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Section 8
Gambling Disorder Comorbidity

Question 8 | Test | Table of Contents

History and epidemiologic factors
Since about 3000 BC, gambling has been a significant part of human culture. It has found a place in religion, government, academia, literature, and psychology. The last two decades have seen a worldwide trend towards legalized gambling as a means for local governments to cheaply and reliably raise revenues to meet increasing governmental responsibilities and expenditures. Gambling-related disorders have followed suit, and the prevalence of pathologic gambling disorder in US adults is now estimated at 1% to 2%. However, the prevalence is twice that in areas in which a casino is within a 50-mile radius.  Pathologic gambling disorder is a chronic disease with an insidious onset and episodic course. It often begins in early adolescence in males and between ages 20 and 40 years in females. Exacerbations peak during periods of high stress and dysphoric mood. Persons with pathologic gambling disorder often delay seeking treatment because they are ashamed of their problem and struggle to keep it a secret while they attempt to recoup financial losses.

Diagnosis and comorbid disorders
Pathologic gambling disorder is defined in the revised fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM) as an impulse-control disorder; however, it can be better viewed as an addiction disorder. The mnemonic WAGER OFTEN, created from the DSM criteria for pathologic gambling disorder, offers a guide to screening for this disease during brief office visits. Each DSM criterion is denoted in the mnemonic by its respective criterion number. Five or more criteria are required for diagnosis. Differential diagnostic considerations include social gambling, problem gambling, manic or hypomanic episodes, obsessive-compulsive disorder and, rarely, professional gambling. Differentiation of gambling behaviors can be simplified by plotting several core issues along a continuum. Problem gambling (not listed as a diagnosis in the DSM) represents social gambling that has begun to exceed limits and cross boundaries, thereby causing problems in the gambler's life. Problem gambling can be associated with increased frequency and rising amounts of betting, continued gambling despite negative outcomes, and a progression to higher risk taking when gambling. However, persons with problem gambling do not meet the full criteria for pathologic gambling disorder. As the illness progresses from problem gambling to pathologic gambling disorder, magical thinking often develops. Such thinking consists of attributing winning to personal skill while attributing losing to bad luck. Gamblers sometimes begin to plan activities and vacations around gambling events. Pathologic gambling disorder may progress in four phases: winning, losing, desperation, and giving up. Two widely used office screening instruments are the South Oaks Gambling Screen and the Gamblers Anonymous 20 Questions.

Certain populations need special consideration. Female gamblers are more likely than male gamblers to live with someone who gambles or drinks, but they are less likely to have alcohol or legal problems themselves. Women usually gravitate towards games that require less strategy (eg, slots) and tend to gamble to escape thinking about life problems. Women are also more likely than men to seek mental health treatment. With the recent increase in legalized gambling, gambling disorders are probably more prevalent in adolescents than in the general population. Common comorbid conditions include substance abuse and mood and anxiety disorders. Alcohol abuse and drug abuse are often associated with pathologic gambling disorder; estimates of prevalence range from 8% to 47%. Alcohol is often served free of charge in casinos (perhaps to lessen the inhibitions of gamblers), a practice that raises the risk of alcohol use disorders. Gamblers are often nicotine-dependent; smoking is associated with increased severity of gambling problems and psychiatric symptoms. Depression is particularly common in female gamblers. Suicide is often contemplated (especially in the losing, desperation, and giving-up phases) and is attempted in a striking 15% to 20% of patients with pathologic gambling disorder. Personality disorders, especially antisocial personality disorder, have been linked with gambling. Recent studies have also suggested a relationship to other impulse-control disorders, such as compulsive sexual behavior and compulsive shopping. Clearly, depression and alcohol use problems are common, destructive conditions in patients with gambling disorders.

