Psychopathology in pathological gamblers seeking treatment

High rates of psychiatric symptoms have been reported in pathological gamblers. This study of psychiatric comorbidity in pathological gamblers is the first to use structured psychiatric interviews assessing DSM-III-R Axis I and II disorders. The Structured Clinical Interview for DSM III-R (SCID-P, SCID-II) was administered to 40 (25 male, 15 male) pathological gamblers seeking outpatient treatment in Minnesota for gambling, and 64 (41 male, 23 female) controls. High lifetime rates of Axis I (92%) but not Axis II (25%) psychopathology were found in pathological gamblers as compared to controls. No differences between male and female gamblers were found in rates of affective, substance use or personality disorders. Females had higher rates of anxiety disorders and histories of physical/sexual abuse. Possible associations between psychiatric disorders and pathological gambling are discussed along with gambler typologies and implications for future research.The authors wish to gratefully acknowledge the assistance of: Gary Christenson, M.D., Carol Peterson, Ph.D., William Meller, M.D., Thomas Mackenzie, M.D.     

Severity of impairment in dually addicted gamblers

While much information about pathological gamblers has been gathered from clinical observations, few data exist from systematic, objective studies. Furthermore, still less is known about that subset of pathological gamblers who are also chemically dependent and/or substance abusers. Previous studies (e.g., McCormick et al., 1984) report that up to 45% pathological gamblers are substance abusers. The present study hypothesizes that inpatient chemically dependent pathological gamblers will exhibit greater impairment on a variety of life-functioning measures than a comparable group of chemically dependent psychiatric inpatient. Twelve chemically dependent pathological gamblers were matched on the basis of age, sex, alcohol/drug history and occupational status with twelve chemically dependent persons with no pathological gambling history. All study members were inpatients in an addictions program at a private psychiatric hospital. Each patient was administered the Addiction Severity Index (ASI) to assess impairment in seven problem areas: medical, employment/support, alcohol, drug, legal, family/social, and psychological/psychiatric functioning. The following findings emerged: 1) Chemically dependent (CD) gamblers report more chronic medical problems than CD psychiatric patients; 2) CD gamblers report more frequent conflicts with relatives and family members than CD psychiatric patients; 3) CD gamblers report more psychiatric symptoms both in amount and duration; Although not reaching statistical significance, 42% of the CD gamblers had made a previous suicide attempt as compared to 8% of the CD psychiatric patients; 4) CD gamblers and CD psychiatric patients appear comparable with regard to employment functioning and amount of legal problems. The clinical and theoretical implications of these findings are discussed further.     

The family environment of married male pathological gamblers,alcoholics, and dually addicted gamblers

The family environments of married pathological gamblers, alcoholics, and alcoholic gamblers were measured with the Family Environment Scale (FES), a measure of 10 characteristics of family life. The total sample consists of 193 hospitalized patients, which includes 73 male alcoholics, 53 female alcoholics, and 67 male pathological gamblers, of whom 34 were alcoholics and 33 were not. All four treatment groups had a significantly lower degree of cohesion than normal controls. Male alcoholic gamblers reported significantly more conflict and less personal independence than controls, while male gamblers (nonalcoholics) reported less independence and intellectual-cultural orientation. Male alcoholics (nongamblers) reported more conflict, less independence, intellectual-cultural orientation, and active-recreational orientation than normals. Female alcoholics (nongamblers) also reported less intellectual-cultural orientation and active-recreational orientation than normals. Except for one comparison, treatment groups did not differ from each other. The implications of these findings for models of addiction are discussed as well as their contribution to understanding family issues for pathological gamblers.     

Personality dimensions of the pathological gambler

MMPI data were examined for 100 white male veterans who were involved in an inpatient treatment program for pathological gamblers. The modal MMPI profile (4-2-7) was suggestive of significant psychopathology, including depression, anxiety, and substance abuse. Disregard for authority, impulsivity, feelings of masculine inadequacy, and histories of overly close relationships with mothers and faulty identification with fathers were suggested. Cluster analysis yielded four types of MMPI profiles among the pathological gamblers. Common elements and differences between profile types were discussed. The need for longitudinal research and greater attention to social factors were emphasized.     

