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Pathological Gambling: A General Overview
Larry L. Ashley Ed.S. LCADC CPGC
a
& Karmen K. Boehlke B.A.
a
a
Department of Educational & Clinical Studies , University of Nevada Las Vegas , Las Vegas ,
NV , USA
Published online: 07 Mar 2012.
To cite this article: Larry L. Ashley Ed.S. LCADC CPGC & Karmen K. Boehlke B.A. (2012) Pathological Gambling: A General
Overview, Journal of Psychoactive Drugs, 44:1, 27-37, DOI: 10.1080/02791072.2012.662078
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Journal of Psychoactive Drugs, 44 (1), 27–37, 2012
Copyright © Taylor & Francis Group, LLC
ISSN: 0279-1072 print / 2159-9777 online
DOI: 10.1080/02791072.2012.662078
Pathological Gambling:
A General Overview
Larry L. Ashley, Ed.S. LCADC, CPGCa
& Karmen K. Boehlke, B.A.b
Abstract — Throughout the course of history, gambling has been a popular activity across most
cultures. In the United States, gambling has transitioned from early acceptance to prohibition to
widespread proliferation. For most, gambling is a relaxing and recreational activity; however, for some
individuals gambling becomes more than harmless fun. The most severe form of gambling, pathological
gambling, is recognized as a mental health disorder. Pathological gambling is currently classified
as an impulse control disorder in the DSM-IV-TR, but it shares many important features with substance
use disorders, especially in terms of diagnostic criteria, clinical course, and treatment. Consequently,
the DSM-V Task Force has suggested that pathological gambling be reclassified and included in a new
category entitled “Addiction and Related Disorders.” The category would include both substance-related
and non-substance/behavioral addictions. This article provides a general overview of some of
the available literature regarding pathological gambling and includes the presentation of a number of
relevant topics including etiology, risk factors, comorbidity, prevention, and treatment. However, as
with most complex, multifaceted, and multidimensional phenomena, more research is needed in order
to improve both prevention and treatment efforts for pathological gambling.
Keywords — behavioral addiction, compulsive gambling, pathological gambling, problem gambling,
process addiction
Chance is an intrinsic feature of life; consequently,
gambling appeals to the inherent risk-taking proclivity of
human nature. A cursory review through the archives of
gambling literature leaves little doubt that gambling and
games of chance have been popular activities for human
beings across most cultures throughout the history of
humankind (Petry 2005). Chinese gambling, for example,
can be traced back more than 4,000 years, while excavations
at Ur (2000 BC), Crete (1800 BC), Egypt (1600 BC)
The authors declare no conflicts of interest with respect to the
authorship and/or publication of this article.
aProfessor, Addictions Specialist, Director of Problem Gambling
Treatment Program, Undergraduate Coordinator, Department of
Educational & Clinical Studies, University of Nevada Las Vegas,
Las Vegas, NV.
bCandidate for M.S. in Clinical Mental Health Counseling,
Department of Educational & Clinical Studies, University of Nevada Las
Vegas, Las Vegas, NV.
Please address correspondence to Larry L. Ashley, Department of
Educational & Clinical Studies, University of Nevada Las Vegas, 4505 S.
Maryland Parkway, Box 453066, Las Vegas, NV 89154; phone: (702)
895-3935, fax: (702) 895-0984, email: larry.ashley@unlv.edu
and India (1000 BC) have unearthed dice and gaming
boards (McMillen 1996).
In North America, gambling preceded the foundation
of the United States. Arriving on the Atlantic seaboard
in the sixteenth and seventeenth centuries, European
explorers and settlers encountered Native tribes who
had well-established systems of wagering. For example,
early explorers in New York witnessed members of the
Onondaga tribe placing bets on the role of stone dice
(Haugen 2006).
However, gambling in the New World was not limited
solely to Native cultures. Historical reports claim that
George Washington purchased the first ticket for a lottery
that financed the colony of Virginia’s development
(Petry 2005). Additionally, lotteries also raised funds for
the Continental Army during the Revolutionary War and
were responsible, in part, for financing the development of
the District of Columbia and early American universities
such as Harvard, Yale, Columbia, and Dartmouth (Evans &
Hance 1998).
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Ashley & Boehlke Pathological Gambling
Yet, despite the developments made possible by the
revenues generated through lotteries, many colonists had
strong moral objections to gambling. Following in the
vein of Cotton Mather, who defined gambling as “unquestionably
immoral and, as such, displeasing to God”
(Rosecrance 1988: 107), the Puritans opposed gambling
because they believed it undermined the “Protestant ethic”
of self-control, hard work, and thrift. Other religious leaders
of the time also condemned gambling on the grounds
that they believed that it destroyed families and exposed
gamblers to additional vices such as alcohol and prostitution
(Ruschmann 2009).
Eventually most forms of gambling and all lotteries
were outlawed by the states beginning in the 1870s
following tremendous scandals in the Louisiana lottery
(Ruschmann 2009). However, in an effort to invigorate a
lagging economy, the state of Nevada once again legalized
casino gambling in 1931(Rushmann 2009), while the
revival of lotteries began in 1964 when New Hampshire
established a state lottery (NGISC 1999). Currently, all
states, with the exception of Hawaii and Utah, offer some
type of legalized gambling (Haugen 2006).
Overall, gambling in the United States has transitioned
from early acceptance to prohibition to widespread
proliferation. Viewed today as a legitimate and socially
acceptable form of entertainment, legalized gambling currently
generates greater revenue than any other popular
leisure-time activity (Schwer, Thompson & Nakamuro
2003). Statistics indicate that approximately 85% of all
Americans have gambled at least once in their lives and
between 65% and 80% reported having gambled in the past
year (NRC 1999).
For most individuals, gambling is a relaxing activity
that does not incur negative consequences. Unfortunately,
however, for some individuals gambling becomes more
than harmless fun. The most severe form of gambling,
pathological gambling, is recognized as a mental
health disorder (Petry 2005). The personal and social
effects of pathological gambling often include psychological
distress, significant financial losses, family problems,
legal and employment difficulties, and suicide (Oei &
Gordon 2008).
While the consequences of pathological gambling are
certainly disturbing, there also exists an equally unsettling
trend with respect to the growth in the population
of pathological gamblers. Statistics indicate that the prevalence
of the disorder is on the rise. In 1976 it was
estimated that the base rate of the U.S. adult population
that constituted pathological gamblers was 0.77% (Kindt
2003). Current studies, however, estimate that approximately
5% of the adult gambling population experiences
significant problems as a result of their gambling activities
(Potenza 2008). This percentage is presumed to be even
higher among special populations including those comprised
of young adults, people with mental health disorders,
and incarcerated individuals (Shaffer, Hall & Vander Bilt
1999). Furthermore, today, problem gamblers account for
approximately one-third of the industry’s revenue (Oei &
Gordon 2008).
DEFINITIONS
Gambling involves risk and uncertainty. Often referred
to as gaming, gambling can be defined as placing something
of value at risk in the hopes of gaining something of
greater value (Potenza 2008). Gamblers Anonymous (GA
1984) defines gambling as any betting or wagering for oneself
or others, whether or not for money, no matter how
slight or insignificant, in which the outcome is uncertain or
depends on “skill” or chance.
Gambling is an activity that occurs along a behavorial
continuum ranging from no involvement to excessive
involvement. Locations along the continuum have been
demarcated using terms such as social, at-risk, subclinical,
problem, pathological, compulsive, and in-transition
(Shaffer & Korn 2002). Individuals experiencing difficulties
with gambling can generally be grouped into two
categories: (1) problem gamblers and, (2) pathological
or compulsive gamblers. Despite some distinctions, these
terms are often used interchangeably in the gambling literature.
All three designations are used to describe a disorder
that is characterized by a loss of control over gambling,
deception regarding the extent of one’s involvement with
gambling, family and job disruption, theft, and “chasing”
losses or attempting to win back money that has been lost
while gambling (Oei & Gordon 2008).
According to Fisher and Harrison (2009), the term
pathological generally refers to those individuals whose
gambling behavior meets at least five of the ten diagnostic
criteria outlined in the APA’s Diagnostic Statistical
Manual of Mental Disorders, Fourth Edition-Text Revision
(DSM-IV-TR; APA 2000), while the term problem gambling
is generally reserved for those individuals whose
behavior meets three of the DMS-IV-TR diagnostic criteria.
The term compulsive gambling is most frequently used by
laypersons such as members of GA; however, the criteria
associated with compulsive gambling do meet the diagnostic
criteria for pathological gambling. Additionally, the
term disordered gambling is also often used in the literature
to identify problem and/or pathological gambling behavior.
A meta-analysis of studies encompassing the years 1975-
1999 revealed that 1.9% of North American adults qualified
for a lifetime diagnosis of pathological gambling, while
4.2% fell into the problem gambler category (Shaffer &
Hall 2001).
CURRENT CLASSIFICATION
Although it is first mentioned in the medical literature
in the early 1800s (Harvard Mental Health Letter
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Ashley & Boehlke Pathological Gambling
2010), the APA did not classify pathological gambling as
a psychiatric disorder until 1980 when it debuted in the
DSM-III (APA 1980). Along with pyromania, kleptomania,
trichotillomania, and intermittent explosive disorder,
pathological gambling is currently classified as an “impulse
control disorder not elsewhere specified” (APA 2000). The
DSM-IV-TR (APA 2000) diagnostic criteria for pathological
gambling are as follows:
A. Persistent and recurrent maladaptive gambling behaviors 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 relieving
a dysphoric mood (e.g., feelings of helplessness,
guilt, anxiety, or depression)
6. after losing money gambling, often returns another day
to get even (chasing ones losses)
7. lies to family members, therapists, 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
THE HIDDEN ADDICTION: GAMBLING AS A
BEHAVIORAL/PROCESS ADDICTION
Irrespective of its current classification as an impulse
control disorder, pathological gambling is often referred
to as an addiction, or, more specifically, the “hidden
addiction” because it manifests none of the obvious physical
signs that usually accompany conventional addictionrelated
behavior, i.e., no needle marks, slurred speech,
alcohol on the breath, or dilated pupils. A urinalysis,
Breathalyzer test, or blood test will not reveal gambling
activity. Consequently, a gambling disorder is significantly
more difficult to detect than a substance use disorder,
a factor that makes early intervention difficult. Finding
it easier to conceal the addiction, individuals tend to
progress more easily, and, often, more rapidly toward
the pathological end of the gambling-behavior continuum
(Phillips 2005).