Types of gambling
General categories of gambling include card games, lotteries, sports games, bingo, keno, slots, and pull tabs. Pull tabs are paper tickets featuring perforated windows that, when pulled back, reveal game symbols or numbers. State government--sponsored, they sell for about 50 cents to a dollar each; winning pull tabs award about $50 to $200 (odds ratio, about 1:6).  In the past decade, Internet gambling has emerged as the most accessible and immediately rewarding form of gambling. Unfortunately, Internet gambling often lacks consumer protections. Some experts suggest that Internet gambling is more addictive than other forms of gambling. However, in general, any game of chance involving risk taking and reward (especially near-immediate reward) can be addictive. Even day-trading on the stock market can be considered a form of gambling.

Genetic and neurobiologic factors
Addiction has been defined as a medical disease of the brain, and only recently has research probed the brain for clues to understanding pathologic gambling disorder. Four brain circuits involved in the progression of addiction may be implicated in pathologic gambling disorder: reward (located in the nucleus accumbens and the ventral pallidum), motivation and drive (located in the orbitofrontal cortex and subcallosal cortex), memory and learning (located in the amygdala and the hippocampus), and control (located in the prefrontal cortex and the anterior cingulate gyms).  At the center of the reward circuit is the nucleus accumbens, also known as the pleasure center of the brain. Existing to ensure reinforcement of behaviors associated with species survival--hydration (thirst), nutrition (satiety), and species procreation (sex and orgasm)--it can be manipulated by various exogenous substances (eg, alcohol, cocaine, nicotine, opiates), resulting in an altered state manifested as a substance use disorder. This circuit has also been implicated in pathologic gambling disorder.

Impairment in the motivation and drive circuit has been identified in pathologic gambling disorder. The orbitofrontal cortex is normally activated when there is insufficient data to make an appropriate decision or when appropriate action requires suppression of previously rewarded responses. This circuit is important in decision making, including consideration of future consequences of behaviors and processing of rewards during the expectation and experiencing of monetary gains or losses. Neuropsychologic testing in male patients with pathologic gambling disorder has revealed impaired frontal cortex functioning. Serotonin dysfunction has been implicated in a number of disorders of impulse control. Pathologic gambling disorder shares some features of serotonin dysregulation. Male patients with pathologic gambling disorder have been found to have abnormally low levels of 5-hydroxyindoleacetic acid (HIAA) and low peripheral levels of monoamine oxidase activity, both of which signify reduced serotonin function. These patients also have abnormal responses to challenges with serotonergic ligands and tend to report a "high" in response to metachlorophenylpiperazine (a drug with high affinity for 5-hydroxytryptamine receptor subtypes 5-HT1A, 5-HT1D, 5-HT2A, 5-HT2C, and 5-HT3).

Complications
An overall decline in financial, social, and legal well-being is often linked to pathologic gambling disorder. Significant complications include depression, debt, divorce (the "3 Ds"), job loss, and incarceration. Rates of past-year job loss are twice as high in patients with pathologic gambling disorder (13.8%) as in nongamblers (5.5%). Rates of having filed for bankruptcy are four times as high in those with the disorder (19.2%) as in nongamblers (4.2%). Similarly, rates of divorce (53.5%) and incarceration (21.4%) are much higher in patients with pathologic gambling disorder than in nongamblers, who have a divorce rate of 18.2% and an incarceration rate of 0.4%. One third of the annual cost of pathologic gambling disorder represents criminal justice expenses. Casino gambling may pose a particularly high physical health risk compared with other forms of gambling. Of the 398 casino-related deaths in Atlantic City between 1982 and 1986, 83% resulted from sudden cardiac death. The rate of second-hand smoke exposure for nonsmoking casino employees and gamblers is high. Observed physiologic changes related to stress during gambling include fluctuations in cortisol, epinephrine, noradrenergic metabolites, blood pressure, heart rate, and immune system modulators.