Pre/Early Adolescent Onset of Gambling and Psychosocial Problems in Treatment-Seeking Pathological Gamblers

This study examined the association between pre- or early-adolescent onset of gambling and severity of gambling and psychosocial problems in treatment-seeking adult pathological gamblers. A total of 236 pathological gamblers entering outpatient treatment completed the South Oaks Gambling Screen (SOGS) and the Addiction Severity Index (ASI). Using a quartile split procedure, gamblers who began gambling during their pre- or early-adolescent years (mean age of 10.5 years; 1st quartile) were compared to gamblers who began gambling later in life (mean age of 23.0 years; 2nd to 4th quartiles). Compared to later onset gamblers, pre/early adolescent onset gamblers reported increased severity of psychiatric, family/social, and substance abuse problems on the ASI. They were more likely to report cognitive problems (trouble understanding, concentrating, or remembering), suicidal ideation, and a history of inpatient psychiatric treatment, and were less likely to be satisfied with their current living situation. Pre/early adolescent onset gamblers also reported earlier age of initiation of drinking, and were more likely to have received treatment for an alcohol use disorder, and to have used cannabis and cocaine in their lifetimes. Taken together, these data suggest that pre/early adolescent-onset of gambling may be a risk factor for later-life psychiatric, family/social, and substance abuse problems in treatment-seeking pathological gamblers.     

The Clustering of Psychiatric Disorders in High-Risk Gambling Populations

The aims of this study were to examine the associations between psychiatric disorders and pathological gambling (PG) and the clustering of psychiatric disorders in high risk gambler populations. The sample comprised 140 regular gamblers who were recruited from the general public. A variety of self- report and semi structured questionnaires was administered, including the Mini International Neuropsychiatric Interview, The Personality Diagnostic Questionnaire-4th Edition, NORC DSM-IV Screen for Gambling Problems Self- administered and Problem Gambling Severity Index. Axis I and Axis II psychiatric disorders and personality disturbances were found to be more prevalent amongst pathological gamblers than other gamblers with the strongest differences observed for mood and anxiety-related disorders. Almost two-thirds of pathological gamblers reported both an anxiety or mood disorder in conjunction with another type of disorder. These differences between the gambling groups existed even after controlling for gender. The results highlight the high rates of co-morbidity in pathological gamblers in the community and the extent to which anxiety and mood disorders co-existing with other forms of pathology. These results highlight the significant challenges facing treatment services in the treatment of PG and the extent to which this should be treated as the primary disorder.     

A comparison: The treatment of wives of alcoholics with the treatment of wives of pathological gamblers

This study was conducted to determine how treatment approaches would differ for two reference groups — wives of alcoholics and wives of pathological gamblers. Data from thirty-nine wives from each reference group were collected over a period of sixteen months. The results indicate that the wives of the pathological gamblers had to deal with specific issues which did not surface in the treatment of wives of the alcoholics. Some of the wives of the pathological gamblers received threatening phone calls from creditors, had to re-pay loans for which they co-signed, had to commence handling the family budget, and had to deal with their own withdrawal from his gambling. They also found trust very slow in coming, realized they would be under great financial straits for an extended period of time, and found a shortage of self-help groups and qualified professionals within a reasonable distance of their home. Finally they found loneliness a very realistic issue in early abstinence because he was spending so much of his time outside the home attending G.A. meetings, aftercare and working two, and sometimes three jobs, in order to repay his gambling debts.     

Roulette gamblers and gamblers at electronic game machines: Where are the differences?

In an unselected group of 46 excessive gamblers who came for psychiatric help or for an expert opinion on legal responsibility, two different groups of gamblers are compared: roulette gamblers and those who played at German-style slot machines. In all excessive gamblers, childhood developmental limitations as well as disorders in the ability to form and maintain partner relationships in later life were frequent; at the same time the childhood conditions and their life histories are diverse. The spectrum of observed psychiatric disorders is rather wide. Gamblers at electronic game machines began to play at an average age of 19 years; they more often belong to the lower classes and show depressive and reactive disorders more frequently. Roulette gamblers began to gamble excessively on average nine years later than other gamblers; they showed signs of personality disorders, especially narcissistic and cyclothymic patterns, significantly more often. Anti-social behavior and delinquency before the onset of excessive gambling were frequent in both groups.     

Withdrawal and Tolerance Phenomenon in Problem Gambling

The phenomenological similarities between gambling and substance dependence have led to the conceptualization of pathological gambling as an addictive disorder. Tolerance and withdrawal are important features of both disorders, suggesting commonalities in the neurobiological processes associated with neuroadaptational underpinnings. However, there are few empirical studies supporting the presence of tolerance and withdrawal reported in the gambling literature. Moreover, there are no studies comparing the equivalence of tolerance and withdrawal between gambling and alcohol dependence. This study compared tolerance and withdrawal features in samples of gamblers, alcoholics and gamblers who also met criteria for alcohol dependence. In contrast to the addiction model, findings indicate that, while a majority of participants increased bet size, the motivation to do so was not for excitement or to maintain arousal levels as indicated by the DSM-IV-TR but because of cognitive factors related to winning. Results supported the notion that pathological gamblers experienced similar levels of withdrawal symptom severity as alcohol-dependent participants. Further research is needed to evaluate whether those symptoms result from the inability to gamble or from the loss of an avoidant stress coping strategy.     

