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The American Psychiatric Association (APA) has proposed new criteria for a diagnosis of pathological gambling (PG) in the next edition of theDiagnostic and Statistical Manual of Mental Disorders, slated for publication in 2013. As reported inIssues and Insightsand discussed at the 2010 NCRG Conference on Gambling and Addiction, the proposed revisions included moving PG from the impulse control category into a new classification, “addiction and related disorders.” It also proposes dropping illegal acts from the 10 criteria and possibly reducing the number of criteria needed for a diagnosis from five to four. A new review article by Howard J. Shaffer and Ryan Martin in the 2011Annual Review of Clinical Psychology(Shaffer & Martin, 2011) provides a critical review of these recommendations.

Currently, the DSM-IV-TR defines PG as a “… persistent and recurrent maladaptive gambling behavior … that disrupts personal, family or vocational pursuits” (American Psychiatric Association, 2000, p. 671).

Individuals who concurrently experience five or more of the following 10 criteria meet the diagnostic threshold for PG (American Psychiatric Association, 2000):

1. Preoccupation with gambling
2. Needing to gamble with increasing amounts of money in order to achieve the desired excitement
3. Repeated unsuccessful efforts to control, cut back, or stop gambling
4. Restless or irritable when attempting to cut down or stop gambling
5. Gambling as a way of escaping from problems
6. After losing money gambling, often returning another day to get even (“chasing” one’s losses)
7. Lying to family members, a therapist, or others to conceal the extent of involvement with gambling
8. Committing illegal acts such as forgery, fraud, theft, or embezzlement to finance gambling
9. Jeopardizing or losing a significant relationship, job, or educational or career opportunity because of gambling
10. Relying on others to provide money to relieve a desperate financial situation caused by gambling

In their review, Shaffer and Martin point out that the rationale for eliminating “committing illegal acts” as a symptom for the diagnosis could be used to eliminate other criteria as well. The DSM-5 Task Force argued that research has shown that this criterion has little to no effect on the prevalence of the disorder or diagnosis in the aggregate. However, Shaffer and Martin point out that the criterion of “jeopardizing relationships, work, or education” appears only at high severity levels of PG, and that preoccupation and chasing losses have such high prevalence among both non-PGs and PGs that these criteria alone have little diagnostic value under the current system (Shaffer & Martin, 2011).

The effect of eliminating illegal acts, they argue, will serve to only reduce the diversity of people who meet diagnostic criteria for PG. Lowering the threshold from five out of 10 symptoms to four out of nine symptoms will have a similar effect of reducing diversity because of the fewer number of combinations that can occur with diagnostic criteria (Shaffer & Martin, 2011).

Shaffer and Martin agree with the DSM-5 task force that there is a large body of evidence for the commonalities between PG and substance use disorders. This evidence provides the rationale for the task force’s recommendation to move PG into the new category of addiction and related disorders. Although the task force concluded that there was insufficient empirical evidence to warrant including behavioral disorders other than PG at this time, the creation of such a classification leaves the door open for Internet addiction and other non-substance-based disorders. Shaffer and Martin foresee a potential problem in the DSM ending up with a laundry list of behavioral disorders defined by their objects; e.g., gambling, the Internet, and sex to name several. In their view, such a list only reinforces the incorrect belief that things are addictive.

To avoid this problem, Shaffer and Martin propose the addiction as syndrome model as an organizing principle (Shaffer, LaPlante, et al., 2004). The syndrome model “postulates that there are shared neurobiological, psychological, and social risk factors that influence the development and maintenance of different manifestations of addiction. These risk factors are similar for both substance-based (e.g., cocaine dependency) and activity-based (e.g., disordered gambling) expressions of addiction” (Shaffer & Martin, 2011, p. 488). The authors maintain that conceptualizing “addiction this way avoids the incorrect view that the object causes the addiction and shifts the diagnostic focus toward patient needs” (Shaffer & Martin, p. 496).

These proposed changes to the DSM-5 will have a significant impact on researchers and treatment professionals alike. What do you think of the DSM-5 recommendations? Share your comments below.