Treatment
Prochaska has researched how patients with addiction view and approach their illness psychologically, including their ideas for changing their maladaptive behaviors. This model of behavioral change supports the theory that recovery from addiction involves a process (rather than an event) that unfolds gradually over time through a series of specific, yet fluctuating, stages of change. The role of the physician in treating pathologic gambling disorder consists of pinpointing the patient's stage of change, providing a brief intervention, presenting information about Gamblers Anonymous, making a referral for specialty care, and offering supportive measures and pharmacotherapy.

A central outcome measure when treating this disorder is abstinence from (or a significant reduction in) gambling behaviors and gambling-related complications. Primary psychosocial treatments include participation in Gamblers Anonymous and psychotherapy. Gamblers Anonymous is based on the 12 steps of Alcoholics Anonymous and modified to the recovery of pathologic gamblers. Gamblers Anonymous, an abstinence-based program founded in 1955, has more than 1,000 national chapters that hold meetings in all 50 states. Its Web site has an interface that allows the user to find a list of local meeting places and times by entering a city and state.

Gamblers Anonymous can also provide free financial, legal, and employment assistance. Both individual and group therapies are efficacious, but cognitive behavior therapy has the best empirical support for treatment of pathologic gambling disorder.

Personal Reflection Exercise Explanation
The Goal of this Home Study Course is to create a learning experience that enhances your clinical skills. We encourage you to discuss the Personal Reflection Journaling Activities, found at the end of each Section, with your colleagues. Thus, you are provided with an opportunity for a Group Discussion experience. Case Study examples might include: family background, socio-economic status, education, occupation, social/emotional issues, legal/financial issues, death/dying/health, home management, parenting, etc. as you deem appropriate. A Case Study is to be approximately 150 words in length. However, since the content of these “Personal Reflection” Journaling Exercises is intended for your future reference, they may contain confidential information and are to be applied as a “work in progress.” You will not be required to provide us with these Journaling Activities.

Personal Reflection Exercise #1
The preceding section contained information regarding Comorbidity and Complications in the Treatment of Gambling Addiction.  Write three case study examples regarding how you might use the content of this section in your practice.

Update
Corrigendum to: Gambling Disorder,
Increased Mortality, Suicidality,
and Associated Comorbidity:
A Longitudinal Nationwide Register Study

- Karlsson, A., & Håkansson, A. (2023). Corrigendum to: Gambling disorder, increased mortality, suicidality, and associated comorbidity: A longitudinal nationwide register study. Journal of behavioral addictions, 12(1), 302. https://doi.org/10.1556/2006.2023.10000

Peer-Reviewed Journal Article References:
Angus, D. J., Pickering, D., Keen, B., & Blaszczynski, A. (2021). Study framing influences crowdsourced rates of problem gambling and alcohol use disorder. Psychology of Addictive Behaviors. Advance online publication.

Dash, G. F., Slutske, W. S., Martin, N. G., Statham, D. J., Agrawal, A., & Lynskey, M. T. (2019). Big Five personality traits and alcohol, nicotine, cannabis, and gambling disorder comorbidity. Psychology of Addictive Behaviors, 33(4), 420–429.

Farstad, S. M., & von Ranson, K. M. (2021). Binge eating and problem gambling are prospectively associated with common and distinct deficits in emotion regulation among community women. Canadian Journal of Behavioural Science / Revue canadienne des sciences du comportement, 53(1), 36–47.

Grubbs, J. B., Chapman, H., Milner, L., Gutierrez, I. A., & Bradley, D. F. (2018). Examining links between posttraumatic stress and gambling motives: The role of positive gambling expectancies. Psychology of Addictive Behaviors, 32(7), 821–831.

Russell, T. I., & Robinson, M. J. F. (2019). Effects of nicotine exposure and anxiety on motivation for reward and gambling-like cues under reward uncertainty. Behavioral Neuroscience, 133(4), 361–377.

QUESTION 8
What are three types of disorders that are commonly comorbid with pathological gambling disorder? To select and enter your answer go to Test.