Gambling Disorder DSM-5

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DSM-5 Category: Addictive Disorders

Introduction

The DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, fifth edition) has recognized gambling as a potential behavioral addiction. Addiction or dependency is typically viewed as the physiological and psychological dependence on a chemical substance. Dependence is defined as needing progressively larger amounts of a substance to acquire the same effect that used to be experienced, a characteristic physiological and/or psychological syndrome that emerges in response to cessation of use, and compulsive use despite consequences. The concept of dependence is being increasingly applied to, or considered for, behaviors such as gambling, as well as shopping, sex, exercise, eating, and using electronic media. The DSM-5 notes that gambling is the only behavior that is currently included as a behavioral addiction (American Psychiatric Association, 2013). In the DSM-IV, (Diagnostic and Statistical Manual of Mental Disorders, fourth Edition), pathological gambling was classified as an Impulse Control Disorder NOS (Not Otherwise Specified). In response to a growing knowledge base of the neurological basis of problem gambling, which has commonalities with addiction; pathological gambling was moved to the Addictive Disorder category (Reilly & Smith, 2013).

Gambling can be defined as risking money or valued items, or sometimes behaviors, in the hope of gaining something of greater value. Many people can engage in gambling without it leading to the criteria for a behavioral addiction, such as intrusion into other areas of life, and causing impairment, or making life unmanageable. People will spend relatively small amounts of disposable income on occasion for entertainment or recreation- e.g. - buying $10.00 worth of scratch tickets, or spending a weekend at a casino, or an afternoon at horse or dog racing. They participate with the expectation that they will probably lose, will not get upset at the loss, and will end when the disposable income or lost winnings are depleted. Winning is a somewhat happy surprise. They may not gamble again for weeks or months, and do not spend a great deal of time thinking of the next gambling event. They may anticipate the next weekend at a casino, but gambling is not the focus- other activities, such as staying at a luxurious hotel, socializing, good food, drink, and music, and exploring the city they travel to. Gambling is just one more event of many, not the focus.

However, some individuals will gamble with money allocated for living expenses, indebt themselves to get more money to gamble with, or Hock their valuables, meaning selling valuable items often far below market value to get money to continue gambling. They will react to losses with shock, outrage, anger, blaming, depression, or even violence. They may experience an excitement which is far in excess of what others gambling experience; more of a desperate frenzy then fun. Some individuals will also risk humiliation, social disapproval, or needless risk by staking behaviors on the outcome- e.g., sex with a stranger if you lose.

Problem gambling may be accompanied by cognitive distortions- rigidly held beliefs in superstition, elaborate systems to minimize losses/maximize gains, denial of reality, magical-fantasy thinking which disregards reality, and failure to grasp a very basic concept in gambling: chance events, by definition, cannot be controlled.

It is believed that Gambling Disorder has neurobiological basis as addiction to substances has. One study by Fledman (2013), employed fMRI (functional Magnetic Resonance Imaging) to identify that brain structures are involved with the reward properties of gambling. Gamblers as previously noted, have cognitive distortions around cause and effect and reward punishment, which can impel to continue taking high risk gambling behaviors even when faced with substantial losses (Feldman, 2013).

People with Gambling Disorder act out a preference for short-term large rewards, rather than long-term losses. This inability to delay gratification is related to dopaminergic function. In substance abusers, it is believed they are chronically dopamine deficient, and the use of psychoactive substances produces an activation of the dopaminergic reward system, specifically the nucleus accumbens, which produces a counterfeit pleasure which addicts come to crave. It cannot be assumed that this same mechanism is at work in gambling addicts until evidence is found which supports these hypotheses.

Personality characteristics associated with Gambling Disorder include:

  • Impulsivity
  • Restlessness
  • Susceptibility to boredom
  • Competitive
  • Depression
  • Loneliness (American Psychiatric Association, 2013).

