The anxiety disorders include many conditions that share features of nervousness, inhibition, avoidance, compulsion and severe stress. I have included a brief description of the different conditions (Source: DSM-IV, APA Press, 1994).

One of the most common anxiety disorders is Panic Disorder, in which one experiences:

• usually unprovoked panic attacks that last 5 to 15 minutes, with intense fear or discomfort
• anxiety, always accompanied by various bodily symptoms such as palpitations, sweating, shaking, shortness of breath, chest pain, nausea, abdominal pain, numbness or tingling sensations in the hands, and dizziness, etc.
• more disturbing features (in some), such as fear of “going crazy,” “derealization” (i.e., feeling of unreality, visual distortion of surroundings), or “depersonalization” (i.e., feeling like one is being detached from oneself, “out-of-body experience”)
• over time, becoming worried about the next attack so that he or she changes his or her behaviour in order to cope — many (25–33%) become agoraphobic, fearing public and open places.

Generalized Anxiety Disorder has more to do with being excessively anxious and worried about things that are beyond one’s control, that occur for a protracted period of time, and is uncontrollable despite the sufferer’s awareness and effort. As well, there are bodily symptoms such as restlessness, unusual fatigue, difficulty concentrating, irritability, muscle tension and sleep.

Clients with either of these conditions are likely to have developed them in their late teens or early 20's. They tend to use gambling as a form of escape, to numb themselves, or as a newly developed compulsion to replace other ones. Thus, they are likely to be better understood in terms of pathway 2. Some other less frequent or less debilitating anxiety disorders are:

Agoraphobia is characterized by anxiety about, or avoidance of places, or situations from which escape might be difficult or embarrassing or in which help may not be available in the event of having a panic attack (e.g., a person commonly avoids crowded or public places such as malls or subways. Victims of this are unlikely to tolerate casinos, but may still use other forms of gambling.)

Specific Phobia is the most common anxiety disorder and is characterized by clinically significant anxiety provoked by exposure to a specific feared object or situation, often leading to avoidance behaviour

Social Phobia is characterized by significant anxiety provoked by certain types of social or performance situations, often leading to avoidance behaviour (e.g., speaking in public, eating in public, waiting in queues, etc.)

Obsessive-Compulsive Disorder is characterized by obsessions that cause marked anxiety or distress (e.g., intrusive worries about cleanliness or security or religious piety that are unwanted), and/or compulsions that are intended to neutralize anxiety (e.g., checking locks 20 times a day, washing hands every five minutes, etc.)

Post-traumatic Stress Disorder (PTSD) is characterized by re-experiencing an extremely traumatic event accompanied by symptoms of increased arousal and by avoidance of stimuli associated with the trauma.

Acute Stress Disorder is characterized by symptoms similar to those of PTSD that occur immediately in the aftermath of an extremely traumatic event. Source: DSM-IV, APA Press, 1994.

Other than PTSD and Acute Distress Disorder, which are consequences of clearly identifiable precipitants (and therefore may follow pathway 1 or 2), the above anxiety disorders all have early onset and clients would probably follow pathway 2 when they present for treatment.

There is evidence that stress and anxiety in general may precipitate gambling activity, and that developing pathological gambling may be related to unresolved trauma-related anxiety. However, there is only moderate support for these associations. At a neurochemical level, anxiety disorders are likely related to a number of neurotransmitters, and are highly genetically influenced. Again, there is no pathway-specific research to identify clients in whom one pathway is more associated with anxiety problems.

Some notable research findings:

• Large-scale self-report studies have shown an increase in panic disorder, agoraphobia, and generalized anxiety disorder in problem gamblers versus non-gambler controls (Linden et al., 1986; Roy et al., 1988).
• Over a lifetime, pathological gamblers had a threefold increase in anxiety disorders in general, a fivefold increase in agoraphobia, and a sixfold increase in obsessive compulsive disorder (ocd) (Bland et al., 1993). However, the relationship between pathological gambling and OCD is still controversial, as some studies had found none (Black et al., 1994). These studies did not note whether the pathological gamblers had anxiety problems prior to their gambling problems.

Many of the factors discussed above in relation to mood disorders will apply here in relation to anxiety disorders. Some additional points:

Screening for Anxiety Disorders
Anticipate and recognize the high prevalence of anxiety disorders — they are among the most prevalent psychiatric disorders, and problem gamblers are no exception. Roughly a quarter of the general population will have some pathologic anxiety over their lifetime; problem gamblers have even higher rates.

Recognize indirect signs — anxiety patients often complain of bodily symptoms, and seek bodily treatment (e.g., headaches, stomach pains) in a primary-care medical setting. These clients are less likely to recognize their anxiety problems, so the counsellor needs to be more vigilant. As well, it is easy to focus on the crisis situations that brought the clients in for treatment and neglect the more chronic, underlying anxiety issues (e.g., generalized anxiety, past trauma, etc.) Some clients with “neurotic” personalities may be that way because of unrecognized underlying anxiety problems that are treatable to a certain extent. Use clinical judgment and the dsm as a rough guide.

The Hamilton Anxiety Rating Scale can be useful (see Appendix a: Assessment and Screening Tools) — consider referral for proper assessment if more than a third of the items are 2 or above.

