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Section 17
Problem Gambling

Question 17 | Test | Table of Contents

John Nikolakis came from a privileged family. Few would have predicted that last September, at the age of 36, he would be alone in a dark, cold Louisiana apartment--all the utilities were cut off because he couldn't pay for them--dead broke and writing suicide notes. He was on probation for having embezzled nearly $80,000 from his former employer. His entire adult life had been consumed by the intoxication and compulsion of gambling away hundreds of thousands of dollars on everything from online poker to sports. He lost two good jobs, one girlfriend, and 17 years of his life. "This gambling crap has cost me everything," he says. "It cost me my pride, my honesty, and the biggest thing it cost was the relationships of people who cared for me."

His story, with as many variations as there are individuals, illustrates the trajectory of most pathological gamblers: a period of exhilaration and great windfalls--punctuated by a little dishonesty here and there--ending in misery, financial ruin, and shattered personal relationships. In 1980, the American Psychiatric Association officially categorized pathological gambling as a diagnosable medical disorder, and since then there has been increasing understanding of the brain chemistry, the biology, even the genetics that play a role. As pathological gambling has become more fully understood as a discrete disorder, more-sophisticated treatments have evolved. But pathological gambling has its own distinct pathology, so there are new and promising drug and therapeutic interventions as well.

Experts often describe pathological gambling as being both a "pure" and a "hidden" addiction. It is pure because it does not change the brain chemistry by introducing other substances like drugs or alcohol do. It is hidden because unlike, say, mainlining heroin, gambling is generally a socially acceptable behavior.

Socially acceptable behavior run amok, that is. The pathological gambler needs to wager more and more money to achieve that deeply satisfying, and addictive, point of excitement. These and other signs (box at right) indicate the difference between the person who takes an occasional trip to Atlantic City and someone with a real problem. And withdrawal can be punishing, with terrible headaches, irritability, and anxiety.

Bad willpower. Experts say that pathological gambling is a problem that affects 11 million people--with 1.6 percent of adults being pathological gamblers and an additional 3.9 percent suffering from problem gambling--and merits far greater attention than it has received. "People think it is poor character, bad willpower, someone is flawed in terms of moral strength," says Jon Grant, assistant professor of psychiatry at Brown Medical School and coauthor of Stop Me Because I Can't Stop Myself. "Many people don't have a clue that this is a biological illness with a distinct pathophysiology."

Scientists are learning that the brain and even the genes of a pathological gambler differ from those of the occasional poker player. In research presented last month at the American Academy of Neurology's annual meeting, scientists pointed to the prefrontal cortex, that part of the brain responsible for decision making and impulse control, as being impaired in pathological gamblers.

Dopamine--a neurotransmitter in a brain that acts like adrenaline and has lots to do with how people behave and experience pleasure--is also thought to be involved. When dopamine is released, the dopamine receptors act like magnets, telling it where to go. For pathological gamblers, the receptor sites in the midbrain that are driven by the anticipation of rewards are especially sensitive, requiring increasing amounts of dopamine to create the rush of happiness. What triggers the dopamine rush? Gambling, of course, and a vicious cycle is created.

In the past, Gamblers Anonymous, a 12-step, self-help program that began in 1957, was the solution. "Medical people wanted nothing to do with gambling," says Joanna Franklin, president of the Maryland Council on Compulsive Gambling. "Their major prescription to someone was telling them to knock it off." And while many credit Gamblers Anonymous with rebuilding lives, one study found that only 8 percent of those who entered GA were still attending after a year. Casinos have attempted to enforce "self-exclusion" policies, in which pathological gamblers empower the casino to call the police if they are spotted. "It is a very good but very, very limited tool," says Keith Whyte, executive director of the National Council on Problem Gambling.

The fact is, no two gamblers are alike, and the secret to stopping the problem is figuring out what triggers the behavior. Often, cognitive behavioral therapy, which aims to adjust behavior by helping patients recognize and refute negative impulses, provides insight into the cycle and other options for managing the trigger feelings. "They need to have alternate forms of leisure activity," says Henry Lesieur, a gambling addiction expert who sees great merit in the therapy. "They have gotten out of the habit of having fun in their lives." While antidepressants have been used, with mixed success, recent research has looked at gambling as a problem with impulse control. In fact, a drug called nalmefene that is supposed to reduce craving and may be able to treat the longing to gamble is currently undergoing clinical trials.

