In Excess

Gambling, Gaming and Extreme Behavior

Compelling Evidence

A brief look at gambling and the DSM

In 1980, pathological gambling was for the first time recognized as a mental disorder in the third edition of the Diagnostic and Statistical Manual (DSM-III; American Psychiatric Association) under the section "Disorders of Impulse Control" along with other illnesses such as kleptomania and pyromania. Adopting a medical model of pathological gambling in this way displaced the old image that the gambler was a sinner or a criminal.

In diagnosing the pathological gambler, the DSM-III stated that the individual was chronically and progressively unable to resist impulses to gamble and that gambling compromised, disrupted or damaged family, personal, and vocational pursuits. The behaviour increased under times of stress and associated features included lying to obtain money, committing crimes (e.g. forgery, embezzlement, fraud, etc.), and concealment from others of the extent of the individual's gambling activities. In addition the DSM-III stated that to be a pathological gambler, the gambling must not be due to Antisocial Personality Disorder.

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These criteria were later criticized for (i) a middle class bias (i.e. the criminal offences like embezzlement, income tax evasion were typically 'middle class' offences), (ii) lack of recognition that many compulsive gamblers are self-employed, and (iii) exclusion of individuals with Antisocial Personality Disorder. It was argued that the same custom be followed for pathological gamblers as for substance abusers and alcoholics in the past (i.e., allow for simultaneous diagnosis with no exclusions). Consequently, the revised criteria (DSM-III-R) that appeared in 1987 were subsequently changed and took on board these criticisms. More importantly, the criteria were modelled extensively on substance abuse disorders due to the growing acceptance of gambling as a bona fide addictive behaviour.

Research carried out among treatment professionals the end of the 1980s highlighted some dissatisfaction with the DSM-III-R criteria and that there was some preference for a compromise between the DSM-III and the DSM-III-R. As a consequence, the criteria were changed for DSM-IV. The DSM-IV criteria represented a combination of DSM-III and DSM-III-R with the addition of “escape” which was added on the basis of empirical research. In the latest DSM-5, 'pathological gambling' has become 'gambling disorder' but the most radical change is that problematic gambling is no longer viewed as a disorder of impulse control but has been placed in the section 'Substance-Related and Addictive Disorders'. This has major implications for other activies described as 'behavioral addictions' as this may lead to the introduction of activities like 'internet-gaming disorder' in the next DSM.

Although many researchers have recognized that there appear to be different types of problem gambler, it was arguably Dr Moran's seminal 1970 typology based upon male gamblers receiving psychiatric help for their gambling problems that proved most influential. The typology comprised the following types of problem gambler: 

Subcultural – Gambles excessively due to others in their social environment gambling heavily. This type lacks independence and conforms to the social group.

Neurotic variety – Gambles excessively as a means of relief to stress and emotional difficulties.

Impulsive variety – Gambles excessively due to a "loss of control". Money is gambled until it runs out and 'symptoms of craving' appear. This variety of pathology is the most serious and produces an economic and social functioning disturbance.

Psychopathic variety – Gambles excessively as part of general global disturbance (i.e. the psychopathic state. Criminality usually occurs but is on the whole unrelated to gambling).

Symptomatic variety – Gambles excessively because of an associated mental illness (e.g., depression) in which the illness is primary and the gambling a secondary symptomatic manifestation.

As with most other typologies, Moran's classification may be clinically useful but the distinctions between each group were not clear and many patients may have had characteristics of more than one sub-type. More recently, Professor Alex Blaszczynski and Dr Lia Nower postulated a pathway model of the determinants of problem gambling based upon a series of clinical observations with problem gamblers and through integration with the literature. In some ways, this model was very similar to that formulated by Moran.

They argue that there are common influences that affect all problem gamblers, such as availability and access, classical and operant conditioning reinforcements, arousal effects, and biased cognitive schemas. However, they suggested that there are three distinct pathways into problem gambling, representing three primary motivating forces that drive different problem gamblers to gamble. The first of these, behaviourally conditioned problem gamblers, are not pathologically disturbed, but instead gamble excessively as a result of poor decision-making strategies and bad judgments. Any features such as preoccupation with gambling, chasing, depression, anxiety and related substance abuse are seen as the consequence, not the cause of their excessive gambling. These gamblers are usually motivated to seek and attend treatment, and re-establish controlled levels of gambling post-treatment.

The second group, emotionally vulnerable problem gamblers, are characterized by a predisposition to be emotionally susceptible. This group use gambling as a means of modifying mood states and/or to meet specific psychological needs. These gamblers display higher levels of pre-morbid psychopathology including depression, anxiety, substance dependence and deficits in coping or managing stress. They tend to engage in avoidant or passive aggressive behaviour, and use gambling as a means of emotional relief through dissociation and mood modification. The psychological dysfunction in these gamblers makes them more resistant to treatment and not suitable to permit controlled gambling. Treatment must focus the underlying vulnerabilities as well as the gambling behaviour.

The third group, ‘antisocial impulsivist’ problem gamblers, have biological dysfunctions, either neurological or neurochemical. They also possess similar psychosocial vulnerabilities as the pathway two gamblers. However, they are characterized by antisocial personality disorder and impulsivity and/or attention-deficit disorders. It is argued that these gamblers have a propensity to seek out rewarding activities (such as gambling) in order to receive stimulation. They tend to be clinically impulsive and display a broad range of problems independent of their gambling. These problems include substance abuse, low tolerance for boredom, sensation seeking, criminal acts, poor relationship skills, family history of antisocial behaviour and alcoholism. Gambling usually begins at an early age, has a rapid onset and occurs in binges. These gamblers are less motivated to seek treatment, have poor compliance rates and respond poorly to all interventions. All three subgroups are affected by environmental variables, conditioning effects and cognitive processes. However, in terms of treatment intervention each subgroup will have specific needs.

References and further reading

American Psychiatric Association. (1980). Diagnostic and Statistical Manual of Mental Disorders (3rd ed.). Washington, DC: Author.

American Psychiatric Association. (1987). Diagnostic and Statistical Manual of Mental Disorders (3rd ed - revised.). Washington, DC: Author.

American Psychiatric Association. (1994). Diagnostic and Statistical Manual of Mental Disorders (4th ed.). Washington, DC: Author.

American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Washington, DC: Author.

Blaszczynski, A. & Nower, L. (2002). A pathways model of pathological gambling. Addiction, 97, 487-500.

Moran, E. (1970). Varieties of pathological gambling. British Journal of Psychiatry, 116, 593-597.

Dr. Mark Griffiths is a Chartered Psychologist and Director of the International Gaming Research Unit in the Psychology Division at Nottingham Trent University (UK).

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