The following is part of a comprehensive study (re-written) on pathological gambling (gambling addiction) from the Library and Archives of Canada: "3. Conceptualizing, defining and measuring problem gambling." The original study is in the public domain.
Pathological gambling is also known as compulsive gambling, problem gambling, and gambling addiction; however, "pathological gambling" often has unintended medical connotations attached to it and is rarely used by the lay person. Those who have a pathological gambling problem are referred to as gambling addicts, pathological gamblers, compulsive gamblers, or problem gamblers. These terms will be used interchangeably.
Pathological gambling is often diagnosed with the criteria in the DSM (Diagnostic and Statistical Manual) tool developed by the APA (American Psychiatric Association). These criteria were created from the behaviors and experiences of pathological gamblers who sought help for their addiction. The APA's DSM-III definition for pathological gambling, as defined by Dr. Rosenthal is:
"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."
A pathological gambling self-assessment can be made by taking the SOGS (South Oaks Gambling Screen) test, which is based on the APA's DSM criteria . The test consists of 16 questions developed by Henry Lesieur, Ph.D., and Sheila Blume, M.D. According to the APA's DSM-III criteria, pathological gambling is a "progressive disorder." However, many researchers have debated whether gambling addiction is in fact a progressive disorder. They point to the fact that it is possible for compulsive gamblers, even those who meet the APA's DSM criteria, to recover on their own without outside intervention.
Treatment for gambling addiction is very similar to treatment for drug addiction and alcoholism, with slight differences between the three. That is, all three addictions are similar in nature.
There are three main groups of pathological gamblers: those who seek help, those who do not seek help, and the general gambling population (including those who gamble and have a problem and those who gamble but do not have a problem). Most studies are from gamblers who have sought help for their addiction-- the treatment seekers. These studies indicate that there are physiological, psychological, and sociological differences between pathological gamblers and non-problem gamblers.
There is a consensus among researchers that pathological gambling is caused by a combination of biological (physiological), psychological, and sociological factors. However, the same researchers cannot agree which factor (physiological, psychological, or sociological) is the primary cause, or if all three factors contribute equally to the problem.
Most pathological gambling studies are performed by psychologists and psychiatrists. Both groups tend to focus on individual factors that contribute to the problem. They suggest that pathological gambling is an internal problem within the individual's psyche and, as a result, treatment is focused on changing the behavior and/or focusing on the biological predisposition of the individual. The psychological approach to treatment is to focus on the internal (pain, suffering) and behavior (anti-social, narcissistic) indicators of distress according to the DSM-IV (Diagnostic Statistical Manual). These indicators include:
- Willingness to risk behavior and social standing in order to continue gambling.
- Preoccupation with gambling (for example, going through "money making systems").
- Lack of control over gambling behavior.
- Guilt over the behavior, usually after the fact.
- Withdrawal symptoms when not in action.
Many scholars believe that pathological gambling is not only an individual or personal problem, but it is social in nature.
There are different models for labeling gambling addiction. One is the disease model, preferred by Gamblers Anonymous and most psychiatrists. In the disease model, the causes are influenced primarily by biological (physiological) factors. Once someone becomes a compulsive gambler, there is no true recovery. The individual now has a "disease" and will always remain a compulsive/pathological gambler. However, many researchers point out that the Gamblers Anonymous' 20 questions mainly focus on the consequences, or the effects, of the addiction and not the underlying causes.
Gambling addiction, conceptualized by Shaffer and Hall (1996), can be divided into 4 levels.
- Level 0 (zero). Level 0 is reserved for non-gamblers, those who don't gamble at all.
- Level 1. Level 1 is reserved for non-problem gamblers, those who do gamble but do not have a problem (occasional recreational gamblers).
- Level 2. Level 2 is reserved for those at risk or in transition (in the early stages) of developing a gambling problem.
- Level 3. Level 3 is reserved for people with the most severe gambling problem, those who meet the APA's DSM criteria for gambling addiction.
- Level 4. Level 4 are all those in Level 3 who present themselves for treatment. Most information from pathological gambling studies is taken from those in this level.
Biological Theories of Pathological Gambling
Biological theories are those that view gambling addiction as caused in part by biological predisposition, or genetic inheritance. However, it is well-established that genetics alone do not determine behavior or addiction. There has to be other factors involved, such as psychological and environmental. Therefore, biological theories by themselves do not fully explain gambling addiction. There is a complex interaction between the predisposition (genetic make-up) of the individual and their environments.
Biological theories assume that addictions, whether to alcohol, gambling, or drugs, tend to run in families. Those who have a gambling problem are likely to have a one or more family member who has a history of addiction. The biological theories of gambling addiction can be examined through three main models.
