Gambling Disorder (Pathologic Gambling)

Gambling Disorder (Pathologic Gambling) is a topic covered in the 5-Minute Clinical Consult.

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Basics

Description

Gambling is the act of placing something of value at risk in the hopes of gaining something of greater value. Pathologic gambling (PG) and problem gambling are often associated with other mental or substance abuse disorders. The essential feature of gambling disorder is persistent and recurrent maladaptive gambling behavior that disrupts personal, family, and/or vocational pursuits.

Epidemiology

  • Growth of the gambling industry may be causing the increased prevalence of gambling problems.
    • In 1978, only two states legalized gambling. In 1998, only two states had not legalized gambling.
  • Predominant sex: male > female, although the gap in gender is narrowing
  • Rates of pathologic and problem gambling are higher in adolescents and middle-age persons compared to older adults. The younger a person starts gambling, the more likely he or she will become a pathologic gambler.
  • Economics: $0.5 trillion is wagered in the United States annually.

Prevalence
  • Lifetime prevalence of pathologic and problem gambling in adults is 1.6% (2.5 million) and 3.85% (3 million), respectively in the United States. Higher rates were reported in children and adolescents (3.88% and 9.45%, respectively).
  • Men are more likely than women to be pathologic, problem, and at-risk gamblers.
  • Living within 50 miles of a casino is associated with approximately doubling the prevalence of problem and PG.

General Prevention

  • Focus on treatment; patient education; awareness of risk factors, associated conditions, and warning signs of pathologic or problematic gambling behaviors.
  • Primary prevention using educational programs that target at-risk youth and adults
  • Public health interventions: Decrease available gambling locations and lottery venues, ban advertising for gambling activities, keep lottery tickets out of sight, add warning labels with risk of problem gambling to packaging of gambling products, enforce legal age of gambling, moratorium on building new casinos (1).

Etiology and Pathophysiology

  • The Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5) characterizes gambling disorder as a nonsubstance-related and addictive disorder. However, there is a debate whether it is a nonsubstance-related disorder or an impulse-control disorder.
  • Impulse control: changes in serotonin metabolites in pathologic gamblers and patients with impulse-control disorders
  • Substance abuse: similarities found between PG and substance users (tolerance, withdrawal, anticipatory craving, relapses)
  • Release of endogenous opioid peptides in the ventral tegmental area of the brainstem simulates a “natural addiction.”
  • More “activation” of the hypothalamic-pituitary-adrenal axis than non-PGs
  • Changes in the brain-reward pathways and prefrontal cortex
  • The brains of pathologic gamblers may have some predisposition to illness. Functional MRI studies indicate that the ventromedial prefrontal cortex is less activated when gambling stimuli are presented to pathologic gamblers.
  • Abnormalities in the neurotransmitters serotonin, norepinephrine, dopamine, and glutamate may be implicated in PG.
    • Norepinephrine: Low levels seem to help a patient avoid gambling, whereas high levels may lead to poor decision making.
    • Serotonin: involved in impulse control by helping a patient weigh the risks of gambling
    • Dopamine: High levels in the nucleus accumbens while gambling lead to a pleasurable rush may induce reversible PG in Parkinson patients who take dopamine agonists.
  • Medicine classes for each category have been used in treatment.

Genetics
  • More prevalent among first-degree relatives of alcoholics than among general population
  • SLC6A4 serotonin transporter gene has been associated with PG in males but not in females.
  • Dopamine receptor genes DRD1, DRD2, DRD3, and DRD4 have been correlated with PG.

Risk Factors

  • Some types of gambling present a greater risk to cause PG than other types: pull tabs, casino gambling, bingo, and card games outside a casino.
  • Multiple gaming modalities
  • Lower socioeconomic status
  • Adults in mental health treatment
  • Substance abuse (nicotine, alcohol, inhalants, marijuana)
  • Childhood abuse and child neglect
  • Witnessing trauma or being a victim of physical attack
  • Positive family history
  • Antisocial personality disorder, depressive and bipolar disorders, other substance abuse disorders
  • Seatbelt nonuse

Commonly Associated Conditions

  • Poor nutrition
  • Stress-related medical conditions (e.g., peptic ulcer disease [PUD], hypertension, migraines, palpitations)
  • Suicidal ideation and attempts
  • Substance abuse disorder (especially alcohol)
  • Attention deficit hyperactivity disorder (ADHD)
  • Bipolar disorder and other mood disorders
  • Impulse-control disorders
  • Personality disorders
  • Incarceration
  • Financial problems (e.g., previous bankruptcy)

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