Treatment of Female Pathological Gambling: The Efficacy of a Cognitive-Behavioural Approach

Given that a substantial proportion of current pathological gamblers are female, it is evident that women are underrepresented in the treatment outcome literature. The current study was designed to redress the limited information on the treatment of female pathological gambling. Although the use of cognitive-behavioural therapy is the most highly recommended approach as ‘best practice’ for the treatment of pathological gambling, no attempt to date has been made to evaluate the efficacy of this approach for female pathological gambling. Nineteen female pathological gamblers with electronic gaming machine problems were treated with a cognitive-behavioural program. While pathological gamblers placed on a waiting list did not show significant improvement on gambling behaviour and psychological functioning measures, the female pathological gamblers showed significant improvement on these measures over the treatment period, and maintained this improvement at the 6-month follow-up evaluation. By the completion of the follow-up period, 89% of participants no longer met diagnostic criteria for pathological gambling. Although further scientific demonstration and replication are required, the outcomes of this study indicate that the therapy that is considered ‘best practice’ in the treatment of pathological gambling is effective for female pathological gambling.     

Treatment Goal Selection for Female Pathological Gambling: A Comparison of Abstinence and Controlled Gambling

The current study was an exploratory investigation of the selection of controlled gambling as a goal of treatment for female pathological gambling. Specifically, it aimed to explore: 1) the popularity of controlled gambling as a goal of treatment; 2) the reasons pathological gamblers select abstinence and controlled gambling as goals of treatment; and 3) the characteristics of pathological gamblers attracted to abstinence and controlled gambling. The sample comprised 85 female pathological gamblers attending a cognitive-behavioural treatment program for pathological gambling. The selection of controlled gambling by one-third (34%) of the sample suggests that, at least in the Australian context, controlled gambling is a relatively popular goal of treatment for female pathological gamblers. In this study, the only differences between treatment-seeking female pathological gamblers selecting abstinence and controlled gambling were that those selecting controlled gambling were older and were less likely to endorse the belief that problematic gambling is a disease or affliction that can only be overcome by lifelong abstinence. Further research investigating the characteristics of pathological gamblers associated with controlled gambling as both a goal and outcome of treatment is required in order to ensure that treatment-seeking pathological gamblers can make an informed decision regarding their goal selection.     

The Involvement of a Concerned Significant Other in Gambling Disorder Treatment Outcome

Interpersonal distress is a common feature in gambling disorder and adding a concerned significant other (CSO) to the recovery process could be an effective tool for improving treatment outcome. However, little empirical evidence is available regarding the effectiveness of including a CSO to interventions. We aimed to compare treatment outcomes (i.e. compliance with therapy guidelines, dropout from treatment, and relapse during treatment) in a CBT program involving a CSO to CBT treatment as usual (TAU) without a CSO. The sample comprised male gambling disorder patients (N = 675). The manualized CBT intervention consisted of 16 weekly outpatient group sessions and a 3-month follow-up period. Patient CSOs attended a predetermined number of sessions with the patient and were provided with resources to acquire a better understanding of the disorder, to manage risk situations, and to aid patients in adhering to treatment guidelines. Patients with a CSO had significant higher treatment attendance and reduced dropout compared to patients receiving TAU. Moreover, patients whose spouse was involved in the treatment program were less likely to relapse and adhered to the treatment guidelines more than those with a non-spousal CSO. Our results suggest that incorporating interpersonal support to gambling disorder interventions could potentially improve treatment outcomes.     

An Exploratory Study of Clinical Measures Associated with Subsyndromal Pathological Gambling in Patients with Binge Eating Disorder

Both binge eating disorder (BED) and pathological gambling (PG) are characterized by impairments in impulse control. Subsyndromal levels of PG have been associated with measures of adverse health. The nature and significance of PG features in individuals with BED is unknown. Ninety-four patients with BED (28 men and 66 women) were classified by gambling group based on inclusionary criteria for Diagnostic and Statistical Manual-IV (DSM-IV) PG and compared on a range of behavioral, psychological and eating disorder (ED) psychopathology variables. One individual (1.1% of the sample) met criteria for PG, although 18.7% of patients with BED displayed one or more DSM-IV criteria for PG, hereafter referred to as problem gambling features. Men were more likely than women to have problem gambling features. BED patients with problem gambling features were distinguished by lower self-esteem and greater substance problem use. After controlling for gender, findings of reduced self-esteem and increased substance problem use among patients with problem gambling features remained significant. In patients with BED, problem gambling features are associated with a number of heightened clinical problems.     

