A brief look at gambling and the DSM
Posted Nov 12, 2013
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.
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.
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.
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.