BRIAN K. UNWIN, MAJ, MC, USA, Darnall Army Community Hospital, Fort Hood, Texas
MARK K. DAVIS, LTC, MS, USA, Eisenhower Army Medical Center, Fort Gordon, Georgia
JASON B. DE LEEUW, CPT, MS, USA, Community Mental Health Service, Fort Meade, Maryland
Am Fam Physician. 2000 Feb 1;61(3):741-748.
See related patient information handout on gambling, written by the authors of this article.
This article exemplifies the AAFP 2000 Annual Clinical Focus on mental health.
Pathologic gambling and problem gambling affect approximately 5 to 15 million Americans and are common in young people. The community-minded family physician is in a good position to identify and assist patients who have gambling-related problems and thereby prevent or treat the resultant personal, family and social disruptions. Provider and community education about the depth and breadth of this condition is crucial for the identification and treatment of a growing problem. As with many psychologic conditions, identification of the disorder and treatment of the patient by the family physician comprise the primary treatment. Screening tools, treatment programs and self-help groups provide additional resources for the family physician. An illustrative case report demonstrates the importance of heightened awareness of and screening for this common condition.
Pathologic gambling is identified in every social class. Unfortunately, no systematic process of educating, screening and treating pathologic gamblers is currently in place. Family physicians need to have a heightened awareness about the impact of the pathologic gambler’s behavior on the family and should be familiar with screening instruments and treatment options.
Continued growth in the gambling industry raises concerns about a possible increase in the prevalence of problem and pathologic gambling. In 1991, 80 percent of the United States’ population gambled in some manner, compared with only 61 percent in the 1960s.1 In 1978 only two states had legalized gambling; in 1998, however, only two states had not legalized gambling.2 The Worldwide Survey of Substance Abuse and Health Behaviors Among Military Personnel3 is a large-scale epidemiologic study that screened personnel for gambling-related problems. The survey reported that in 1992 and 1998, 7.1 percent and 8.1 percent, respectively, of all Department of Defense personnel had at least one gambling-related problem, and 2 percent exhibited behaviors suggestive of pathologic gambling. This high prevalence of gambling-related problems in military personnel is not surprising, given the younger demographics of this population. Most pathologic gamblers began gambling in their youth; 11- to 18-year-olds in one study showed a 4 to 7 percent prevalence rate of problem gambling behaviors.4
Comorbidity with Alcohol Abuse and Depression Because pathologic gambling is likely to be increasing in incidence, it is important for family physicians to identify and treat this condition as a psychiatric disorder. It is also important to recognize the high incidence of comorbidity of alcohol abuse and depression in gamblers. In one study,3 approximately 12.9 percent of heavy drinkers had one or more gambling-related problem compared with 5 percent of nondrinkers. Eighteen percent of persons with probable alcohol dependence had at least one gambling-related problem, and 10 percent of heavy drinkers were probable pathologic gamblers.
A major depressive disorder is likely to occur in 76 percent of pathologic gamblers, with recurrent depressive episodes likely to occur in 28 percent of pathologic gamblers. Because of this high correlation, the coexistence of depression and gambling may help discriminate pathologic from nonpathologic gambling; however, the severity of depression does not correlate with the amount of money spent on gambling.5 Suicide risk is also high in pathologic gamblers—Las Vegas, Nev., and Atlantic City, N.J., have some of the highest suicide rates in the nation.6
ILLUSTRATIVE CASE A 51-year-old businessman presented with complaints of fatigue and weight loss. Pertinent findings revealed evidence of alcohol dependence and depression. The patient’s spouse provided additional history of withdrawal from family and social activities, and a lifelong history of compulsive gambling. In the previous three years alone, he had lost over $13,000 playing the state lottery and slot machines. His spouse was concerned about possible economic and personal ruin if her husband’s gambling persisted. The patient acknowledged that he had claimed nonexistent winnings, gambled more than intended, felt guilty, had difficulty stopping, hid the evidence of his gambling and secured loans to cover gambling debts. He related a long history of gambling and binge alcohol consumption beginning as a teenager. The patient had had a successful military career and retired from the Army to own a small business.
The patient was referred to Gamblers Anonymous and Alcoholics Anonymous, and he also received assistance from community mental health services. The patient’s spouse attended Al-Anon meetings. Although he attended only one Gamblers Anonymous meeting and one Alcoholic Anonymous meeting, he believed he could control his behaviors without the assistance of these services. However, he continued to attend counseling sessions and supportive visits with his family physician. His spouse continued to regularly attend Al-Anon meetings.
The patient’s depressive symptoms and behavior improved; he reduced alcohol consumption, ceased gambling and attended individual and family counseling sessions conducted by his family physician. The patient and spouse reported improvement in their relationship and communication. She reported being satisfied with his “controlled” drinking and felt less fearful of potential financial ruin.