A Preliminary Investigation of Abstinence and Controlled Gambling as Self-Selected Goals of Treatment for Female Pathological Gambling

The current study aimed to provide a preliminary evaluation of the differential efficacy of a cognitive-behavioural treatment program for female pathological gamblers delivered with the goals of abstinence or controlled gambling. The findings were based on the comparison of pathological gamblers selecting abstinence and pathological gamblers selecting controlled gambling on measures of gambling behaviour and psychological functioning. The findings revealed that pathological gamblers selecting controlled gambling displayed comparable levels of improvement to those displayed by gamblers selecting abstinence. Using a treatment completer approach, 89% of the gamblers selecting abstinence compared with 82% selecting controlled gambling no longer satisfied the diagnostic criteria for pathological gambling by the completion of the 6-month follow-up period. Although further scientific demonstration is required, the findings of this study provide preliminary support for the practice of offering controlled gambling as an alternative goal in the treatment of pathological gambling.     

Sociodemographic,Psychopathological and Clinical Characteristics of Pathological Slot-Machine Gamblers in Treatment: A Descriptive Study of Spanish Male Gamblers

The purpose of this study is to describe the sociodemographic, psychopathological, and clinical characteristics of a sample of Spanish male pathological slot-machine gamblers in treatment. The sample was made up of 80 men who met the criteria of the DSM-IV for pathological gambling. The mean age was 29 years, and the mean age at which they had started slot-machine gambling was 20 years, with a mean problem duration of three years before they sought treatment. Regarding employment status, service sector workers were the most frequently represented (36.3%), followed by students (20%) and the unemployed (15%). The most influential psychopathological variables noted were the prevalence of affective disorders (36.2%), past abuse of alcohol (12.5%), and regular use of illegal substances (26.3%), either in the past or at the time of seeking treatment. Also discussed is the low age of the men seeking treatment for gambling problems, the way they finance their gambling and explanations for their gambling behaviour.     

Problems in Measuring the Effectiveness of Cognitive Therapy for Pathological Gambling

Cognitive therapy is a relatively new approach to the treatment of pathological gambling. Theoretically, there are strong grounds for believing that cognitive treatments will be effective in helping individuals cut back and stop excessive levels of gambling. However, there is evidence that cognitive therapy for pathological gambling is being confused with cognitive-behaviour therapy. In this paper, the distinction between treatments that are cognitive and those that are cognitive-behavioural is highlighted. Such a distinction has strong implications for the manualisation of therapy. Additionally, a range of problems that confront the evaluation of all therapies for pathological gambling is considered. Spontaneous recovery without therapeutic intervention has been documented in both field studies of both problem and non-problem players and controlled trials of cognitive therapy compared to a waiting list control group. The implications of the phenomenon of spontaneous recovery for the evaluation of cognitive therapy are described. Other problems common to all evaluations of psychotherapies are considered in relation to gambling and recommendations made for outcome study designs.     

Examining DSM-IV Criteria for Pathological Gambling: Psychometric Properties and Evidence from Cognitive Biases

We examined the DSM-IV criteria for pathological gambling as assessed with the DSM-IV-based Diagnostic Interview for Gambling Severity (DIGS; Winters, Specker, & Stinchfield, 2002). We first analyzed the psychometric properties of the DIGS, and then assessed the extent to which performance on two judgment and decision-making tasks, the Georgia Gambling Task (Goodie, 2003) and the Iowa Gambling Task (Bechara, Damasio, Damasio, & Anderson, 1994), related to higher reports of gambling pathology. In a sample of frequent gamblers, we found strong psychometric support for the DSM-IV conception of pathological gambling as measured by the DIGS, predictive relationships between DIGS scores and all cognitive performance measures, and significant differences in performance measures between individuals with and without pathological gambling. Analyses using suggested revisions to the pathological gambling threshold (Stinchfield, 2003) revealed that individuals meeting four of the DSM-IV criteria aligned significantly more with pathological gamblers than with non-pathological gamblers, supporting the suggested change in the cutoff score from five to four symptoms. Discussion focuses on the validity of the DSM-IV criteria as assessed by the DIGS and the role of cognitive biases in pathological gambling.     