References

American Psychiatric Association. (2000).Diagnostic and Statistical Manual of Mental Disorders., Fourth Edition, Text Revision. Washington, DC: American Psychiatric Association.

American Psychiatric Association (2010). 312.31 Pathological gambling. In Proposed Draft Revisions to DSM Disorders and Criteria. Arlington, VA: American Psychiatric Association.

Shaffer, H. J., LaPlante, D. A., LaBrie, R. A., Kidman, R. C., Donato, A. N., & Stanton, M. V. (2004). Toward a syndrome model of addiction: Multiple expressions, common etiology.Harvard Review of Psychiatry, 12, 367-374.

Shaffer, H. J., & Martin, R. (2011). Disordered gambling: etiology, trajectory, and clinical considerations.Annual Review of Clinical Psychology, 7, 483-510.

NCRG staffResearch UpdateaddictionAmerican Psychiatric AssociationCambridge Health AllianceDivision on AddictionsDSMgamblinggambling disordersHarvard UniversityHoward ShaffermanualNational Center for Responsible Gamingpathological gamblingproblem gamblingpsychologyRyan Martinslots

TheNational Center for Responsible Gaming(NCRG) presented the first installment of the 2011NCRG Webinar Seriesto more than 250 participants in March – one of the highest attended sessions for the NCRG. Led by Dr. Jon Grant, M.D., the webinar was titled “Gambling Disorders: What Addiction Professionals Need To Know” and cosponsored byNAADAC, the Association for Addiction Professionals. Visit theNCRG websitefor an archived version of the presentation.

Dr. Grant, a board-certified psychiatrist and principal investigator of the NCRG Center for Excellence in Gambling Research at the University of Minnesota, presented what he described as a “crash course” on gambling disorders for an audience that included many health care providers who specialize in drug and alcohol counseling. Dr. Grant discussed the nature and prevalence of gambling disorders (GD), vulnerable populations, comorbidity of GD and other mental health conditions, similarities between GD and other substance use disorders, and screening and diagnosis of GD as well as treatment options.

During his discussion of treatment options for gambling disorders Dr. Grant emphasized the variety of techniques that are currently being used to treat GD. Among these are several that are well-known to counselors and therapists, such as casino self-exclusion programs, psychotherapy, cognitive behavioral therapy, and motivational interviewing.

Dr. Grant also discussed less well-known techniques such as cue exposure therapy (CE). This therapy is based on theories of classical conditioning that hold that a person can learn to control cravings to gamble by being repeatedly exposed to situational cues in a therapeutic setting and learning to monitor and control their emotional and mental responses to each cue. CE therapy uses pictures and audio and video media related to gambling situations to trigger urges to gamble in clients, and teaches clients how to respond to these feelings.

If you missed the live presentation, you can access it and other past sessions free of charge in theWebinar Archivessection of theNCRG website. If you attended the NCRG Webinar in March, we would love to hear your feedback to improve future sessions. As always, we welcome your thoughts and questions, including suggestions for webinar topics, in the Comments section below.

NCRG staffContinuing Education Opportunitiesaddiction counselingcontinuing educationdisordered gamblinggendergeneticsinterventions for problem gamblingJon E. GrantNAADACtreatment for pathological gamblingUniversity of Minnesotawebinars

Have you ever been screened for a health problem? The answer is probably yes if you’ve ever been questioned by your doctor about symptoms or responded to a telephone survey about health. There are numerous screening instruments used by clinicians to determine if a client has a gambling problem, and some often appear in general population surveys to research the prevalence of the disorder. The Division of Addictions at Cambridge Health Alliance, a teaching affiliate of Harvard Medical School, recently released the Brief Biosocial Gambling Screen (BBGS) to help people decide on their own whether to seek a formal evaluation of their gambling behavior. Development of the screen was funded by the NCRG.