What saved Nikolakis, who attends GA meetings, was a stint earlier this year at one of the few residential treatment facilities in the country exclusively for pathological gamblers. The Center of Recovery was established in Louisiana in 1998 and has served over 600 clients. "These people know how to start gambling, and they know how to stop," says Corinne Dumestre, the CORE program director during Nikolakis's stay. "You either go to the machine or you don't. What they don't know is what exists between those two poles." The CORE day is filled with physical fitness programs, therapy sessions, education sessions, and chores. Three quarters of those who complete the program never gamble again.

After his CORE success, Nikolakis credits GA with keeping him clean. "I used to be the guy who was the big shot with $600 in my pocket," says Nikolakis, who plans to attend cooking school. Now, "I can have $3 in my pocket and am three times as happy."

MYTH Casinos lace their air with chemicals that put you in a betting mood.
REALITY Casino executives scoff and say their ventilation systems just filter cigarette smoke. But a Chicago neurologist says he sells some casinos (which he wouldn't identify) a "pleasant odor" that his studies show boosts slot betting.

Warning signs
It was once considered a moral failing. But the American Psychiatric Association classifies pathological gambling not as an addiction but as an "impulse control" disorder like pyromania. To be considered pathological, a person must demonstrate five or more of these 10 characteristics:
1 Is preoccupied with gambling, reliving gambling experiences, or thinking of ways to get money to gamble.
2 Needs to gamble with a larger pot of money in order to achieve the desired level of excitement.
3 Tries repeatedly but fails to control, cut back, or stop gambling.
4 Becomes restless or irritable when attempting to scale back or stop gambling.
5 Gambles as a way to escape from family or work problems or to relieve a depressed or unhappy mood.
6 After losing money, often returns another day to get even.
7 Lies to family members, therapists, colleagues, or others to conceal the extent of the gambling habit.
8 Has committed illegal acts like forgery, fraud, theft, or embezzlement to finance gambling habit.
9 Has jeopardized or lost a significant relationship, job, or educational or career opportunity because of the need to gamble.
10 Borrows money from friends, family, even strangers to pay off catastrophic debts from gambling.

Szegedy-Maszak, M. (2005). The Worst of All Bets. U.S. News & World Report, 138(19).

Treatment, Prevention, and Responsible Gambling Programs
Lostutte, T., Philander, K., & Walter, T., & Larimer, M. (2019). Treatment, Prevention, and Responsible Gambling Programs in Washington State. 5-76.

The article above contains foundational information. Articles below contain optional updates. Personal Reflection Exercise #10
The preceding section contained information regarding warning signs of pathological gambling for the family.  Write three case study examples regarding how you might use the content of this section in your practice.

Peer-Reviewed Journal Article References:
Canale, N., Cornil, A., Giroux, I., Bouchard, S., & Billieux, J. (2019). Probing gambling urge as a state construct: Evidence from a sample of community gamblers. Psychology of Addictive Behaviors, 33(2), 154–161.

Kim, H. S., Sears, C. R., Hodgins, D. C., Ritchie, E. V., Kowatch, K. R., & McGrath, D. S. (2021). Gambling-related psychological predictors and moderators of attentional bias among electronic gaming machine players. Psychology of Addictive Behaviors. Advance online publication.

Kvam, P. D., Romeu, R. J., Turner, B. M., Vassileva, J., & Busemeyer, J. R. (2021). Testing the factor structure underlying behavior using joint cognitive models: Impulsivity in delay discounting and Cambridge gambling tasks. Psychological Methods, 26(1), 18–37.

Rogier, G., Beomonte Zobel, S., Marini, A., Camponeschi, J., & Velotti, P. (2021). Gambling disorder and dissociative features: A systematic review and meta-analysis. Psychology of Addictive Behaviors, 35(3), 247–262.

How is pathologically gambling a "pure" and a "hidden" addiction? To select and enter your answer go to Test.

Section 18
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