Twelve-Step Facilitated Versus Mapping-Enhanced Cognitive-Behavioral Therapy for Pathological Gambling: A Controlled Study

This study examined the efficacy of two group treatments for pathological gambling, a node-link mapping-enhanced cognitive-behavioral group therapy (CBGT-mapping) and twelve-step facilitated (TSF) group treatment. Forty-nine participants meeting criteria for pathological gambling were recruited from local newspaper advertisements. These participants were randomly assigned to one of three conditions: TSF (n = 11), CBGT-mapping (n = 18), and Wait-List control (n = 9); 11 refused treatment prior to randomization. Outcome measures included number of DSM-IV criteria met, perception of control/self-efficacy, desire to gamble, and frequency of gambling episodes. Analyses revealed a significant treatment group × time interaction (η2_partial = .39). Specifically, the group treatments resulted in significant improvements in the dependent measures, while the Wait-List group remained relatively stable. Overall, CBGT-mapping and TSF had no significant differences on any outcome measure at follow-up assessments. Analysis of post-treatment and 6-month follow-up reveal a significant improvement in gambling outcomes (i.e., fewer DSM-IV criteria met, greater self-efficacy, and fewer gambling episodes (η2_partial = .35), with treatment gains maintained at 6 months. These results are consistent with previous research for group treatment for pathological gambling and provide support for the utility of TSF and a mapping-based CBT therapy as viable intervention for pathological gambling.     

Treatment issues pertaining to pathological gamblers with a comorbid disorder

Evidence of an increased risk for various psychiatric disorders among pathological gamblers far exceeds our understanding of the impact that this psychiatric comorbidity has on the outcome of treatment for pathological gambling. One major source of the problem is that treatment efficacy and effectiveness studies for pathological gambling typically have not addressed comorbidity's impact on outcome. This paper discusses epidemiological, clinical, health service delivery, and research issues pertaining to the intersection of pathological gambling treatment outcome and comorbid psychiatric disorders. It is argued that this topic suffers from major knowledge gaps in terms of the nature of comorbidity of pathological gambling and other psychiatric disorders and the role of client characteristics on treatment outcome for pathological gambling. Research priorities are identified.     

Screening for college problem gambling in Chinese societies: psychometric properties of the Chinese version of the South Oaks Gambling Screen (C-SOGS)

A total of 979 Chinese college students were recruited in order to examine the psychometric properties of the Chinese version of the South Oaks Gambling Screen (C-SOGS). The C-SOGS was internally consistent and correlated with gambling-related problems and negative mental health status. Results of likelihood ratios (LRs) and receiver operating characteristic (ROC) curve supported the C-SOGS as a valid screening instrument for probable pathological gambling. Using the DSM-IV criteria for pathological gambling, the conventional cut score of 5 on the C-SOGS showed satisfactory sensitivity, specificity and false negative rates. This cut score identified 85% of the true positives and 95% of the true negatives. In general, the C-SOGS overestimated the number of pathological gamblers relative to DSM-IV criteria. Future research on Chinese gambling should build on current empirical work on the SOGS to refine the C-SOGS for use with Chinese populations.     

Pathological gambling: A review of the literature (prepared for the American Psychiatric Association task force on DSM-IV committee on disorders of impulse control not elsewhere classified)

This is a review of the literature on pathological gambling prepared for the work group on disorders of impulse control, not elsewhere classified of the American Psychiatric Association. It introduces the new DSM-IV criteria as well as outlines the phases of the career of the pathological gambler. Research discussed includes that on pathological gambling and psychiatric disorders, substance abuse, family issues, children, finances, and crime. Psychoanalytic, personality, behavioral, sociological, psychologically based addiction theories, and physiological research are also summarized. Finally, treatment outcome studies are outlined.This article is dedicated to the memory of Robert L. Custer, MD whose inspiration and encouragement stimulated much of the research discussed herein.     

Problem Gambling and Comorbid Psychiatric and Substance Use Disorders Among Drug Users Recruited from Drug Treatment and Community Settings

Little is known about gambling rates of drug users recruited from drug treatment compared with those recruited from the community. We use the Diagnostic Interview Schedule (DIS) to provide lifetime prevalence estimates of problem gambling (i.e., at least one gambling problem) and DSM-III-R pathological gambling (i.e., at least four gambling problems) and describe the association between gambling and psychiatric disorders for drug users recruited from drug treatment settings (n = 512) and from the community (n = 478). We also report the relative risk of being a recreational and problem gambler in this sample. The sample was first interviewed in 1989–90 as a partof two NIDA-funded St. Louis-based studies. The prevalence of problem gambling in the overall sample was 22% and the prevalence of pathological gambling was 11%. There were no statistically significant differences in problem and pathological gambling rates for subjects recruited from drug treatment and those recruited from the community. The conditional prevalence rates, that is, the rate of problem and pathological gambling only among gamblers were 27% and 13.5%, respectively. Major findings indicate that problem gambling was associated with Antisocial Personality Disorder (ASPD), even after controlling for recruitment source and socio-demographic characteristics. In fact, when examining the temporal order of these disorders, we found that pathological gambling was always secondary to ASPD, occurring on average 11.4 years after the onset of ASPD. Problem gamblers, compared with everyone else, were more likely to be male, African-American, recruited from drug treatment, have ASPD and be dependent on illicit drugs. Multinomial logistic regression analysis predicted the relative risk of being a recreational and problem gambler (compared with a nongambler) in this sample according to socio-demographics, ASPD, and dependence on illicit drugs. Results imply that screening for gambling problems will need to be broad-based among drug users.     