Traditionally, the term “addiction” has been used to
explain a compulsive attraction or pathological attachment
to a substance; consequently, “addiction” has generally
been reserved for the description of substance-using
behaviors (Grant et al. 2010). However, many of the current
diagnostic criteria for pathological gambling share features
with those of substance use disorders. For example, tolerance,
withdrawal, repeated unsuccessful attempts to cut
back or quit, and interference in major areas of life function
are diagnostic criteria associated with both pathological
gambling and substance use disorders (Potenza 2008).
These similarities have led some clinicians and scholars to
challenge pathological gambling’s present classification in
the DSM-IV-TR and, instead, argue for its reclassification
as an addiction (Harvard Mental Health Letter 2010).
The questions regarding reclassification are not limited
solely to pathological gambling. In addition to gambling,
many researchers and clinicians now recognize that some
individuals can become addicted to a variety of behaviors,
e.g. sex, eating, Internet use, etc. Addictions to behavioral
processes are termed behavioral addictions or process
addictions (Grant et al. 2010).
The essential feature of a behavioral addiction is the
failure to resist an impulse, drive, or temptation to perform
an act that is harmful to the individual or to others.
Behavioral addictions are distinguished by a recurrent pattern
of behavior that manifests this fundamental feature
within a particular domain. Analogous to the trajectory of
substance use disorders, the repetitive engagement in these
behaviors eventually interferes with functioning in other
domains (Grant et al. 2010).
While the issue surrounding behavioral addictions
remains somewhat controversial, resolution with respect
to the matter may be close at hand with the forthcoming
issuance of the DSM-V slated for publication
in 2013. Proposed revisions include the elimination of
the current “Substance-Related Disorders” classification
and the addition of a new category entitled “Addiction
and Related Disorders,” a category which would encompass
both substance-related and non-substance/behavioral
addictions. As a result, the DSM-V Task Force has suggested
moving pathological gambling from its current classification
as an impulse control disorder to the category of
“Addiction and Related Disorders” (Grant et al. 2010).
THE COURSE OF PATHOLOGICAL GAMBLING
The degree to which an individual gambles or wagers
ranges along several dimensions. If examined over time, an
individual’s gambling activities and problems can decrease,
increase, remain at the same level, or recur (Petry 2005).
Predicated on the results of two surveys, the Gambling
Impact and Behavior Study (GIBS) and the National
Epidemiologic Survey on Alcohol and Related Conditions
(NESARC), Slutske (2006) concluded that the pattern
or course of pathological gambling is best described as
“variable.”
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Ashley & Boehlke Pathological Gambling
Gambling behavior can occur on different levels and
progress through different phases. Shaffer, Hall and Vander
Bilt (1999) demarcated four levels ranging from zero (no
gambling) to three (pathological gambling) in order to
illustrate the various degrees of gambling involvement.
Lesieur and Custer (1984) identified three phases—the
winning phase, the losing phase, and the desperation
phase—in order to describe the course of progression.
Recently, an additional phase—the hopeless phase—was
added (Petry 2005). Not all gamblers experience all levels
or phases, nor is the progression through which individuals
traverse necessarily linear.
ETIOLOGY
Over time, several models have been constructed in
order to explain or describe the development of gambling
disorders. Early theories identified and investigated
specific factors such as learning, cognition, affect, and
genes; however, the models examined each component
separately (Turner et al. 2008). While these paradigms certainly
provided insight and a deeper understanding of each
of these independent variables, they had limited descriptive,
explanative, and predictive value. Due to their onedimensional
nature, they were unable to fully account for
all the intricacies related to the development of pathological
gambling.
Today, pathological gambling is understood as a complex,
multifaceted, and multidimensional phenomenon. It is
generally considered a heterogeneous disorder in which
multiple variables interact in multiple manners. Current
research demonstrates that biological, psychological, and
social factors are all relevant to the development of problematic
levels of gambling (Sharpe 2002).
To date, no one single theory has been developed
that can fully explain the onset and maintenance of disordered
gambling. While several more-comprehensive models
have been developed, including the General Theory of
Addictions, the Pathways Model, and the Public Health
Model, each continues to have limitations with respect to
its ability to account for either the multiplicity of variables
associated with the development of problem gambling or
for the seemingly endless combinations and permutations
of these variables (Derevensky & Gupta 2004). However,
unlike earlier theories, these models seek to both identify
the multiple etiological factors involved, as well as describe
the relationships between these variables.
General Theory of Addictions
The General Theory of Addictions, developed by
Jacobs in 1986, was the first theory to attempt to account for
both physiological and psychological factors in the etiology
of pathological gambling and other addictive behaviors
(Nower & Blaszczynski 2008). According to Jacobs, any
mood-altering behavior that gives a psychologically vulnerable
individual an opportunity to escape pain, fulfill
grandiose fantasies, and create a new identity will lead
to addiction (Graybar & Varble 2002). Because the need
or desire to escape from one’s problems occurs more frequently
among individuals who have poorly developed
coping capacities (Gupta & Derevensky 2000), the model
suggests that excessive substance use and/or excessive
behaviors, such as gambling, represent maladaptive coping
skills (Turner et al. 2008).
