81–9.
• Thompson, W. N., & Schwer, R. K. (2005). Beyond the limits of recreation: Social costs of gambling in Southern Nevada. Journal of Public Budgeting, Accounting & Financial Management, 17(1), 62–93.
• Walker, M. B. (1992). Irrational thinking among slot machine players. Journal of Gambling Studies, 8(3), 245–61.

Wiley D. Harwell, DMin, LPC, CEAP, ICGC-II

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Wiley D. Harwell, DMin, LPC, CEAP, ICGC-II, is the executive director of the Oklahoma Association for Problem and Compulsive Gambling. Harwell has a doctor of ministry degree from Southern Methodist University; a master’s of divinity from Southern Seminary in Louisville, Kentucky; and a bachelor’s degree from Wayland Baptist University. In July 2012, he was elected to serve as a board member of the National Council on Problem Gambling (NCPG) and was reelected in 2015 for a total of six years.

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