Gambling Disorder

Gambling disorder is chronic, recurrent, maladaptive gambling behavior that results in impairment in social or personal life. The disorder fits under the umbrella of addictive disorders due to a strong compulsion to gamble as well as tolerance and withdrawal effects that are similar to substance use disorder. Gambling disorder differentiates itself from nonpathologic gambling by the level of tolerable risks. The disorder can be managed with psychotherapy and medications. The prognosis is usually poor, with high rates of relapse and complications.

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Overview

Definition

Gambling disorder: 

  • Characterized by repeated betting behavior
  • Can have negative effects on a person’s finances, profession, personal life, or other relationships
  • Mostly a chronic condition
  • High risk of relapse

Gambling is defined as placing something of value at risk with the hope of gaining something of greater value.

Epidemiology

  • Lifetime prevalence in the general population is between 0.4% and 1%.
  • More common in men 
  • < 10% of adult gamblers develop a gambling problem.
  • Increased incidence in individuals with a family history of psychiatric disorders

Pathophysiology

  • The impulsive and risky behaviors are thought to arise from issues with neurocognitive functioning in the frontostriatal circuitry. 
  • Compared with healthy controls, those with gambling disorder have deficits in: 
    • Inhibition 
    • Planning 
    • Time management 
  • Neuroimaging shows decreased activity in ventral striatum and ventromedial/ventrolateral prefrontal cortex during rewarding events.

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Diagnosis

DSM-V diagnostic criteria:

  • Persistent and recurrent problematic gambling behavior results in clinically notable impairment or distress.
  • Criteria:
    • Constantly preoccupied and thinking about gambling
    • Has the urge to gamble with extra money to increase excitement
    • Fails to control or stop gambling
    • When cutting down on gambling, becomes restless or irritable
    • Gambles to escape from problems
    • Gambles after losing money (“chasing”) 
    • Lies to hide severity of gambling
    • Significant effect on professional and personal life
    • Asks others for money to relieve a desperate financial situation
  • Manic mood features must be excluded.
  • Lasts at least 12 months

Management

Psychotherapy

  • 1st line: CBT
  • Goals: 
    • Emphasize psychoeducation.
    • Identify urges to gamble.
    • Create other activities to mitigate the triggers. 
  • Alternative: group therapy with a 12-step program (Gamblers Anonymous)

Pharmacotherapy

Opioid antagonists (naltrexone) are commonly used.

  • Mechanism of action: thought to influence the mesolimbic pathway  
  • Studies show reduced gambling urge and behavior.

Differential Diagnosis

  • Bipolar disorder: a highly recurrent psychiatric illness characterized by fluctuating periods of manic/hypomanic features (distractibility, impulsivity, increased activity, decreased sleep, talkativeness, grandiosity, flight of ideas) and depressive symptoms. Management includes mood stabilizers such as lithium, anticonvulsants, and antipsychotics. Loss of judgement and gambling are common features of a manic episode. Careful history taking must rule out bipolar disorder as underlying the gambling behavior.
  • Nonpathologic gambling: when a patient does not meet the criteria for diagnosis or participates in professional or social gambling. This type of gambling typically has a reduced or acceptable amount of risk compared with that found in gambling disorder.

References

  1. Sadock BJ, Sadock VA, & Ruiz P. (2014). Kaplan and Sadock’s synopsis of psychiatry: Behavioral sciences/clinical psychiatry (11th ed.), Chapter 20, Substance use and addictive disorders, pages 690-693. Philadelphia, PA: Lippincott Williams and Wilkins.
  2. Leppink, E. (2017). Gambling disorder and related behavioral addictions. DeckerMed Medicine.

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