Pathways Model
In an effort to integrate the complex array of biological,
personality, developmental, cognitive, learning theory,
and ecological determinants of problem and pathological
gambling, Blaszczynski and Nower (2002) proposed the
Pathways Model. Beyond their more inclusive conceptualization,
the authors also suggest that gamblers do not represent
a homogeneous population. While individuals share
a number of common ecological factors, i.e., cognitive distortions,
behavioral contingencies of reinforcement, access
to gambling opportunities, etc., they differ with respect
to other biopsychosocial factors (Nower & Blaszczynski
2008). Based on these dissimilarities, Blaszczynski and
Nower (2002) posited three distinct groups of gamblers:
(1) behaviorally conditioned problem gamblers, (2) emotionally
vulnerable problem gamblers, and (3) antisocial,
impulsivist problem gamblers.
Public Health Model
Shaffer and Korn (2002) have described a public health
approach to gambling. Similar to the public health models
used for alcohol, tobacco, and other drugs, this paradigm
describes the complex interrelationships and interactions
between three specific variables: the host, the agent, and the
vector/environment. With respect to gambling, the host is
defined as the individual who decides to gamble. He or she
might be at risk for developing problems based upon his or
her own particular neurobiology, psychology, and behavior
patterns. The agent represents the gambling activities. The
vector refers to the money and the environment represents
both micro- and macro-levels. The micro-environment consists
of the gambling venue, family, and local community
in which the host resides. The macro-environment includes
the socioeconomic, cultural, societal, and political context
in which the gambling occurs, i.e., whether gambling
is legal or not, the degree of accessibility or availability,
and whether or not the activity is socially sanctioned
or promoted. The public health model recognizes that
gambling generates both positive outcomes (e.g., socioeconomic
gains, employment opportunities, tax revenues,
etc.) and negative outcomes (e.g., consequences of problem
gambling), and it is the confluence of the variables which
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Ashley & Boehlke Pathological Gambling
has the capacity to produce a variety of consequences
ranging from desirable to undesirable.
NEUROBIOLOGY
Although neurobiological studies related to pathological
gambling are still in their infancy, preliminary results
indicate that pathological gambling and substance use
disorders share neurobiological underpinnings (Mutschler
et al. 2010). Both psychoactive drugs (e.g., alcohol,
cocaine, heroin, etc.) and behaviors (e.g., gambling, compulsive
shopping, etc.) have the capacity to stimulate neurobiological
systems. For example, the results from functional
magnetic resonance imaging (fMRI) studies have
revealed that the manner in which money and beauty energize
the reward system is similar to that associated with the
anticipation of the effects of cocaine among users (Shaffer
et al. 2004).
A growing body of literature supports the hypothesis
that several neurotransmitter systems related to arousal,
mood regulation, and reward regulation may all play a
role with respect to impulsivity, mood disorders, and
impaired control (Blaszczynski & Nower 2002). Research
results have implicated the noradrenergic, serotonergic,
and dopaminergic neurotransmitter systems in the pathophysiology
of behavioral addictions and substance use
disorders (Potenza 2008). Central noradrenaline (norepinephrine)
is involved in the physiological functions associated
with arousal and impulse control (Blanco et al.
2000). Serotonergic function is linked to behavioral initiation,
inhibition, and aggression, while dopaminergic function
is associated with reward and reinforcement mechanisms
(Iancu et al. 2008).
Several brain circuits implicated in the development of
addictive behavior have also been studied in pathological
gambling. Four of these circuits have generated particular
interest: (1) the reward circuit, which is located in the
nucleus accumbens; (2) the motivational and drive circuit,
which is located in the orbitofrontal cortex; (3) the memory
and learning circuit, which is located in the amygdala
and the hippocampus; and (4) the control circuit, which is
located in the dorsolateral prefrontal cortex and the anterior
cingulated gyrus (Iancu et al. 2008). Additionally,
neuropsychological studies of pathological gamblers have
demonstrated that pathological gamblers display deficits
in the frontal lobe reward system, leading investigators
to hypothesize that impairment of executive function may
play a role in the etiology of pathological gambling (Iancu
et al. 2008).
GENETICS
Current research results indicate a likely genetic vulnerability
to pathological gambling. While the specific
phenotype through which such a particular vulnerability
is expressed remains obscure, genetic studies suggest
that the presence of the dopamine D2A1 allele receptor
gene may result in deficits in the dopamine reward
pathways (Derevensky & Gupta 2004). Deficiencies in
D2 receptors may influence individuals to pursue pleasuregenerating
activities and, consequently, increase the risk
for the development of multiple addictive, impulsive,
and compulsive behaviors including pathological gambling,
substance abuse, and binge eating (Blum et al.
2000).
RISK FACTORS
In addition to neurobiological and genetic vulnerabilities,
several other risk factors have been identified
with respect to the development of pathological gambling.
