Gambling addiction

Abstract

Addictive behavioural problems bear resemblance to alcohol and substance misuse, although no drug is consumed. Compulsive gambling can leave an individual and their friends and family in serious debt, along with significant detriment to their health and emotional wellbeing, and there is an increased risk of suicide. Gambling problems are more common in younger adult males and those with insecure finances and employment. It is also associated with violence and recognising it can lead to improved treatment and support for those affected.

The GP curriculum and gambling addiction

Clinical module 3.10: Care of people with mental health problems requires GPs to:

Know that people with unexplained physical symptoms may have underlying psychological distress, but be aware of the dangers of medicalising distress. Repeated investigation is costly in terms of patient suffering and healthcare costs

Know that an exploration of physical, psychological, social, cultural and spiritual issues should be integrated into both the consultation and the management of illness; cultural issues can impact on how mental health issues present and the acceptability of diagnosis

Be aware of the need to promote hope and demonstrate compassion and their use as resources to aid healing

Understand the epidemiology of mental health problems in general practice

Know the prevalence of mental health problems and needs among your own practice population

Be able to assess and manage risk/suicidal ideation

Clinical module 3.14: Care of people who misuse drugs and alcohol requires GPs to:

Agree that as a doctor you are there to treat people and not to make non-clinical judgements about their lives

Be aware that addiction affects us all, either personally or through its impact on family and friends, the community and the culture in which we live

Understand that addiction is not a lifestyle choice – although it could have started off that way. It needs proper treatment

Understand the home and family circumstances of the patient and look for hidden harm to children or vulnerable adults

Be aware of the patient's housing needs and if necessary direct them to the relevant service

Refer to and liaise with local specialist and secondary care services, as appropriate, to make a comprehensive treatment plan work

An individual has a problem with an addiction when they continue with a behaviour despite adverse consequences, and show cravings and urges to engage in the addictive behaviour (Yau and Potenza, 2015). Certain behaviours in gambling addiction resemble the dependence seen in those who are affected by substance misuse. Gambling addiction shows similar clinical signs as substance misuse dependence, such as craving, tolerance, withdrawal symptoms, comorbidities and neurobiological profile (Leeman and Potenza, 2012). Like those affected with substance misuse addiction, gambling addiction may show a chronic and relapsing pattern, with some individuals managing to recover without any formal treatment, whereas the vast majority require varying degrees of support to re-establish control over their addiction. The Diagnostic and Statistical Manual-5 (DSM-5) has only formally classified gambling disorder within the ‘Substance-Related and Addictive Disorders' category in the last few years as distinct from previous editions (Yau and Potenza, 2015).

Why is it hard to detect?

With substance misuse, the effects can be much more readily apparent, and the effects are reasonably well recognised and understood by clinicians and society. However, with behavioural addiction, the impact, such as imprisonment, financial difficulty and family dysfunction, can be easily overlooked (Shaw et al., 2007). Pathological gambling can contribute to dysfunction and chaos, causing disruption to relationships. The family members of someone affected by problem gambling are more likely to suffer depressive and anxiety disorders and substance misuse themselves, and problem gambling is associated with child abuse and neglect (Shaw et al., 2007). As clinicians, it can be easier to deal with the medical issues such as anxiety, without getting to the root cause of the problem.

If you suspect a patient has a gambling problem, or they present to you concerned about a lack of control, there are questions that can help screen for problem gambling (See Box 1). Adverts exist in the media promoting gambling, showing people having fun and often winning (though the odds are stacked against them), and the internet has made gambling easier and more convenient than ever, increasing the opportunities to gamble. It can also be easy to normalise some addictive behaviours as socially acceptable; placing a bet on a sporting event is an activity many partake in, much like consuming an alcoholic drink after work or at a party. The problem develops when this activity escalates out of control. The first awareness of a gambling problem within a family may not be until bailiffs knock on the door and debt collectors start telephoning.
Box 1.
Problem gambling questionnaire.

• Do you bet more than you can afford to lose?

• Do you need to gamble with larger amounts of money to get the same feeling?

• Have you tried to win back money you have lost (chasing losses)?

• Have you borrowed money or sold anything to get money to gamble?

• Have you wondered whether you have a problem with gambling?

• Has your gambling caused you any health problems, including feelings of stress or anxiety?

• Have other people criticised your betting or told you that you had a gambling problem (regardless of whether or not you thought it was true)?

• Has your gambling caused any financial problems for you or your household?

• Have you ever felt guilty about the way you gamble or what happens when you gamble?

Score 0 for each time you answer: ‘never’

Score 1 for each time you answer: ‘sometimes’

Score 2 for each time you answer: ‘most of the time’

Score 3 for each time you answer: ‘almost always’

If the total score is eight or higher, you may be a problem gambler

Source: NHS Choices (2018) © Crown Copyright.

Epidemiology

A systematic review reports a prevalence for lifetime gambling addiction ranging from 0.01–10.6%, with higher prevalence among younger adults compared with older adults (Subramaniam et al., 2015). Gambling disorder is more likely to affect men than women and those who are single, divorced or separated (Subramaniam et al., 2015). Older adults may gamble if they have limited access to other stimulating activity, but are particularly vulnerable when their prospects for future earnings are limited and when they are on fixed incomes such as a pension (Subramaniam et al., 2015). Gambling addiction can be high frequency, repetitive and associated with suicidal ideation (Nower et al., 2018) and violence against a partner, with over one third of problem gamblers being either a victim (38.1%) or perpetrator (36.5%) of violence (Dowling et al., 2016). There is association between violence and gambling problems for individuals experiencing less than full employment, clinical anger problems, substance misuse, and in young adults (Dowling et al., 2016). Gambling has been associated with increased likelihood of weapons being used in violent acts, with between a quarter and one third of problem gamblers becoming involved in fights while intoxicated (Roberts et al., 2016). Even accounting for mental illness and impulsive behaviour, the association with violence remains significant, but it is unclear whether there is a common underlying cause for violence and gambling, or whether one increased the risk of the other (Roberts et al., 2016).

Although men are more likely to gamble, progression to problem gambling in women appears to be more rapid (Tavares et al., 2003). This phenomenon is called ‘telescoping' and describes an accelerated course from first encounter with an addiction through to onset of dependence and treatment, which is also seen in alcohol and substance misuse in women (Greenfield et al., 2010). Gambling addiction tends to progress to become more frequent and with greater stakes placed. Similar to substance and alcohol misuse, the repertoire narrows often to one or two forms of gambling.

Effects

In keeping with other compulsive behaviours, gambling addiction can lead to an individual gambling with greater frequency and a greater amount of money per bet in order to reach the same effect, a term referred to as tolerance. Increasingly there will be preoccupations with gambling, thinking about it repeatedly and obsessively, seeking a venue or opportunity to gamble. This can significantly interfere with life and cause detriment to others with more time spent away from work and other responsibilities such as childcare or household tasks neglected. The individual may also exhibit withdrawal symptoms of irritability and restlessness, if unable to reach their ‘fix' and gamble. Given the odds of winning money are stacked against the individual; they are likely to lose money and proceed to place further bets in an attempt to regain losses. ‘Chasing' losses in this way only perpetuates the loss further. When money to fund the gambling runs out, individuals seek other sources of funding by borrowing money from friends and family, engaging in crime and lying to cover up where money is going or coming from (American Psychiatric Association, 2013). DSM-5 suggests 4 out of 9 features should be present in a 12-month period to meet diagnostic criteria. Box 2 outlines the DSM-5 criteria.
Box 2.
DSM-5 criteria for gambling disorder.

• Tolerance; gambling with increasing amounts to achieve the same effect

• Restlessness or irritability when cutting down or stopping gambling

• Repeated unsuccessful efforts to control, reduce or stop gambling

• Preoccupation with gambling, such as thinking of past gambling events, planning the next venture or how to get money in order to gamble

• Gambling with negative feelings such as guilt, anxiety or low mood

• Gambling further in an attempt to recoup loses

• Lying to conceal involvement in gambling

• Adverse effect on relationships, employment, career or educational opportunities due to gambling

• Reliance on others to relieve financial desperation

Adapted from DSM-5 312.31 (F63.0) Diagnostic criteria for gambling disorder, American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders (DSM-5®). American Psychiatric Pub.

Comorbidity

Of those who meet the diagnostic criteria for gambling disorder, 96% also meet criteria for at least one other psychiatric disorder, and 49% have been treated for mental illness (Kessler et al., 2008). Mood, impulse control, anxiety and personality disorders are commonly seen in those with gambling problems (Lorains et al., 2011). Meta-analysis also suggests almost 60% co-occurrence of substance misuse and gambling (Lorains et al., 2011). Gambling problems may arise as a negative coping mechanism for psychiatric disorders (Kessler et al., 2008). Suicidal ideation and attempts are higher in problem gamblers compared with the general population, particularly when reaching financial desperation and significant debt. This emphasises the importance of screening for suicidal thoughts in the general population and particularly in gambling addiction. Tachycardia and angina are more common among individuals with gambling problems compared with the general population (Morasco et al., 2006). There is a well-documented association between Parkinson's disease and gambling, with dopamine agonists used to treat Parkinson's disease being implicated (Moore et al., 2014). However, the association between Parkinson's disease and gambling may be multi-aetiological and dopamine antagonist medication has not demonstrated efficacy in treating gambling disorders (McElroy et al., 2008).

Neurobiology and psychology of gambling addiction

Dopamine is important in reward behaviours, as well as learning and motivation. Dopamine release from the ventral striatum has been particularly associated in studies of reward mechanisms. Photon emission computed tomography studies found the dopamine effect to be comparable to psychostimulant drugs such as amphetamine (Farde et al., 1992). Other neurotransmitters such as noradrenaline may be involved in arousal associated with gambling, but have not been widely studied or implicated (Yau and Potenza, 2015).