1. EEG waves.
2. Plasma Endorphin levels.
3. Other brain chemical imbalances.
EEG Waves (related to attention deficit). Through EEG wave studies, researchers (Goldstein and Carlton, 1988) have found that certain brain patterns in problem gamblers resemble that of children who have ADHD(Attention Deficit Hyperactivity Disorder). Problem gamblers are also more likely to have childhood behaviors that are consistent with those who have ADD (Attention Deficit Disorder). The attention deficit problems could explain the poor impulse control in problem gamblers. For this reason, in 1994 the APA (American Psychiatric Association), through its DSM-IV (Diagnostic Statistical Manual) characterized gambling addiction as a "disorder of impulse control."
Endorphin Levels (Arousal theory). Laboratory research as shown that those who gamble on horse racing (slower moving) have lower base levels of endorphins than those who gamble on video poker machines (faster moving). Thus, those who prefer faster moving games have higher base levels of endorphins.
The primary measure of arousal is the increase in heart rate. It has been found that the heart rate of compulsive gamblers is much higher and more persistent than non-problem gamblers. For compulsive gamblers, even exposure to gambling-related audible or visual stimuli can create arousal (increase in heart rate). These stimuli include the ringing sound of slot machines; seeing the word "casino" or "win", pictures of horses or race tracks, pictures of playing cards, a poker table, a stock ticker, and so on. The arousal theory suggests that problem gamblers are attempting to seek and maintain an optimum level of stimulation through gambling. Problem gamblers are seeking a high.
Arousal Theory and the General Theory of Addictions
The arousal theory can be best explained by the General Theory of Addictions (Jacobs, 1986). The theory suggests that a physiological pre-condition (genetics) is combined with two other factors: unipolar physiological resting state and psychological problems as the causes of addiction.
1. Unipolar physiological resting state. The compulsive gambler is chronically under stimulated or over-stimulated due to chemical imbalances. Compulsive gamblers were found to be more prone to boredom and gamble to seek stimulation to relieve boredom. They were also more prone to depression, but researchers did not find a correlation between boredom and depression. A common treatment method to reduce arousal is to practice relaxation techniques (deep breathing, meditation, visualization, imaging, walking).
2. Psychological problems. Feelings stemming from rejection, humiliation, insecurity, guilt, failure, shame can create considerable psychological pain. In addition, negative moods such as depression and anger contribute to the persistence of gambling behavior.
These factors combined cause discomfort in the individual, leading them to self-medicate by engaging in addictive behavior, such as compulsive gambling or excessive drug and alcohol use. The individual seeks to move into a dissociative state in order to escape the discomfort or pain. The individual is attempting to escape from an adverse reality into an altered state of consciousness. In this alternate reality the gambler feels like a different person and loses track of time; the gambler is in a hypnotic trance.
In the General Theory of Addiction, there are three stages in the development of gambling addiction.
2. Resistance to change.
Dr. Jacobs suggested that successful changes can be made in stages 1 (discovery) and 3 (exhaustion).
The General Theory of Addiction combines the biological and psychological theories of addiction into its framework. The "unipolar physiological resting state" (over or under stimulation) is a key factor with this theory, suggesting that gambling addiction is in part inherited through genetics, rather than learned. The General Theory of Addiction is an attempt to explain all addictions, including gambling.
In the biological theories, pathological gambling is not viewed as a disease. But biological components act as contributing factors, which combined with other components (psychological, medical) describe the framework of pathological gambling. Biological theories view gambling addiction as a behavior that is learned or acquired and not a disease or illness. However, biological theories point out that there are physiological weaknesses in the individual that manifest themselves in gambling addiction. These weaknesses are found in the internal structures of the individual and include:
- The inability to plan ahead.
- The inability to recognize the consequences of one's actions in the long-run.
- The strengths of the biological theories are:
- Biological imbalances can be detected.
- It can lift "a large burden of guilt from both the patient and the family."
- It does not shift blame to the individual, pointing to his or her moral failing or weakness of character.
Medical or Disease Model of Pathological Gambling
The medical or disease model of gambling addiction is the most dominant one in North America (U.S., Mexico, Canada). "Compulsive" is a term usually used by the lay person, while the term "pathological" is often used by clinicians (researchers, psychologists, psychiatrists, scientists). In the disease model, the individual is considered either a compulsive gambler or a non-gambler. There is no in-between; the compulsive gambler is considered qualitatively different from non-gamblers. The qualitative differences between compulsive gamblers and non-gamblers are due to a combination of factors that can be measured.
- Physiological factors which pre-dispose the individual to gambling addiction.
- A mental illness such as obsession or compulsion.
- Environmental circumstances.
In the disease model, pathological gambling is a behavioral pattern. One that is repeatedly harmful to the individual and is outside of the individual's conscious control. It is an involuntary action, something that just happens to the individual without his or her choosing-- the problem is an impulse control disorder. In the disease theory, gambling addiction is itself a disease and not a symptom of another disease or illness. The disease, pathological gambling, is manifested through characteristic signs, symptoms, and stages of development (Blume, 1987).