Some of these risk factors include earlier age of
onset; gender; social modeling (i.e., the gambling attitudes
and behaviors of parents and peers; Derevensky
& Gupta 2004); personality factors, i.e., impulsivity and
sensation-seeking traits (McDaniel & Zuckerman 2003)
and antisocial behaviors (Derevensky & Gupta 2004); ineffective
coping strategies (Hulsey & Lightsey 2002); preexisting
mood disorders, anxiety disorders, and/or substance
abuse disorders; low self-esteem; and lack of social support
(Derevensky & Gupta 2004). However, it is important
to remember that, as with other addictions and behaviors,
it is the interaction between a variety of variables or factors,
and not the factors alone, that may put an individual
at higher risk for developing a problem with gambling.
Therefore, risk factors cannot be assumed to be causative
factors.
TRAUMA
While histories of abuse and trauma have frequently
been reported by individuals diagnosed with substance
use disorders, a link between problem gambling and
trauma is appearing in the literature with increasing frequency.
Gambling has been characterized as a way of
coping with trauma and abuse, especially among women
(Lesieur & Blume 1991). In a study conducted with pathological
gamblers undergoing treatment, Kausch, Rugle
and Rowland (2006) found that 64.4% reported some
history of abuse; 56.8% reported a history of emotional
abuse, 40.5% reported physical abuse, and 24.3%
reported a history of sexual abuse. Multiple (two or
more) incidents of abuse were reported by 42.3% of the
gamblers, and both physical and sexual abuse histories
were reported by 16.2% of the sample. Women were significantly
more likely to report abuse than men in this
sample.
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ERRONEOUS COGNITIONS
Many studies have supported the theory that cognitive
distortions or irrational beliefs may play a role in
the development and maintenance of both addictive behaviors
in general and pathological gambling specifically (Oei
& Gordon 2008). Despite the objective statistical probability
of failure related to games of chance, problem
gamblers tend to harbor inaccurate perceptions about their
ability to control or influence the gambling outcomes.
Cognitive distortions associated with disordered gambling
include: (1) the gambler’s fallacy, i.e., the belief that completely
random events, such as the outcome of a coin toss,
are influenced by recent events (Johnson & Malow-Iroff
2008); (2) illusions of control, i.e., superstitious behaviors
by which the gambler thinks that he/she has a reliable
means of manipulating the event outcome in his/her favor
(Johansson et al. 2009); (3) the magnification of gambling
skills, i.e., exaggerated self-confidence (Iancu et al. 2008);
and (4) recall bias, i.e., the tendency to remember and overestimate
wins while forgetting about, underestimating, or
rationalizing losses (Blanco et al. 2000).
ACCESSIBILITY
Although the results of a report developed by Gerstein
and colleagues (1999) indicated that the prevalence rates
of both problem and pathological gambling were double
that of the general population for individuals living within
a 50 mile radius of a casino, it is not possible to determine
precisely what role, if any, location plays in the development
of disordered gambling. While it is possible that
the availability of or access to gambling opportunities may
increase an individual’s vulnerability for developing a gambling
problem, it is also possible that individuals with a
pre-existing gambling problem may relocate to areas that
provide multiple gambling opportunities. Furthermore, it is
equally possible that casinos locate to areas where the population
has already demonstrated high rates of disordered
gambling (Shaffer & Korn 2002).
COMORBIDITY
Comorbidity is the term used to describe the
co-occurrence of two or more disorders. Each disorder
can occur independently, a pattern identified as lifetime
comorbidity, or two or more disorders can occur simultaneously,
a pattern known as current comorbidity (Petry
2005). Research results indicate a high incidence of associated
comorbid disorders and pathological gambling.
Comorbid disorders for pathological gambling include substance
use disorders, attention-deficit hyperactivity disorder
(ADHD), antisocial, narcissistic, and borderline personality
disorders, depression, cyclothymia, and bipolar
disorder (Phillips 2005). In addition, pathological gamblers
frequently engage in multiple impulsive and dysfunctional
behaviors simultaneously, such as compulsive shopping
and compulsive sexual behavior (Kausch 2003).
Suicide is also highly associated with gambling disorders
(Phillips 2005).
However, with respect to comorbidity, it is necessary
to remember that the statistics reported represent correlations.
Determining a causal role, if one or any exist,
is difficult, if not impossible. For instance, do substance
abusers gamble or do gamblers abuse substances? Do
individuals with a psychological disorder(s) gamble to selfmedicate
their emotional distress or does the stress generated
by gambling-related problems facilitate the development
of psychological disorders (Shaffer & Korn 2002)?
Regardless of the order of onset, however, it is possible
that all three—substance abuse disorders, psychological
disorders, and gambling disorders—may interact and, subsequently,
perpetuate one another (Petry 2005).
CRIME
The literature has established a link between crime and
gambling behavior (Blaszczynski & Farrell 1998). In the
U.S., a 1996 study by Thompson, Gazel, and Rickman
(Nower 2003) found that, on average, the serious problem
gambler had lost nearly $100,000 and owed $38,644 before
seeking help. As financial resources dwindle, gamblers
may resort to crime in order to pay debts, maintain appearances,
and acquire more money with which to gamble. It is
estimated that crimes such as fraud, theft, embezzlement,
forgery, robbery, assault, and blackmail are committed
by 21% to 85% of pathological gamblers (Nower 2003).