Symptoms of Gambling Disorder

The DSM-5 indicates that the symptoms of Gambling Disorder are:

Gambling which persistently and repeatedly leads to clinically significant impairment or distress over a 12-month period, as indicated by four or more of the following criteria:

1) Tolerance- the need to gamble with progressively more money to achieve the desired level of excitement.

2) Withdrawal- restlessness and irritability accompanying effort s to cut back or stop gambling.

3) Repeated unsuccessful attempts to cut back or stop gambling.

4) Preoccupation with gambling, including ruminating on past gambling, planning future gambling, or thinking of ways to acquire money for gambling.

5) Self-soothing and medicating mood with gambling.

6) Chasing losses- following a gambling loss, further gambling is engaged in to try to recover the losses.

7) Shame- engages in lies to hide the extent of gambling.

8) Intrusion of consequences or time spent gambling into peripheral areas of life- e.g. work, education, and relationships.

9) Becomes reliant on others for money for expenses that has been depleted due to gambling.

10) The gambling behavior is not better accounted for by a manic episode.

There are several specifiers the clinician can apply to the diagnosis:

  • Episodic: The above diagnostic criteria- at least four of 10 criterions- are met at different times over a several month period, with periods of the behaviors not present.
  • Persistent: Continuously meeting the diagnostic criteria over a period of years.
  • In early remission: above criteria were met at one time, but none are met for the past three months.
  • In sustained remission: none of the criteria is met for a 12-month period.
  • Severity: indicated by the number of criteria fulfilled:
  • Mild- four or five criteria.
  • Moderate- six or seven criteria.
  • Severe- eight or nine criteria (American Psychiatric Association, 2013).

Risk Factors for Gambling Disorder

The DSM-5 identifies a number of risk factors for Gambling Disorder:

  • Temperamental Factors: Some gamblers will begin in childhood or early adolescence. This early onset is correlated with development of Gambling Disorder (American Psychiatric Association, 2013).
  • Genetic and physiological factors: Gambling disorder can be familial due to environmental/social learning and genetic predisposition. The catecholamines (serotonin, norepinephrine, dopamine) as well as opioid and glutamate neurotransmitter systems have been implicated in Gambling Disorder (Potenza, 2013), although it is unclear if this is genetically based, or due to environmental influences. PET (Positron Emission Tomography) scans have not found evidence for three hypotheses related to the dopamine theory of compulsion to gamble:

1) No evidence supported the low dopamine hypothesis

2) High risk, maladaptive decision-making in gambling disorder is not associated with higher dopamine release during gambling.

3) Maladaptive decision-making in gambling disorder is not associated with higher dopamine release during winning.

There is a maximum release of dopamine during exposure to a stimuli with maximum uncertainty as to the outcome- e.g. - gambling. The act of placing a bet and awaiting the outcome produces maximum stimulation of the pleasure centers, teasing the brain, as it was (Linnet, 2013). Other factors include an increased rate of gambling disorder among those who are dependent on alcohol (American Psychiatric Association, 2013).

Onset of Gambling Disorder

The DSM-5 notes that Gambling Disorder can begin in adolescence or young adulthood, although it may appear in middle or late adulthood. It is also noted that women tend to progress more rapidly (American Psychiatric Association, 2013).

Differential Diagnosis in Gambling Disorder

The DSM-5 describes a number of diagnostic rule-outs for problem gambling:

  • Nondisordered gambling: Gambling behavior that is not indicative of pathology. The DSM-5 lists two distinctions in this category- social and professional gambling. Social gambling is described in the Introduction section of this article. Professional gamblers are noted to minimize risks and practice discipline in their gambling.
  • Manic phase of bipolar disorder: During the course of a manic episode, reckless and impulsive behavior may be acted out, which could include high-stakes gambling without assets to support the behavior.
  • Antisocial Personality Disorder: Antisocial individuals may gamble as part of their propensity for impulsive and risk taking behavior, or as part of their manipulative/power/domination behaviors, hustling others for gain. An example is creating the impression they are unskilled at playing pool, deliberately losing games, which encourages the other players to bet increasing amounts of money. The antisocial individual will then play at their true skill level, easily beating the other players and collecting the winnings.
  • L-dopa and similar medications for Parkinson’s disease are noted to create the urge to gamble. If the urge diminishes when the medication is changed or the dose is lowered, this does not indicate Gambling problems, as it’s causality can be directly related to an adverse medication reaction (American Psychiatric Association, 2013).