An Empirical Study of Personality Disorders Among Treatment-Seeking Problem Gamblers

The primary aims of this study were to examine the prevalence of personality disorders in problem gamblers, to explore the relationship between personality disorders and problem gambling severity, and to explore the degree to which the psychological symptoms highlighted in the biosocial developmental model of borderline personality disorder (impulsivity, distress tolerance, substance use, PTSD symptoms, psychological distress and work/social adjustment) are associated with problem gambling. A secondary aim was to explore the strength of the relationships between these symptoms and problem gambling severity in problem gamblers with and without personality disorder pathology. Participants were 168 consecutively admitted problem gamblers seeking treatment from a specialist outpatient gambling service in Australia. The prevalence of personality disorders using the self-report version of the Iowa Personality Disorders Screen was 43.3 %. Cluster B personality disorders, but not Cluster A or C personality disorders, were associated with problem gambling severity. All psychological symptoms, except alcohol and drug use, were significantly higher among participants with personality disorder pathology compared to those without. Finally, psychological distress, and work and social adjustment were significantly associated with problem gambling severity for problem gamblers with personality disorder pathology, while impulsivity, psychological distress, and work and social adjustment were significantly associated with problem gambling severity for those without personality disorder pathology. High rates of comorbid personality disorders, particularly Cluster B disorders, necessitate routine screening in gambling treatment services. More complex psychological profiles may complicate treatment for problem gamblers with comorbid personality disorders. Future research should examine the applicability of the biosocial developmental model to problem gambling in community studies.     

Diagnosis and therapy of male gamblers in a university psychiatric hospital

From 1980 to mid-1990 fifty-one gamblers were evaluated and treated at the psychiatric university hospital of Homburg/Saar in Germany. All were men with a mean age of 33.7 years. Gambling had lasted 5.2 years on average. Most patients were motivated to undergo therapy by members of their family. The majority of them had been in psychotherapeutic treatment before. Thirty-six of the 51 patients had committed punishable acts including fraud and embezzlement and, in 7 cases, robbery. The sample could be divided into three clinical subgroups. The first group consisted of patients with severe psychiatric diseases such as schizophrenia, manic-depressive illness or organic brain disorder. Patients of the second group suffered from serious personality disorders. Those of the third group showed deep-rooted problems in their current relationships.This article is an extension of the special issue on Gambling in Europe edited by Iver Hand, M.D.     

Comorbid mood and adjustment disorders among pathological gamblers seeking treatment in Hong Kong

Research findings on comorbidity and pathological gambling are non–existent in Chinese communities. The objectives of this study were to: (a) determine the prevalence of comorbid mood and adjustment disorders among pathological gamblers seeking treatment in Hong Kong; (b) compare demographic profiles and clinical features in pathological gamblers with and without comorbid mood and adjustment disorders; and (c) explore the association and temporal relationship between pathological gambling and comorbid mood and adjustment disorders. Assessment instruments included demographic data, BSI, SCID-I, ASI and LIFE-RIFT. Results showed that about two-thirds (63.7%; n = 128) of 201 participants reported lifetime comorbid psychiatric disorders. Most common comorbid disorders were mood disorders (29.4%; n = 59) and adjustment disorders (20.9%; n = 42). Pathological gamblers with comorbid mood or adjustment disorders showed more severe levels of psychopathology, impairment in psychosocial functioning and gambling problems. This study is important because it is the first scientific comorbidity study among pathological gamblers in a Chinese context.     

Pharmacological treatments of pathological gambling

Medication treatment studies have demonstrated short-term efficacy of various SRIs, opioid antagonists, and mood stabilizers in sub-samples of adult treatment seeking pathological gamblers. Pathological gambling is frequently comorbid with bipolar spectrum disorders, substance abuse/dependence, and attention-deficit/hyperactivity disorder (ADHD), and comorbidity may influence treatment response in pathological gambling. This review focuses on recent research examining the treatment of pathological gambling and highlights methodological challenges for future studies.     

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.     