Alcohol Use and Prior Substance Abuse Treatment in Relation to Gambling Problem Severity and Gambling Treatment Outcome

Recent research has made it clear that problematic gambling is often accompanied by problematic alcohol use. Unfortunately, little is known about the nature of this association, especially as it relates to gambling treatment outcome. The purpose of this study is to explore the effect of current alcohol use level and previous substance abuse treatment on the symptoms of a large cohort of pathological gamblers as well as on their response to treatment for pathological gambling. The sample included 464 men and 301 women recruited at six gambling treatment programs in Minnesota. Gambling treatment patients were assessed on a number of gambling problem severity and related clinical variables using the Gambling Treatment Outcome Monitoring System (GAMTOMS). Patients with frequent alcohol use had greater gambling involvement at baseline than infrequent alcohol users. Patients with a previous history of substance abuse treatment had more severe psychosocial problems, ostensibly resulting from their gambling behavior, than patients without past substance abuse treatment. A MANOVA with repeated measures showed that neither pretreatment alcohol use, nor past substance abuse treatment exerted significant effects on gambling treatment outcome. While the level of pretreatment alcohol use and a history of substance abuse treatment are markers for greater gambling problem severity, treatment outcome for pathological gambling was not adversely impacted by these variables.     

Gambling Disorder: Exploring Pre-treatment and In-treatment Dropout Predictors. A UK Study

The aim of this study was to identify predictors of treatment dropout in a sample of gamblers attending a specialist clinic for gambling disorder. We analysed data on 846 treatment-seeking pathological gamblers. Firstly, we investigated differences in socio-demographic and clinical variables between treatment completers and pre-treatment dropouts, as well as between treatment completers and during-treatment dropouts. Subsequently, variables were entered into a multinomial logistic regression model to identify significant predictors of pre-treatment and in-treatment dropout. Overall, 44.8% of clients did not complete the treatment: 27.4% dropped out before starting it, while 17.4% dropped out during the treatment. Younger age and use of drugs were associated with pre-treatment dropout, while family history of gambling disorder, a lower PGSI score, and being a smoker were related with in-treatment dropout. Our findings suggest that pre-treatment dropouts differ from in-treatment dropouts, and, thus, further research will benefit from considering these groups separately. In addition, this newly gained knowledge will also be helpful in increasing treatment retention in specific subgroups of problem gamblers.     

Reliability,Validity, and Cut Scores of the South Oaks Gambling Screen (SOGS) for Chinese

We examined the reliability, validity, and classification accuracy of the South Oaks Gambling Screen (SOGS) when adopted for use in Chinese. The DSM-IV criteria for pathological gambling served as the standard against which the classification accuracy of the SOGS was tested. A total of 283 Chinese adults in the community and 94 Chinese treatment-seeking gamblers were recruited. The internal reliability of the SOGS was satisfactory for the general sample and acceptable for the gambling sample. The SOGS was correlated with the DSM-IV criteria items as well as psychosocial and gambling-related problems. Relative to the DSM-IV criteria, the SOGS tended to overestimate the number of pathological gamblers in both samples. In general, we were relatively confident that individuals were not pathological gamblers if the SOGS scores were between 0 and 4 and were pathological gamblers if the SOGS were between 11 and 20. There was about 50–50 chance of being pathological gamblers if the SOGS scores were between 8 and 10. However, the probability of individuals being pathological gamblers was about 0.30 if the SOGS scores were between 5 and 7. We proposed a SOGS cut score of 8 to screen for probable pathological gambling in Chinese societies.     