Comorbidity with Gambling Disorder

The DSM-5 notes the following conditions are co-morbid with Gambling Disorder:

  • Increased risk of general medical problems: Gambling disorder is correlated with general poor health, including a correlation with two specific conditions: tachycardia and angina pectoris. Both conditions are noted to occur more frequently in those with Gambling disorder. While Angina pectoris is indicative of heart disease, tachycardia may or may not indicate pathology. A high resting heart rate can be due to multiple factors, including anxiety and excitement.
  • Increased incidence of mental disorders:
  • Substance use disorders.
  • Depressive disorders.
  • Anxiety disorders.
  • Personality disorders, particularly Antisocial Personality Disorder (American Psychiatric Association, 2013).

Treatment of Gambling Disorder

The DSM-5 does not specify treatment options for Gambling Disorder (American Psychiatric Association, 2013); however, other sources provide information about treatment options. This includes:

Self-help and peer support groups such as GA (Gamblers Anonymous) typically modeled on 12-step programs for chemical dependence, and brief, solution-focused motivational therapy. CBT (Cognitive–Behavioral Therapy) is frequently used, but it is unclear how effective it is, A combination of CBT and self-help appears to offer advantages such as accessibility to treatment, and enhanced follow through with treatment (Rash & Petry, 2014).

Pharmacological interventions may be developed at some point. If Gambling has an obsessive/compulsive feature, it could be speculated that SSRI’s (Selective Serotonin Re-uptake Inhibitors) could be an effective treatment; neither dopamine agonists nor antagonists have been effective. Dopamine antagonists actually increase gambling motivation and behavior in persons diagnosed with Problem Gambling. Dopamine and norepinephrine agonists, e.g., amphetamines also produced increased gambling behavior (Potenza, 2013).

Prognosis of Gambling Disorder

The DSM-5 notes that many people with Gambling disorder are likely to resolve their [gambling] problem over time, but the definitions used are unclear (American Psychiatric Association, 2013). It is open to interpretation if resolve means cessation of the most problematic behaviors, or complete abstinence. Over time can mean months when losses and consequences first appear, or only after years of loss.

References

American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders. (5th Edition). Washington, DC.

Linnet, J. (2013). The Iowa Gambling Task and the three fallacies of dopamine in gambling disorder. Frontiers in Psychology. 4: 709. doi:10.3389/fpsyg.2013.00709. PMCID: PMC3792697

Feldman, M.A. (2013). Increasing The Odds. (8). A Series Dedicated to Understanding Gambling Disorders. Centers of Excellence in Gambling Research. Retrieved November 9, 2014, from www.ncrg.org/sites/default/files/uploads/.../ncrgmonograph8_fnl.pdf

Potenza, M.N. (2013). How central is dopamine to pathological gambling or gambling disorder?

Frontiers of Behavioral Neuroscience. 7: 206. doi:10.3389/fnbeh.2013.00206. PMCID: PMC3870289

Rash, C.J., and Petry, N.M. (2014). Psychological treatments for gambling disorder. Psychological Research on Behavioral Management. 7: 285–295. Doi:10.2147/PRBM.S40883. PMCID: PMC4199649

Reilly, C., and Smith, N. (2013). The Evolving Definition of Pathological Gambling in the DSM-5. National Center for Responsible Gaming. Retrieved November 9, 2014, from www.ncrg.org/sites/default/files/uploads/.../ncrg_wpdsm


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