In addition to reclassifying gambling disorder, the DSM-5 authors considered adding Internet gaming disorder to the non-substance-related disorder category. But for the present time, they have included gaming in “Section 3” as a disorder requiring further study. Although there is ample evidence to indicate that Internet gaming is becoming a problematic behavior in its own right, the available research was not considered sufficiently well-developed to justify including it in the diagnostic system at the present time. Other disorders that the work group considered adding were “sex addiction,” “exercise addiction,” and “shopping addiction,” to name a few. However, the work group believed there were even fewer empirical studies in peer-reviewed articles to justify their inclusion even in the experimental categories of Section 3.
Along with a reclassification of gambling disorder, psychiatry and psychology now have new understandings of the nature of the disorder, who gets it, why, and how distorted thinking patterns perpetuate the disorder in people who develop it. This problem behavior is receiving increasing research attention, providing answers to the many questions that you may have about your own risk and those of people close to you. We also know a great deal more about the common thought problems that keep people pressing that one-armed bandit’s lever, shuffling those cards, or rolling those dice.
What are the Symptoms of Gambling Disorder?
This rethinking of gambling disorder emphasizes the view that people who gamble to a pathological degree experience cravings, increasing needs to gamble, and negative social consequences of their behavior. Like those with substance disorders, their gambling must be so intense that they experience significant impairment or distress. However, people with gambling disorder also engage in behaviors unique to their condition, such as chasing a bad bet, lying about how much they have lost, seeking financial bailouts, and committing crimes to support their gambling.
How Many People have Gambling Disorder?
Unfortunately, as venues for gambling continue to become available on a more widespread basis, including online gambling, the incidence of gambling disorder appears to be on the increase. As I noted above, the lifetime prevalence (individuals who ever had the disorder) is estimated to be as high as 3.5%. In the U.S., although the large majority of adults have gambled at some point in their lives, about .6% have this diagnosis. The highest prevalence occurs after people had gambled 1000 times in their lives (Whitbourne & Halgin, 2013).
Who is Likely to Develop Gambling Disorder?
The highest risk of developing gambling disorder occurs among people who engage in gambling on games involving mental skill (such as cards), followed by sports betting, gambling machines, and horse races or cock/dog fights according to a large-scale national study conducted by Kessler in 2008. People with gaming disorder who bet on sports tend to be young men who also have substance disorders. Those who bet on slot machines are more likely to be older women who have higher rates of other psychological disorders and begin gambling at a later age (Petry, 2003). In general, women are less likely than men to engage in the type of gambling that depends on strategy, such as poker (Odlaug et al., 2011).
What Other Conditions Go Along with Gambling Disorder?
People with pathological gambling also have high rates of other disorders, particularly nicotine dependence (60%), dependence on other substances (58%), depressive disorder (38%), and anxiety disorder (37%). In the case of depressive and anxiety disorders, the symptoms seem to precede, not follow, the individual’s development of gaming disorder (Lorains et al., 2011).
What Causes Gambling Disorder?
It’s most helpful for you to think of gambling disorder as reflecting a lethal combination of abnormalities in biology, behavior and thinking patterns, and social factors.
Researchers who are studying biological explanations of gambling disorder focus on abnormalities in the chemical messengers in the nervous system known as neurotransmitters. Unfortunately, there isn’t just one neurotransmitter that researchers can pinpoint. Instead, people with gambling disorder seem to have multiple abnormalities. They include neurotransmitters (listed with their function) such as dopamine (pleasure), serotonin (mood), noradrenaline (arousal), and opioids (pleasure). Some researchers believe that it’s the imbalance between the mechanisms involved in strong urges and those involved in control of urges. Genetics might play a role as well, possibly involving some of those dopamine abnormalities (Lobo et al., 2010).
From a behavioral standpoint, gambling is a matter of simple reinforcement. Because payouts occur on average, every “X” number of times you bet, your behavior is maintained at a high, steady rate and it’s very difficult for you to unlearn the betting-reward connection. Slot machines, in particular, produce payoffs on this type of schedule, maintaining high rates of responding by gamblers. Classical conditioning is also involved in maintaining this behavior. Gamblers learn to associate certain cues to gambling (such as the sights, sounds, and smells of the gambling environment) with the way they feel. Seeing ads for gambling triggers these associations in the gambler.