The Division on Addictions at Cambridge Health Alliance launched the BBGS on itswebsite. This 3-item survey is based on the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) criteria for pathological gambling. The BBGS asks:

o During the past 12 months, have you become restless, irritable or anxious when trying to stop/cut down on gambling?

o During the past 12 months, have you tried to keep your family or friends from knowing how much you gambled?

o During the past 12 months, did you have such financial trouble as a result of your gambling that you had to get help with living expenses from family, friends or welfare?

A “yes” answer to any of the questions means the person is at risk for developing a gambling problem. A confidential, personalized message is provided to help guide the person to consider seeking further evaluation.

The development of the BBGS is described in the scientific paper, “Optimizing DSM-IV-TR Classification Accuracy: A Brief Biosocial Screen for Detecting Current Gambling Disorders Among Gamblers in the General Household Population,” published in theCanadian Journal of Psychiatrylast year (Gebauer et al., 2010). The authors derived the three questions from the results of the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) a survey of 43,093 households which has yielded the largest sample of pathological gamblers. Their objective was to develop a screening instrument that would correctly identify the largest proportion of current pathological gamblers and exclude non-pathological gamblers (i.e., reduce the number of false positives). Another consideration was the length of the screen. A concise survey is easy to use in a clinical setting or for a self-assessment and can be easily incorporated into a general survey.

Out of the 10 possible criteria listed in the DSM-IV , the authors’ analysis found that the top three criteria for identifying pathological gambling patterns and avoiding false positives were withdrawal, lying about one’s gambling and borrowing money to gamble. The resulting BBGS questions focus on these criteria. A copy of this paper is available for download from the Division on Addictionswebsite.

What do you think about the BBGS and other gambling screens? Please let us know in the Comments section below. The NCRG always welcomes your feedback.

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The relationship between the brain chemical dopamine and disordered gambling has been well-established over the past several years (we discussed this relationship in the context of Parkinson’s Disease inthe July 2010Issues and Insights). Dopamine is associated with the reward system of the brain, which affects feelings of enjoyment and behavior reinforcement. It and other brain chemicals are, by their very nature, difficult to observe and thus difficult to translate into preventive applications. To bridge the gap between brain chemistry and disordered behavior, researchers can link the two with quantifiable emotions like excitement. The most recent edition ofThe WAGER(Worldwide Addiction Gambling Education Report) reviews a study that looks at those factors as they relate to pathological gambling.

The 2010 study, featured inThe WAGER – Vol. 16(3), examined the amount of dopamine released in the brain, excitement levels and gambling task performance in samples of people with pathological gambling (PG) and healthy controls (HC) (Linnet, Møller, Peterson, Gjedde, & Doudet, 2011). Researchers monitored the dopamine levels of 18 PGs and 16 HCs at baseline and while they completed a gambling task. The participants also reported their feelings of excitement during the task. The researchers found that PGs whose brains released more dopamine reported higher levels of excitement. Additionally, differences in dopamine release from non-gambling to gambling conditions were significantly correlated with changes in excitement level. The authors suggest that dopamine release may be doubly problematic, by reinforcing gambling behaviors and also promoting risky decision-making.

These findings further previous research which suggests that feelings of excitement while gambling reinforce unhealthy behaviors for some people with PG. This subset of people with PG crave feelings of excitement more than recreational gamblers or other people with PG, and may find gambling especially rewarding because of this (Vachon & Bagby, 2009).

For the full review or to access online reviews of research on other addictive disorders, visitThe BASIS (Brief Addiction Science Information Source).
As always, we welcome thoughts and questions in the comments section below.

References

Linnet, J., Møller, A., Peterson, E., Gjedde, A., & Doudet, D. (2011). Dopamine release in ventral striatum during Iowa Gambling Task performance is associated with increased excitement levels in pathological gambling.Addiction,106(2), 383-390. doi:10.1111/j.1360-0443.2010.03126.x

Vachon, D. D., & Bagby, R. M. (2009). Pathological gambling subtypes.Psychological Assessment,21(4), 608-615. doi:10.1037/a0016846

NCRG staffIn the Newsdisordered gamblingDivision on AddictionsexcitementgamblingHarvardHarvard Medical Schoolnew researchpublicationsThe WAGER