Social and Cultural Issues Forms of gambling are recorded through the ages and across cultures. Although the personal costs of gambling rarely gain public attention, one prominent example is that of Pete Rose, who was denied induction into the Baseball Hall of Fame as a result of sports gambling.
The economics of gambling are staggering. The amount of money wagered annually in the United States is estimated to be $0.5 trillion.7 Americans spend approximately $31.5 billion annually on state lottery games, with many states becoming increasingly reliant on revenues from legalized gambling.8 Legalized gambling, organized crime and violence have historically shared a long relationship. Findings from the 1999 Gambling Impact and Behavior Study8 (sponsored by the National Gambling Impact Study Commission) revealed the following changes since 1975: (1) only 14 percent of people have never gambled compared with 33 percent in 1975; (2) 50 percent of people have played the lottery, and 25 percent have gambled in casinos (double the rates from 1975); (3) approximately 2 million Americans are pathologic gamblers, 3 million adults can be considered problem gamblers and an additional 15 million are considered at-risk for problem gambling; (4) direct and indirect costs to American society from problem and pathologic gambling (e.g., health care, bankruptcy, criminal costs) are approximately $5 billion per year.
State-supported assistance programs and insurance coverage for treatment and prevention of problem gambling seems limited in comparison to the problem. The average individual gambling debt reported to a gambler’s help line was $35,185.9 In contrast, the state of Georgia spent only $31,000 in 1998 on programs to assist problem gamblers despite a quadrupling of Gamblers Anonymous chapters since the start of the state lottery in 1993.10
Epidemiology Pathologic gambling is typically a problem of men between 21 and 55 years of age, although gambling disorders are also commonly encountered in teenagers and persons over the age of 65. Women comprised 24 percent of the problem gamblers who called the New Jersey gambler’s hotline in 1997—up from 13 percent in 1990.9 No consistent data are available about the role that racial, ethnic, income or educational factors play in problem or pathologic gambling. A survey of self-reported behaviors administered to 21,297 students in 8th to 12th grades in Vermont revealed that 7 percent of these students had problem gambling behaviors. In this study, drug and anabolic steroid use, violence and carrying a weapon to school were all more common in young people who gambled, especially in those who were problem gamblers.4
Diagnosis The term “pathologic gambling” is reserved for persons who meet the criteria in the Diagnostic and Statistical Manual of Mental Disorders, 4th ed. (DSM-IV) for this condition (Table 1).11
“Problem gambling,” “probable pathologic gambling” and “gambling addiction” are terms used to describe gambling-related behaviors that may not meet specific DSM-IV criteria. The diagnosis of pathologic gambling requires that the patient gamble in a persistent and maladaptive manner that disrupts relationships and daily activities and is not caused by manic episodes (Table 1).11 Suicide attempts, felony convictions, spouse and child abuse, and unemployment are common in pathologic gamblers.12 Gamblers may hide or deny gambling-related problems, however, making pathologic gambling an often overlooked and undiagnosed condition.
TABLE 1. Diagnostic Criteria for Pathologic Gambling A. Persistent and recurrent maladaptive gambling behavior as indicated by five (or more) of the following: 1. Preoccupation 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 of 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 one’s losses) 7. Lies to family members, therapist, 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. Reprinted with permission from American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 4th ed. Washington, D.C.: American Psychiatric Association, 1994:615–18. Copyright 1994.
Evidence points to the common existence of narcissistic personality characteristics and impulse control problems in pathologic gamblers. High rates of personality disorders (e.g., obsessive-compulsive, avoidant, schizotypal and paranoid) are noted in several studies.8,13 Personality profiles of persons who are alcoholics and pathologic gamblers are also similar in some studies. Some experts view pathologic gambling as an addictive disorder, citing as evidence the tolerance and withdrawal symptoms exhibited by pathologic gamblers because of debt escalation behaviors.14 However, no physical or biochemical markers exist to help physicians make the diagnosis.
SCREENING TOOLS Several surveys are available to assist physicians in diagnosing this condition. The 1998 Gambling Impact and Behavior Study8 used a new screening tool based on DSM-IV criteria. The South Oaks Gambling Screen (SOGS) is the only extensively used, validated screening tool for the evaluation of patients who are pathologic gamblers15 (Figure 1).16 Although it is not validated, the Gamblers Anonymous Survey (Table 2), which includes 20 questions, may be helpful in providing clinical information and can orient the gambler to the Gamblers Anonymous program. Seven positive responses to the survey questions suggest the diagnosis of pathologic gambling. A similar survey, “Are you living with a compulsive gambler?”16 can be used to assist family members in coping with a problem gambler.
The South Oaks Gambling Screen
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