Ego strength and achievement motivation in pathological gamblers

This paper argues that there area priori reasons to extract measures of ego strength and achievement motivation from the psychometric data base routinely collected from inpatient pathological gambers in order to clarify the meaning of these constructs and to evaluate their roles in personality organization. A sample of 57 subjects engaged in an inpatient treatment program for pathological gamblers was studied using Barron's Ego Strength Scale (ES) from the Minnesota Multiphasic Personality Inventory and two measures of achievement motivation from the California Personality Inventory, Achievement via Conformance (Ac) and Achievement via Independence (Ai). Compared to the standardization group norms on these instruments, pathological gamblers are significantly deficient in both ego strength and one type of achievement motivation, Ac. Clinical impressions of gamblers in treatment suggest that narcissistic characteristics are a major problem in treatment and that future research should attempt further detailed studies of ego structure in order to refine treatment objectives.     

Inpatient treatment of male pathological gamblers in Germany

Pathological gambling is viewed as a disease of unknown cause which requires treatment. Demographic and psychological traits of fifty-eight male patients are described. A control group of fifty-four patients with other addictions was used to determine the validity of a diagnostic test which aims to differentiate between harmless gambling behavior and addiction to gambling. This test is described along with the stages of pathological gambling and the process of treatment for the disorder. Most of the gamblers are young, often previously convicted of theft, highly indebted, in danger of committing suicide, and susceptible to other addictive substances, especially alcohol. Harmless, critical and chronic stages are described. Regarding in-patient treatment, it has proved to be useful to integrate individual members into groups of alcoholics as they are a therapeutic benefit to these groups. The pragmatic and symptom-oriented therapy proved to be good for gamblers as well. A follow-up with forty-nine patients for one year and twenty-five for two years found 71% abstinent after one year and 62% abstinent after two years of treatment. These results are similar to those obtained with alcoholics.     

In Search of Executive Impairment in Pathological Gambling: A Neuropsychological Study on Non-treatment Seeking Gamblers

Pathological gambling is characterized by a persisting maladaptive and recurrent behavior with severe social and psychological consequences. There is evidence of strong comorbidity with psychiatric manifestations as well as cognitive mainly involving executive functions. This study aimed to investigate impairment in executive functions and working memory, and personality traits in a sample of Greek gamblers. Twenty-four men involved in various gambling activities were recruited from ecological settings as probable pathological gamblers. They were assessed with a comprehensive neuropsychological battery involving several executive tasks, the Zuckerman–Kuhlman Personality Questionnaire, the Hospital Anxiety Depression Scale, and the Difficulties in Emotion Regulation Scale. An age- and education-level matched group of 21 men without history of habitual gambling served as controls. As a group, gamblers displayed significantly lower scores on indices of inhibition, decision making and self-reported emotional awareness, and scored higher on impulsivity/sensation seeking personality traits. Notably, gamblers scored similarly or significantly higher on measures of verbal and visuospatial working memory, cognitive flexibility, processing speed, verbal fluency, and sustained attention. Overall, we argue that gamblers do present with specific cognitive deficits, but there is no evidence for a generalized executive impairment, and further stress the importance of investigating cognitive, personality, and psychiatric aspects of gambling on the basis of an ecologically valid sampling.     

Event frequency,excitement and desire to gamble,among pathological gamblers

In this study we compared gambling behaviour of 15 pathological gamblers (PG) and 15 non-problem gamblers (NPG) on two conditions of a commercially available slot machine. One condition used a commercially available two-second event frequency (games per minute), while the other condition used an experimental three-second event frequency. The payback percentage (wins relative to losses) and reward frequency (wins over number of games played) varied randomly across conditions. The results showed that PG had significantly higher measures than NPG on time spent gambling, excitement level and desire to play again in the two-second condition. In the three-second condition there were no differences in excitement level and desire to play again. The number of PG playing the maximum time (60 minutes) was reduced in the three-second version, and reward frequency contributed to reduction in time spent gambling. The results may have implications for understanding behavioural mechanisms of pathological gambling among slot machine players.     

The role of natural recovery in alcoholism and pathological gambling

While most pathological gamblers, like most alcohol abusers, recover on their own, it seems likely that they are at greater risk for relapse than those who have been through successful treatment. Accordingly, a substantial increase in treatment resources for pathological gamblers, along with greater efforts to establish the effectiveness of these treatments, ought to receive national priority. If the data on alcohol-abusing self-changers are generalizable to self-changing pathological gamblers, the prognosis for gamblers who stop gambling all together is better than for those who aspire to controlled or nonproblem gambling. While pathological gamblers with comorbid substance abuse are more difficult to treat than those without it, the impact of comorbid substance abuse on the decision by pathological gamblers to change has not yet been explored, although it should be. Similarly, the impact of other Axis I pathology on pathological gambling self-change, especially depression and anxiety, should be thoroughly explored. The most pressing problem in this field appears to be definitional. As a consequence, until consensus is reached on a reliable, valid, and useful classification scheme for pathological gambling, both research and clinical efforts will continue to suffer.