During the 1980s and 1990s, studies reported that between
12.5% and 15% of all pathological gamblers would become
incarcerated (Kindt 2003). However, as with comorbidity,
it is difficult to separate cause from effect. In other words,
do criminals gamble or do gamblers become criminals
(Shaffer & Korn 2002)?
BANKRUPTCY
A high percentage of gamblers will also face
bankruptcy. According to the Gambling Impact Behavior
Study (GIBS) released in 1999, nearly 25% of both problem
and pathological gamblers filed for bankruptcy compared
to 5.5% of social gamblers and 4.2% of nongamblers.
Additionally, pathological gamblers in that study reported
rates of indebtedness that were 25% greater than those
of social gamblers and 120% greater than nongamblers
(Nower 2003).
SUICIDE
Although a causal link has not been established,
emerging evidence suggests that gambling severity elevates
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Ashley & Boehlke Pathological Gambling
the risk for suicidal ideation and behavior. As consequences
and losses mount, some individuals may view suicide as
the only viable solution to both their emotional distress
and financial stress (Hodgins, Mansley & Thygesen 2006).
It has been suggested by some researchers that pathological
gamblers are five to ten times more likely to attempt suicide
than the general population (Blaszczynski & Farrell
1998). Studies involving treatment-seeking pathological
gamblers found that 36% to 50% had a history of suicidal
ideation (Lejoyeux et al. 1999; Linden, Pope & Jonas
1986), and 20% to 30% of pathological gamblers had made
suicide attempts (Schwer, Thompson & Nakamuro 2003).
Moreover, the mood and substance use disorders that commonly
co-occur with pathological gambling are also highly
associated with suicide (Crockford & el-Guebaly 1998),
thereby further increasing an individual’s vulnerability for
suicidal ideation and/or attempts.
However, the role that gambling itself plays in precipitating
suicidal ideation and/or behaviors remains unclear.
Studies have generated mixed and inconclusive results. For
example, a study by Kausch (2003) found that 64.3% of
those who had attempted suicide reported that their most
recent suicide attempt was related to gambling. Conversely,
a study by Hodgins, Mansley and Thygesen (2006)
revealed that suicide attempts were nearly universally made
when participants reported feeling depressed. Additionally,
more than half of these respondents reported that the majority
of their suicide attempts had been made under the
influence of alcohol or other drugs. Furthermore, in this
sample, those reporting gambling-related suicide attempts
tended to experience prior nongambling-related suicidal
ideation. Based on these contradictory findings, it appears
that gambling problems are but one of a number of stressors
that may contribute to suicidal ideation and attempts.
SPECIAL POPULATIONS
Historically, pathological gambling has been viewed as
a male-dominated problem. Today, however, it is clear that
individuals experiencing gambling problems do not reflect
a homogeneous group. Rather, excessive gambling affects
individuals with diverse biopsychosocial profiles and cuts
across age, gender, ethnicity, and social class.
Gender
Studies indicate that women make up the fastest growing
group of individuals seeking help for problem gambling
(Petry 2005). An estimated one-third of problem gamblers
are now women (Volberg 1994). Research indicates that
female gamblers tend to be drawn to the activity as a means
of “escape,” while male gamblers tend to be intrigued by
the “action” (Boughton & Falenchuck 2007). As a result,
women generally participate in games of “luck,” (e.g., slot
and video poker machines, bingo, keno, etc.), whereas men
typically engage in gaming activities that require “skill”
(e.g. card games, horse race betting, sports betting, etc.;
Turner et al. 2008). Although the age of onset for problem
gambling in women is generally later than that of men,
women are found to experience a more rapid progression
into a gambling problem than men, a phenomenon referred
to as “telescoping” (Grant et al. 2010). However, while
women tend to initiate gambling activities at a later age
than men, they also tend to seek treatment for problem
gambling earlier than men (Petry & Ladd 2002).
Adolescents
Gambling by teenagers is not a new phenomenon;
however, according to Jacobs (2004), adolescents in the
1990s were the first U.S. generation reared in a culture
in which gambling was viewed not only as an acceptable
recreational activity, it was also identified as a potential
career option. As a result, adolescent gambling prevalence
rates are on the rise. During the 1980s, it was estimated
that 45% of adolescents had gambled (Jacobs 2004). Today,
however, data from multiple North American surveys
demonstrate that 60% to 80% of all adolescents have gambled
for money (Derevensky & Gupta 2007; Jacobs 2004).
Furthermore, Derevensky & Gupta (2007) report that of
the percentage of adolescents who gamble, 10% to 15%
are at risk for developing gambling problems. These rates
are significantly higher than those reported in the general
adult population. In fact, research results indicate that adolescents
experience this problem at approximately 2.5 to
three times the rate of their adult counterparts (Shaffer &
Korn 2002).
