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Understanding the Shift from Compulsive to Pathological Gambling

Most people are social gamblers, who gamble for entertainment and typically don’t risk more than they can afford. If they should “chase” their losses to get even, they do so briefly. There is none of the preoccupation, long -term chasing, or progression of the pathological (compulsive) gambler.

In referring to gambling, the terms “pathological” and “compulsive” are often used interchangeably. Compulsive is the layman’s term and the one used by Gamblers Anonymous. Pathological is preferred by clinicians and was introduced in 1980 when the American Psychiatric Association first recognized pathological gambling as a bona fide mental disorder and included it in its Diagnostic and Statistical Manual (DSM-lll). Compulsive gambling was thought a misnomer since, in the language of psychiatry, compulsive behavior is involuntary and “ego-dystonic” (external or foreign to the self). Examples of a compulsion would include repetitive hand washing or the irresistible urge to shout an obscenity. Pathological gambling, at least in its early stages, is typically experienced as pleasurable.

Pathological gambling has been defined as a progressive disorder characterized by a continuous or periodic loss of control over gambling; a preoccupation with gambling and with obtaining money with which to gamble; irrational thinking; and a continuation of the behavior despite adverse consequences.

This is essentially the definition of an addiction, and in the most recent edition of the Diagnostic and Statistical Manual (DSM-5) (2013), the disorder has been reclassified and renamed. It now appears in the same category as the alcohol and substance use disorders. Its name has been changed to Gambling Disorder to further emphasize its similarity with the substance use disorders. Significantly, it is the first behavioral or non-chemical addiction to be recognized in the official nomenclature.

Action vs Escape

While money is important, male gamblers in particular say they are seeking “action,” an aroused, euphoric state comparable to the ”high” derived from cocaine or other drugs. Some gamblers will go for days without sleep and for extended periods without eating or taking care of bodily needs. Clinicians have described the presence of cravings, the development of tolerance (increasingly larger bets or the taking of greater risks to produce a desired level of excitement), and the experience of withdrawal symptoms. Gamblers report a “rush,” characterized by sweaty palms, rapid heartbeat, nausea or queasiness; this can be experienced while gambling, in anticipation of gambling, or in response to any situation or feeling which reminds them of gambling.

There are other kinds of intense physiological reactions. Some individuals with a gambling disorder are less interested in the excitement, or action, than they are in escape. They are seeking to numb themselves, and will speak of their quest for “oblivion.” This latter group includes many women gamblers, as well as many slot and video poker machine players. Many gamblers, both male and female, experience amnesic episodes, trances and dissociative states in relation to their gambling.

For both the action seekers and the escape gamblers, there are distortions in thinking. These include denial, fixed beliefs, superstition and other kinds of magical thinking, and notably omnipotence. This illusion, or delusion, of power and control is born out of desperation.The more helpless the gambler’s situation, the greater their sense of certainty about a positive outcome.

To be diagnosed with a gambling disorder, an individual must meet at least four of nine diagnostic criteria established by the American Psychiatric Association (2013). These criteria have been thoroughly tested for validity and reliability. The nine criteria include: loss of control, tolerance, withdrawal, increasing preoccupation, gambling to escape problems and dysphoric feelings, long-term chasing, lying about one’s gambling, jeopardizing family, education, job or career, and serious financial difficulties requiring a bailout.

Four phases have been described: winning, losing, desperation, and hopelessness. As the disorder progresses, there is not only an increase in amounts wagered and time devoted to gambling, but an increase in feelings of shame, guilt, helplessness, and depression. Some gamblers will turn to illegal activities and do things that were previously thought inconceivable; twenty percent will attempt suicide. There may be the development or exacerbation of other mental disorders, notably anxiety and depressive disorders and other addictive disorders. Stress-related physical illnesses are also common.

It is not bad luck, greed or poor money management that causes one to develop a gambling disorder. These may cause one to temporarily develop a problem, but most people will then stop, they won’t keep going back, causing themselves more pain. Very few individuals with a gambling disorder can stop before sustaining serious losses although a few do become concerned about their intense physical reactions to gambling or the effect that their preoccupation, the time they devote to it, is having on other aspects of their life.

One need not lose everything to have a gambling disorder, nor is it necessary to think about gambling every day. Some individuals are binge or episodic gamblers. Some lose control only while engaged in one kind of gambling; they may not be interested in other forms of gambling, or may even gamble at other types of games in order to get money, which they will then lose on their game of choice.

Gambling disorders are very treatable, especially when one consults an experienced counselor or therapist. While it may not be necessary to know why one gambles in order to stop, an understanding of the reasons for one’s gambling is important for sustained abstinence. Individual psychotherapy, preferably in conjunction with participation in Gamblers Anonymous, is the preferred form of treatment. Medication has also been used, especially for those individuals who have intense cravings or who have co-occurring disorders (depression, anxiety, attention deficit disorder, and impulsivity). Most gamblers, however, can be treated without medication.

For additional information on gambling disorders please review the Expert Q&A hosted by the American Psychiatric Association: