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
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 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.
Problem gambling questionnaire.
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
DSM-5 criteria for gambling disorder.
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).
Useful resources to tackle problem gambling.
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