Seniors
Older adults comprise one of the fastest growing segments
of the population. They also represent that portion of
the population experiencing the highest gambling activity
growth rate (Desai et al. 2004). According to Gerstein and
colleagues (1999), lifetime gambling rates in older adults
increased from 35% in 1975 to 80% in 1998.
Seniors may be especially vulnerable to developing a
gambling problem for a number of reasons. First, seniors
tend to have both more discretionary time and discretionary
income than members of the general population (Desai
et al. 2004). These factors alone can serve to increase gambling
frequency and involvement. Second, the desire to
numb or escape from the uncomfortable feelings associate
with life changes—e.g., death of a spouse, health or financial
problems, boredom, etc.—may motivate some seniors
to gamble (Illinois Department on Aging 2005). Third,
seniors may have greater accessibility to gambling opportunities
than the general population. Bus trips or group excursions
to casinos are popular activities sponsored by senior
living centers (Illinois Department on Aging 2005), while
in-house gambling activities (e.g., bingo) are frequently
offered at residential and assisted-care facilities (Parekh &
Morano (2009).
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ASSESSMENT
A variety of instruments have been developed for
screening and classifying gambling behaviors (Petry 2005),
including the South Oaks Gambling Screen (SOGS),
the National Opinion Research Center DSM Screen for
Gambling Problems (NODS), the Lie/Bet Questionnaire,
and the Gamblers Anonymous 20 questions. The SOGS
is highly correlated to the DSM-IV-TR diagnosis of pathological
gambling (McCown & Chamberlain 2000) and has
been demonstrated to be valid and reliable; however, it has
been criticized for its tendency to generate false positives
(Petry 2005). On the other hand, the NODS, originally
developed as a survey instrument for research purposes,
has a propensity to generate false negatives (Phillips 2005).
While all four instruments are effective screening tools,
the most significant limitation with respect to each is the
same limitation associated with all self-report inventories:
individuals can easily misrepresent themselves when
responding (Phillips 2005).
TREATMENT
Despite its increasing prevalence, pathological gambling
often remains untreated. While effective treatment
for gambling problems does exist, relatively few individuals
experiencing gambling problems seek treatment
(Cunningham 2005; Petry 2005). Data analysis based on
the qualitative information derived from two national population
surveys conducted since 1989 in the U.S. (Slutske
2006; Cunningham 2005) found that only 7.1% to 9.9%
of lifetime pathological gamblers had sought treatment or
attended Gamblers Anonymous (GA). The outcome of this
analysis indicates that 90.1% to 92.9% of the individuals
experiencing gambling problems neither seek treatment nor
attend GA.
Both process/behavioral addictions and substance
use disorders often respond favorably to the same
treatments. Cognitive-behavioral therapy (CBT), motivational
enhancement/motivational interviewing (ME/MI)
and 12-Step approaches commonly used to treat substance
use disorders have been used successfully to treat
pathological gambling. The psychosocial interventions
for both behavioral addictions and substance use disorders
are generally structured within the context of a
relapse prevention model. This model encourages individuals
undergoing treatment to develop and maintain
abstinence through the process of identifying patterns
of abuse, developing the strategies necessary to avoid
and/or to cope with high-risk situations, and generating
lifestyle changes that reinforce healthier behaviors (Grant
et al. 2010).
Behavioral interventions have also been found to be
useful for some individuals engaged in the recovery process.
Both self-exclusion and funds-management strategies
can help facilitate abstinence and/or gambling-behavior
modification. For example, some casinos offer a program
that allows individuals to ban themselves from the establishment,
thereby limiting an individual’s access to a highrisk
situation. Also, individuals can elect to limit their
access to funds. Useful strategies include canceling credit
cards, removing ATM cards, credit cards, and/or cash from
wallets, and utilizing direct-deposit options for paychecks
(Ladouceur & LaChance 2007).
Lipinski, Whelan and Meyers (2007) examined the
reviews of psychological treatments for pathological
gambling and generated three conclusions. First, pathological
gambling responds to psychosocial treatment.
Interventions falling within the cognitive-behavioral spectrum
have the most empirical support at present (Toneatto
& Ladouceur 2003). Second, brief outpatient treatments
that have been successful with other addictive behaviors
show promise for the treatment of pathological gambling.
Third, positive change from psychological treatment is not
limited to abstinence-only outcomes; rather, the reduction
of gambling behaviors to more normal or functional levels
has been demonstrated to be viable treatment goal and
outcome for some individuals.
Korn and Shaffer (1999) suggest that the most effective
treatments for gambling problems will reflect a
multimodal “cocktail approach” combined with clienttreatment
matching. They recommend a multidimensional
treatment approach that includes combinations of
psychopharmacology and psychology coupled with financial,
educational, and self-help interventions. And, while
formal treatment is useful for some, it is not always a
necessary prerequisite for recovery (Suurvali, Hodgins &
Cunningham 2010). Utilizing data from previous studies,
Slutske (2006) found that approximately one-third of the
lifetime pathological gamblers participating in the studies
had recovered without formal treatment.
Pharmacotherapy
Research assessing the efficacy of pharmacotherapies
for use in the treatment of gambling addiction is limited.
Currently, there are no U.S. Food and Drug Administration
(FDA) approved medications for the treatment of pathological
gambling (Grant, Chambers & Potenza 2004).