Individuals with addictions may exhibit impulsive and sensation-seeking behaviours, with poor harm avoidance strategies (Leeman and Potenza, 2012). Compulsive behaviour leads to repeating the act of gambling to prevent a perceived negative outcome, but this itself leads to negative consequences (Fineberg et al., 2010). Problem gamblers are less likely to wait for the possibility of a larger reward, opting to take smaller rewards at an early opportunity. Operant conditioning and positive reinforcement occur when a desirable event (reward of money) is presented as a consequence of a behaviour (placing a bet), potentially increasing the occurrence of that behaviour in the future. Although every time a bet is placed, the individual may not win, the predictability or scheduling of reinforcement can encourage further occurrence of that behaviour. Gambling, and in particular slot machines, use an intermittent or variable ratio before the reward is given e.g. a slot machine may pay out after two bets, then next time after nine bets, then after three bets and so on, with the reward (payout) having some unpredictability to it. Variable ratio reinforcement is highly resistant to behaviour extinction, i.e. the behaviour persists despite not always receiving a reinforcing reward, and this is particularly important in slot machines becoming a source of problem gambling (Griffiths, 1993). All types of gambling, except the National Lottery, contributed to the prediction of an increased risk of gambling problems in the British gambling prevalence survey (LaPlante et al., 2009). It may be that the fixed odds and a long interval between one lottery draw and the next make the behaviour harder to learn.

Treatment

Treatment of an addiction can be considered in three phases: a detoxification phase to reduce immediate withdrawal symptoms; a recovery phase to sustain motivation, avoid relapse and improve healthy behaviour; and a relapse prevention phase to sustain long-term abstinence (Yau and Potenza, 2015). There are no licensed medications for treating problem gambling, however, pharmacological treatments can be prescribed for comorbid symptoms, such as antidepressants for low mood (Royal College of Psychiatrists, 2014). Opioid receptor antagonists such as naltrexone have empirical evidence to support their use, and they have been used for drug and alcohol dependency for several years (Krystal et al., 2001). Although naltrexone is not licensed, a small study involving 43 participants looked at fluvoxamine, topiramate, buproprion and naltrexone and found that most participants did not gamble within 6 months of discontinuing medication. Those who did gamble again reported reduced gambling losses (Dannon et al., 2007). Selective serotonin reuptake inhibitors have demonstrated mixed results when used for gambling addiction (Potenza et al., 2009).

Behavioural and psychological interventions for problem gambling show significant benefit. With many addictions, individuals may attempt self-help rather than seek professional treatment. It may favour those who have not acknowledged their problem, feel stigmatised or feel they cannot commit to a psychological treatment programme. Online programmes have efficacy in reducing gambling symptoms (Carlbring et al., 2012). Gambler’s Anonymous is a mutual support group based on a similar model to Alcoholics Anonymous, with steps of progress and sponsors. However, evidence for efficacy is inconsistent (Schuler et al., 2016) and some individuals clearly benefit more than others from this approach. Brief motivational interviewing is effective through exploring reluctance and apathy to address a gambling problem. Self-help material can have benefits over no treatment, but benefits are weaker than other psychological approaches (Pallesen et al., 2005).

Cognitive behavioural therapy (CBT) can focus on identifying the thought processes and behaviours that perpetuate compulsive behaviours, leading to strategies that change the addictive behaviour. CBT may involve keeping a diary of activities, thoughts, feelings and behaviours in order to help the individual understand the problem and then focus on a solution. A Cochrane review found CBT to have the strongest evidence of benefit compared with other psychological approaches in the treatment of problem gambling (Cowlishaw et al., 2012).

As with other addictions, treatment is not expected to achieve a cure for the individual, but is considered an attempt to prevent relapse. Individuals may have periods of abstinence, however, they subsequently relapse, as with addictions like alcohol, substance misuse and tobacco. GPs can help by approaching treatment multi-factorially, supporting treatment of comorbidities and returning the individual back to a place of greater self-control and self-efficacy. Sign posting to sources of help, particularly surrounding legal, financial and social advice will be important, especially where the gambling is associated with debts. Other sources of support may also focus on safeguarding of both adults and children, particularly where there is a risk of abuse or neglect, and mental health support may be required. Box 3 outlines some useful resources to help tackle problem gambling.
Box 3.
Useful resources to tackle problem gambling.

GambleAware® https://about.gambleaware.org

When the fun stops, stop™ www.whenthefunstops.co.uk

Advice guide from the Citizens Advice Bureau www.gamblingtherapy.org/en/adviceguide-citizens-advice-bureau-uk

Gambling Commission www.gamblingcommission.gov.uk/for-the-public/Safer-gambling/Getting-help-to-control-your-gambling.aspx

KEY POINTS

Gambling addiction is increasingly common

It can have devastating psychological and social impacts beyond the individual affected

Gambling addiction is associated with increased suicidal ideation

Gambling addiction is associated with increased risk of being a victim or perpetrator of violence

Pharmacological treatment is not currently licensed, but psychological approaches can be effective

In primary care early diagnosis, treatment of comorbidities, encouraging self-efficacy and sign posting to sources of help may improve outcomes

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