Pathological gambling among adolescents: Massachusetts Gambling Screen (MAGS)

This article describes the development of the Massachusetts Gambling Screen (MAGS). The purpose of the MAGS is to provide a brief clinical screening instrument that can (1) yield an index of non-pathological and pathological gambling during a 5 to 10 minute survey or interview and (2) document the first psychometric translation of the proposed DSM-IV pathological gambling criteria into a set of survey or clinical interview questions. The development data for this instrument were obtained from a survey of 856 adolescents who were students in suburban Boston high schools. The results provided evidence that weighted item scores (i.e., discriminant function coefficients) could correctly classify 96% of adolescent gamblers as pathological, in transition or non-pathological when DSM-IV criteria were employed as the conceptual referent. The results also describe the prevalence of a variety of social and emotional problems associated with adolescent gambling. Finally, the discussion examined the normalization and contemporary social context of gaming and the impact of these influences on the measurement and identification of pathological gambling.Thanks are extended to Dr. Thomas Sharkey, Mary Kaddaras, Alan Bryce, David Shaffer, and Reingard Heller for their assistance during the development and implementation of this project.     

When Does Premature Treatment Termination Occur? Examining Session-by-Session Dropout Among Clients with Gambling Disorder

Premature termination challenges the successful outcomes of psychological treatments for gambling disorder. To date, research has primarily identified clients who are at particular risk for dropping out of treatment. A smaller but growing body of literature has investigated when dropout occurs. Typically, those studies have not considered improvement in psychological distress within their operationalizations of dropout and therefore may have misrepresented when dropout occurs. The current study examined when dropout occurs using an operationalization based on the criteria of attaining reliable change in a naturalistic sample of clients with gambling disorder, and the classification rates yielded from that operationalization were compared to the rates from a more common operationalization. Participants (n = 334) were clients meeting diagnostic criteria for gambling disorder at an outpatient private practice who completed a measure of psychological distress at baseline and prior to each subsequent treatment session. A survival analysis was conducted to determine temporal patterns of treatment dropout (i.e., clients who discontinued treatment before realizing reliable changes in psychological distress) and completion (i.e., clients who discontinued treatment after realizing reliable changes in distress) at each treatment session. Forty-nine percent of clients were classified as dropouts, and the majority of those clients did so in the first few sessions. The more common operationalization of dropout classified clients as dropouts when they had improved in their distress and clients as completers when they had not improved in their distress. Discussion centers on the implications of dropout occurring at various stages of treatment and future directions.     

Clinical Profiles as a Function of Level and Type of Impulsivity in a Sample Group of At-risk and Pathological Gamblers Seeking Treatment

Level and type of impulsivity are essential variables to be taken into consideration during the initial evaluation of a pathological gambler. The aim of this study was to measure the score for 4 impulsivity-related traits (Urgency, (lack of) Premeditation, (lack of) Perseverance and Sensation seeking) in a sample group of at-risk and pathological gamblers, and to highlight any links with certain elements of clinical data. The UPPS Impulsive Behaviour Scale was administered to 84 problem gamblers seeking treatment. The severity of gambling disorders was evaluated using the diagnostic criteria of the DSM-IV. Psychiatric and addictive comorbidities were also explored. The results indicated that the score for the Urgency facet had a positive correlation with the severity of gambling disorders. It appeared that participants displayed different clinical profiles according to the level and type of impulsivity. Several of the UPPS scales were identified as risk factors for mood disorders, risk of suicide, alcohol use disorders, and Attention Deficit/Hyperactivity Disorder (ADHD). The results confirm both the complexity of the multi-dimensional concept of impulsivity and the reason why the UPPS is of interest for a more in-depth study of the subject.     

Prevalence of Adult Problem and Pathological Gambling between 2000 and 2005: An Update

Background Excessive gambling is a prominent Public Health problem with high prevalence rates in many countries. Substance abuse and other co-morbidities often constitute a major health hazard for the person which gambles with a loss of material and social resources, as well as being a major concern for his or her significant others. The present study updates and extends prevalence data to include work published between 2000 and 2005 in English and other European languages. Methods In a three-step search and exclusion process, studies with current adult prevalence rates were gathered. Results Almost all studies fulfil basic research standards. The weighted mean prevalence rates for excessive gambling (problem and pathological) are 3.0% for the South Oaks Gambling Survey (problem 1.2%; pathological 1.8%), 3.3% for the Canadian Problem Gambling Index (problem 2.4%; pathological 0.8%) and 3.1% for the DSM-IV (problem 1.9%; pathological 1.2%). Conclusion The prevalence rates are comparable and relatively stable between countries and across survey instruments, and do not differ from earlier reviews. The regular epidemiological monitoring of excessive gambling remains a major Public Health issue although the distinction between pathological and problem gambling is not appropriate for epidemiological research. Further studies are needed with respect to concomitant lifestyle characteristics.