However, neurobiological similarities between pathological
gambling and drug addiction suggest that medications
used for the treatment of drug addiction might be useful
in the treatment of pathological gambling (Mutschler
et al. 2010). For example, naltrexone, a mu-opioid receptor
antagonist approved by the FDA for the treatment
of alcoholism and opioid dependence, has demonstrated
efficacy in controlled clinical trials for the treatment of
pathological gambling (Kim et al. 2001). Medications
that alter glutamatergic activity have also been used to
treat both behavioral addictions and substance use disorders
(Grant et al. 2010). Selective serotonin reuptake
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Ashley & Boehlke Pathological Gambling
inhibitors (SSRIs) have also shown some promise with
respect to reducing the craving to gamble (Mutschler et al.
2010).
Gamblers Anonymous
A less formal, but commonly utilized intervention
for problem gambling is the mutual-aid fellowship called
Gamblers Anonymous (GA). Modeled on the 12-Step
Alcoholics Anonymous (AA) program, GA is a self-help
group for compulsive gamblers that was founded in Los
Angeles, California, in 1957 (Frank 1962). Since its inception,
GA has expanded internationally, and today over
1000 GA chapters are available in the U.S. alone (Petry
2005).
While research has found that GA meeting attendance
is often associated with increased abstinence (Oei &
Gordon 2008), high rates of attrition limit GA’s efficacy.
Research indicates that the majority of GA attendees fail to
maintain active engagement in the fellowship. A study conducted
by Stewart and Brown (1988) found that only 18%
of the sample attended GA meetings consistently for a year
or more. Of all the new members surveyed in the study only
7.5% attained a one-year abstinence pin and 7.3% received
at two-year pin (Petry 2005).
RELAPSE
Similar to addiction to alcohol and other drugs, pathological
gambling is characterized as a chronic relapsing
disorder (Grant, Williams & Kim 2006). Relapse rates, in
general, range from 80% to 90% in the first year following
treatment (Shaffer et al. 2004). Hodgins and el-Guebaly
(2004) found that only 8% of the participants in their sample
were entirely free of gambling during the 12-month
period, which meant that 92% relapsed. Therefore, the
prevention of relapse is a crucial and critical element of
effective treatment. Relapse prevention should be integrated
into therapy and addressed throughout the entire
therapeutic process, not only in an effort to help prepare
individuals to prevent relapse, but also to help them manage
a relapse should one occur (Ladouceur & LaChance 2007).
PREVENTION
Problematic gambling results in far-reaching and longlasting
negative consequences; therefore, prevention is a
primary factor when addressing the issue. While prevention
efforts are critical in averting the development of problems
in all segments of the population, the specific type of
prevention approach or approaches that should be adopted
remains unclear. The questions central to the issue pertain
to which form of prevention is best for targeting the issue
of gambling problems (Derevensky et al. 2004).
Currently, prevention approaches are classified under
two global paradigms: abstinence or harm-reduction.
While not mutually exclusive, these two approaches are
predicated upon different short-term goals and processes
(Derevensky et al. 2004). Clearly, abstinence both prevents
problems from developing as well as terminates behaviors
after problems have developed.
The goals of the harm-reduction approach are
essentially two-fold: (1) information dissemintation, and
(2) facilitation of a recovery process in which abstinence
is not necessarily the goal. In an effort to foster public
awareness, harm-reduction models are designed to alert
consumers to both the warning signs and the consequences
of problem gambling, as well as to provide information
related to help options and/or treatment resources. Most
governments today have implemented a harm-reduction
approach aimed at reducing or minimizing the negative
impact of gambling without negating gaming revenues or
access to the general public (Derevensky et al. 2004).
CONCLUSION
Gambling is imbedded in a cultural and social context,
as well as in a psychological one (Suurvali, Hodgins
& Cunningham 2010). While research tends to focus on
the adverse mental health and social consequences associated
with problem gambling, gambling does generate
positive benefits for both individuals and societies. For
example, gambling can, for some, provide an opportunity
to socialize, to experience a sense of connectedness,
or to enjoy an entertaining respite from life’s daily
demands. Benefits can also accrue to communities through
gambling-related economic growth. For instance, casinos
can provide employment opportunities, as well as serve as
catalysts for drawing and/or developing additional business
ventures within local communities (Shafffer & Korn
2002).
While most individuals who gamble are able to do
so without incurring negative consequences, a small percentage
of individuals who do gamble develop serious
problems with gambling and, as a result, experience significant
difficulties. Excessive gambling has the potential
to interfere with an individual’s healthy functioning
in all areas of life. Pathological gambling is associated
with increased physical and psychological distress, psychiatric
comorbidity, financial and legal difficulties, academic
and/or employment disruptions, and familial and other
relational discord. In addition to the problems experienced
by the individual him/herself, pathological gambling also
results in collateral damage. Studies have found that pathological
gambling is also associated with child neglect and
domestic violence (Wong et al. 2010).
Most research into pathological gambling is preliminary.
However, data indicate that, like substance abuse
disorders, disordered gambling is amenable to treatment.
However, much more research is needed in order to
improve both prevention and treatment efforts.
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