When to Refer for a Psychiatric Assessment

• when the client reports a family history of anxiety disorder. Genetic and environmental factors are strong predisposing forces for anxiety disorders.
• when counsellors want to use other professionals for support or a second opinion — anxiety clients tend to be trickier about who they feel safe with and trust — identifying this factor early is helpful (e.g., when the client is not responding to current treatment, a referral to a more neutral party may help to identify impasses, particularly with personality issues).
• when unresolved medical issues are present, refer for medical and psychiatric consultation — like mood disorders, many medical conditions mimic anxiety disorders (e.g., thyroid abnormalities, hormonal imbalance, blood abnormalities, nutritional deficiencies, medication interactions, etc.), particularly those who have their first illness after their mid-30's, have no family history, or are lacking precipitating events.
• when there is significant and acute suicide risk — though the prevalence of suicide is less than in those with mood disorders, profound anxiety ranks high in suicide rated clients as well, particularly for those with acute overwhelming stresses and those with very poor coping skills in general.

Psychiatry has identified some very effective treatment modalities for anxiety disorders. For example, cognitive-behaviour therapy (CBT) has been a well-studied and proven effective approach, some say particularly with concurrent anti-anxiety medications such as serotonin specific reuptake inhibitors (SSRIs, e.g., Prozac®, Zoloft®, Paxil®, etc.), or benzodiazepines (e.g., Xanax®, Ativan®, etc.). Insight-oriented and supportive therapies are also useful. In general, the combination of psychotherapy and pharmacotherapy is believed to be better than counselling or medication alone, therefore making it a good general reason for a referral.

Issues to Consider while Counselling with other Mental Health Professionals

• A supportive and reassuring approach is crucial — spending a little longer in the beginning to assess the comfort level fully will pay off later in rapport developed, as anxiety-disordered clients are usually “easily frightened,” sensitive and somewhat avoidant. These clients are likely to have great fears of being thought of as “going crazy,” and are prone to feel embarrassed and anxious about the encounter with the counsellor.
• Assess other aspects of mental health over time — more than half of anxious clients also have significant depression. These may not be picked up by other professionals in one-time-only or brief assessments.
• Prepare and allow for the paradoxical — an anxiety-prone gambler may venture into a crowded place such as a casino, and participate in anxiety provoking activity such as gambling. Examples of this include the person who gambles alone in a crowded place because of social phobia, the person who gambles in order to avoid and escape debilitating generalized anxiety problems, and the gambler with post-traumatic stress disorder who copes with distress through the numbing experience of gambling.
• Nature of anxiety may also be gender related — studies show that among gamblers, females had higher rates of anxiety disorders and history of physical/sexual abuse. It is important to ask all clients about a possible history of abuse as standard practice.
• Some treatment approaches may involve cognitive and behavioural therapies, which are time- and labour-intensive. Collaboration and frequent implementation of these strategies by both the consultant and the counsellor would optimize the treatment, particularly since the counsellor is the one who sees the client on a more frequent basis.
• Communicate with other mental health professionals (with prior consent) to discuss gambling-related anxiety issues and progress, as others are unlikely to know these aspects in detail. They would appreciate the feedback and information.

Case study: panic/anxiety

Ms. C is a single 25-year-old university graduate, who has a satisfying office job at a major newspaper. She had recently arrived from another province and has few friends in town. With the little time she has left after spending long hours at work, she prefers to stay at home, largely out of fear of having panic attacks in public places, where she feels escape is difficult. Since her late teens, she has had many episodes of unprovoked “panic attacks,” characterized by intense feelings of racing heart, shortness of breath, stomach cramps, sweating, and losing all sense of time. These attacks typically lasted anywhere from a few minutes to a quarter of an hour. She was seen by a number of emergency room physicians and had gone through several tests to rule out heart and lung problems. The results were all negative. In the last few years, after she had become more homebound, her “panic” symptoms have largely subsided. That is, until recently.

Ms. C experienced another intense “attack” at a bingo hall one month ago, before her psychiatric consultation. After leaving her old home, Ms. C had found life in the big city stressful and unfriendly. She craved familiar and comfortable surroundings — she found them in bingo halls. She had thought she would be the last person on earth who would like bingo, with its images of blue-collar, older, unemployed, “chain-smoking bingo-yelling fanatics.” She would have nothing to do with it. She succumbed to the temptation one day after learning from the newspaper about a bingo event at a nearby church. She was feeling lonely and elected to choose a seat close to the fire-exit, in case she felt an urgent need to leave. She quickly came to love bingo, with the anticipation, excitement of winning, and the intense but sometimes jovial and friendly atmosphere. She made some “friends” quickly, and was soon attending almost every night. She always took a seat close to the door, and secretly laughed at the irony of finding such a crowded place suitable for a panic-prone person like her. She was overjoyed that her attention to the game made her forget her worries about “attacks.” She soon started to gamble away half of her paycheque at one sitting, nearly losing her rent money at one point. She abandoned what little social engagement she had and plunged into bingo at a rate that surprised her.

She realized it was a problem when the “attack” occurred. She had felt more nervous and irritable as she focused more on her losses, leaving each evening feeling frustrated and thinking about the jackpot the next day. Her work suffered. One night, without any apparent precipitant, she had the “attack.” Since then, she has had up to three or four a week. She was referred to a psychiatrist, who diagnosed panic disorder with agoraphobia (i.e., fear of public, open spaces). She is being treated pharmacologically with a new antidepressant for her panic attacks, and through cognitive-behaviour therapy to overcome her fear of public places. In addition, she was referred to gambling services to deal with problem gambling, using social skill and behaviour charting techniques. She is currently functioning well, and abstaining from bingo.

Applying the Pathways Model
The above case has elements of both pathway 1 and pathway 2. The client is normally a high-functioning person, well-adapted to her panic/anxiety problems. Life circumstances led her to gambling. Like the case study on mood disorder, this client is also psychologically vulnerable and her attraction to gambling reactivated and exacerbated her previous psychiatric condition. She required limited interventions, responded well to proper medication for anxiety, cognitive reframing, behavioural modification, and focused her “homework” in cbt in developing a supportive social/familial network.

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