The cognitive perspective focuses on the distortions in logic that develop in people with gambling disorder. Understanding these logical flaws can give you true insight into the core of this disorder, so I will outline them here:'
Discounting probabilistic rewards: People with gambling disorder place higher value on rewards they could obtain in the future (i.e. the advantages of putting money into savings) than on the rewards they can obtain right now (i.e. by gambling) (Petry, 2011).
The Gambler’s Fallacy: When events generated by a random process have deviated from the population average in a short run, such as a roulette ball falling on red four times in a row, the gambler erroneously believes that the opposite deviation (e.g., ball falls on black) becomes more likely
Overconfidence: Gamblers express a degree of confidence in their knowledge or ability to win that is not warranted by objective reality.
Trends in number picking: Lottery players commonly try to apply long-run random patterns to short strings in their picks such as avoiding duplicate numbers and adjacent digits in number strings.
Illusory correlations: Gamblers believe that events that they expect to be correlated, due to previous experience or perceptions, have been correlated in previous experience such as wearing a “lucky hat” that they wore when they won previously. Obviously, these are illusory correlations because nothing about what they wear can influence their gambling outcomes.
Availability of others’ wins: When gamblers see and hear other gamblers winning, they start to believe that they will be more likely to win as well.
Inherent memory bias: Gamblers are biased to recollect wins more than they do their losses. They selectively forget their losses, allowing them to rationalize their decision to continue gambling.
Switching and double switching: Gamblers understand that gambling involves risks when they're not gambling. Once they start, though, they abandon their logical thought processes.
The biopsychosocial perspective puts all of these factors together, including the fact that gambling is becoming increasingly available as a social activity. What is known as the pathways model begins by assuming that the gambler has a genetic vulnerability to the disorder. This interacts with the poor coping and problem-solving skills that we just looked at to make the individual particularly susceptible to the effect of their early gambling experiences. The infamous big win is one of the strongest experiences that hooks the gambler on his or her self-destructive behavior (Hodgins & Peden, 2008).
Is There Hope for the Person with Gambling Disorder?
Fortunately, these new models of gambling disorder do provide evidence that people with this disorder are treatable. There are medications that may reduce the urge to gamble, including some that act on opioids and others that target cognitive processes.
However, based on the pathways model, even if researchers find the silver bullet medication, people who have gambling disorder still require psychosocial interventions. Many gamblers turn to Gamblers Anonymous, but there are actually few studies of its efficacy. Though it may be helpful, psychologists believe that targeting the gambler’s addictive behavioral patterns and cognitive disorders ultimately will provide more long-lasting reduction of the gambler's symptoms.
The most thoroughly studied intervention for gambling disorder is cognitive-behavioral therapy. The typical treatment following this model involves these 4 steps (Morasco et al, 2009):
1. Teach clients to understand the triggers for their gambling.
Triggers for gambling include having nothing to do, feeling depressed or anxious, watching sports or casino ads, and having some cash in hand. Therapists help their clients identify these triggers as well as the situations that do not trigger gamblign.
2. Increase pleasant activities other than gambling.
Gamblers need to find something else to trigger their reward centers than gambling and then must set aside time to engage in those activities. They also need to find ways to handle their cravings or urges.
3. Change the faulty cognitions.
All of those flaws in logic can provide a jumping-off point for the gambler to start to think more rationally about gambling. Therapists work with their clients to question their irrational thoughts and then, ultimately, to change them.
4. Prepare for setbacks.
It’s inevitable, unfortunately, that gamblers will fall back into their old habits from time to time. Through relapse prevention, they can learn that just because they fail from time to time doesn’t mean that they can’t overcome their gambling. Over time, those setbacks should occur less frequently.
Given how common gambling and gaming have become, we all need to be vigilant to the signs and symptoms of gambling disorder in ourselves and those who are close to us. Fortunately, with the extensive research we now have available in psychology and psychiatry, there is reason to be optimistic that individuals with this disorder can be helped to lead more fulfilling lives.
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Copyright Susan Krauss Whitbourne, Ph.D. 2013
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