Components of Gambling Addiction Defined by the Disease Model
1. Gambling addiction is a single phenomenon. It is a disease by itself and not a symptom of another illness or disease.
2. Compulsive gamblers are qualitatively different from other gamblers. These differences can be measured.
3. Compulsive gamblers gradually lose control and are eventually unable to stop gambling despite negative consequences.
4. Compulsive gambling is a progressive condition, a slow deterioration.
Stages of Gambling Addiction as Defined by the Disease Model
a. The winning stage. The initial success is characterized by the "big win". The gambler develops unrealistic expectations of future winnings.
b. The losing stage. There is a progressive, slow loss of money. The gambler believes that only through increased gambling can he or she win back this money. The gambler believes he or she is in a temporary slump and their luck will soon change.
c. The desperate stage. The gambler feels the need to be in action and is driven by irrational optimism about winning. His or her time and energy are consumed with gambling.
d. Money becomes a means to gamble; it has no other value.
e. The gambler suffers psychological distress, as unresolved feelings of guilt keeps him or her gambling, or "in action."
f. The chasing stage. In desperate attempts to win back money lost, the gambler will do almost anything to be in action, including illegal activities such as embezzlement, fraud, and theft.
g. The gambler experiences bouts of guilt and self-castigation and attempts to quit. This is followed by a period of reflection and rationalization. However, unable to stop, the gambler continues with the downward spiral. Gambling is now a compulsion, undertaken in a frantic, even ritualistic manner.
h. The rock bottom stage. All money sources are exhausted and the gambler admits he or she has a problem and seeks help.
In the disease model, gambling addiction is a permanent and irreversible condition. The only cure is total abstinence. If the gambler places one bet after a period of abstinence, he or she would go through all the stages described above (a-h) again.
Studies have shown that social gamblers, who can control their gambling behavior for years, can be at risk of becoming compulsive gamblers. Other studies have shown that long-time social gamblers remain social gamblers without developing a gambling problem.
The disease model, similar to the biological model, is "useful in lifting a large burden of irrational guilt from both the patient and the family," (Blume, 1987). The disease model stresses that gambling addiction is an involuntary behavior. Therefore, the gambler doesn't have to carry the moral burden, knowing that gambling is sometimes viewed as immoral. The disease model is simple to explain to the families of compulsive gamblers. It is also a useful template for dealing with the problem. Since gambling addiction is viewed as an involuntary action, in the legal context, it is outside the individual's responsibility. Once diagnosed with a gambling addiction disease by a licensed professional, the individual can ask their insurer to pay for treatment.
In the disease model, the gambler is labeled as a "sick" individual. Some argue that this "sick" label (championed by Gamblers Anonymous) can be detrimental since it leads to a mentality of hopelessness or despair. The individual would have no real defense against a full relapse (Oldman, 1978; Rosecrance, 1985). The "sick" label also marginalizes the individual and puts the gambler in a deviant group. Those compulsive gamblers who refuse to accept the sick label are considered to be "in denial."
The sick label component of the disease model shifts the reasonability from the individual to a disease process. The "experts" are now in charge of treating the "sick" individual. Some argue that although the individual is considered a sick person, it does not mean that the gambler should be passive in his or her own treatment. It just means that the individual was not responsible for contracting the disease on his or her own but the fact that they sought help is evidence that they are capable of playing an active role in their treatment alongside a professional.
There are several criticisms of the disease model (gambling addiction is just something that happens to the individual).
- Too much emphasis is placed on treatment and little emphasis on preventive measures.
- It was developed by clinicians from information gathered from only those who sought treatment. These individuals might have been considered the "sickest." It does not take into consideration those who have a gambling problem but have not sought treatment.
- It overvalues biological and physiological factors and undervalues environmental and sociological factors. Basically, the disease model is "behavior determinism" and rules out freewill (individual choice).
- The only possible treatment is total abstinence with the disease model. However, studies have shown that it is possible for compulsive gamblers to gamble in a controlled manner after treatment.
Some view the disease model as a successor to the moral model (Shaffer and Gambino, 1989). Both models do not blame the individual for their gambling addiction. Compulsive gamblers are no longer viewed as immoral individuals but are still viewed as anti-social or unbalanced in some way.
Gamblers Anonymous is a supporter of the disease model. Another big supporter of the model is the "gaming" industry. Since compulsive gamblers are "sick" individuals, they are different from the norm. This suggests that opportunities (nearness to casinos, Internet) to gamble has nothing or very little to do gambling addiction. For example, the alcohol industry asserts that just as sugar is not the cause of diabetes, alcohol is not the cause of alcoholism (Single, 1984). Therefore, the gaming industry asserts that gambling is not the cause of gambling addiction.