by Darryl Upfold
Gambling is commonly thought of as an addiction, even though it is not included with other addictions in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV, American Psychiatric Association, 1994). In describing diagnostic categories for problems related to alcohol and other drugs, the DSM-IV uses the term Substance-Related Disorders, which includes, among others, alcohol, amphetamines and caffeine. Gambling problems are referred to as pathological gambling, which is listed as one of six disorders under Impulse-Control Disorders.
The DSM-IV recognizes two levels of severity with the substance-related disorders — substance dependence and substance abuse. Substance dependence is distinguished from substance abuse by several diagnostic criteria, the most significant difference being that the presence of tolerance and withdrawal are required for a diagnosis of dependence. If tolerance and/or withdrawal are present, a diagnosis of abuse cannot be made. In comparison, only one level of problem severity is considered for gambling — pathological gambling.
A review of the diagnostic criteria of these disorders suggests some similarity between them. Substance dependence is described as “a maladaptive pattern of substance use, leading to clinically significant impairment or distress.” The DSM-IV then itemizes seven diagnostic criteria, of which at least three need to be present during a 12-month period to warrant a diagnosis of substance dependence. The same definition is used for substance abuse, with only one diagnostic criterion needing to be present during a 12-month period to warrant the diagnosis. However, it is essential to note that although the description for abuse is the same as dependence, the diagnostic criteria are much different. Most notably, the criteria of tolerance and withdrawal, which are included in the criteria for dependence, are absent in the diagnostic criteria for abuse.
Pathological gambling is described as “persistent and recurrent maladaptive gambling behaviour,” similar to the description for substance dependence and abuse. There are 10 diagnostic criteria, of which at least five need to be present to warrant a diagnosis of pathological gambling. The criteria are worded in the present tense, suggesting that the criteria need to be present at the time of the diagnostic interview to warrant the diagnosis.
An examination of the respective diagnostic criteria indicates a similarity between the disorders. For example, two of the criteria for substance dependence are tolerance and withdrawal, two concepts most commonly associated with the ingestion of a substance, like alcohol or other drugs. Tolerance in relation to substance dependence is described as a need for markedly increased amounts of the substance to achieve intoxication or desired effect. One of the criteria for pathological gambling is a need to gamble with increasing amounts of money in order to achieve the desired excitement. This is quite similar to the definition of tolerance.
Similarly, the concept of withdrawal, described in the criteria for substance dependence as “the development of a substance-specific syndrome due to the cessation or reduction in substance use that has been heavy and prolonged,” is also identified as a criterion for pathological gambling. It is not labelled as withdrawal, but is described as being restless or irritable when attempting to cut down or stop gambling.
Another criterion for substance dependence includes “a persistent desire or unsuccessful efforts to cut down or control substance use.” Pathological gambling involves “…repeated unsuccessful efforts to control, cut back, or stop gambling.”
Additional similarities include the presence of preoccupation, and compromising social, occupational or recreational activities and legal problems (which are not included in the criteria for dependence).
The criteria depart in only two areas of diagnosis. Substance dependence includes a criterion that refers to the substance use continuing despite the individual knowing that continued use of the substance is likely to result in recurrent physical or psychological problems. The criteria for pathological gambling do not address this issue. On the other hand, the criteria for pathological gambling emphasize the negative impact on family and friends in three criteria, while impact on others is not addressed in the criteria for substance dependence.
It is not clear why pathological gambling is positioned with impulse control disorders in the DSM-IV, since there appear to be more similarities between pathological gambling and substance-related disorders, than there are between pathological gambling and impulse-control disorders, at least in terms of their diagnostic criteria.
In a more general sense Marlatt et al. (1999) defined addictive behaviour as:
A repetitive habit pattern that increases the risk of disease and/or associate personal and social problems. Addictive behaviours are often experienced subjectively as “loss of control” — the behaviour contrives to occur despite volitional attempts to abstain or moderate use. These habit patterns are typically characterised by immediate gratification, often coupled with delayed, deleterious effects. Attempts to change an addictive behaviour (via treatment or self initiation) are typically marked with high relapse rates (Marlatt et al., 1988; 224)
From Marlatt’s definition, gambling and substance disorders share a number of addictive behaviour characteristics, again suggesting a phenomenological similarity.
Many similarities exist in terms of how substance dependence/abuse and pathological gambling are treated. Professional and self-help interventions are available for both disorders. The concept of matching the individual to the appropriate professional or self-help (or both) intervention appears to be an important factor in determining outcomes for both disorders. Substance dependence treatment relies more on residential services, including withdrawal management and treatment, than does pathological gambling. Medical intervention is likely more frequently required for individuals with substance dependence.
There is a similar range of therapeutic modalities and orientations available for both disorders, including individual, group and family modalities, as well as cognitive-behavioural and psychodynamic approaches.
Substance abuse and gambling share a common controversy in treatment planning: abstinence vs. reduced use/gambling as a treatment goal. The scientific research and ideological argument on substance dependency and abuse has been well documented. Far less research has been done into the viability of goals of reduced gambling, but the ideological argument for and against abstinence/reduced goals has been imported from the substance abuse literature into the gambling literature. It remains a contentious issue in both fields.
Both disorders are recognized to have potentially serious deleterious effects on family members. Recent literature on children of alcoholics identifies the developmental, interpersonal and emotional issues involved in a family where there is a parent with a substance dependency or abuse problem. Studies on children of pathological gamblers have found increased health-threatening behaviours (such as smoking, overeating, substance abuse, gambling), dysphoria, and deficits in functioning (Jacobs, Marston, Singer et al., 1989).
One significant difference between the two disorders is that problem gambling is recognized as a more cognitively based disorder than substance dependence or abuse. Most researchers (Griffiths, 1995) have concluded that excessive gamblers characteristically demonstrate core cognitive distortions in their belief systems about their ability to win at gambling. These beliefs can persist even when the gambler continues to lose at gambling. It is essential to assess the gambler’s beliefs about his or her ability to win. Some gamblers also have cognitive distortions not only about their ability to win, but also their need for excitement, and a correlating distorted belief that they will not be able to function without the excitement that they derive from gambling. Cognitive therapy is required to identify, challenge and modify cognitive distortions, or relapse to gambling is likely (because the gambler believes that he or she is going to win if he or she gambles). Other interventions may be appropriate and effective (e.g., behavioural therapy, family therapy, impulse control training, etc.), but cognitive assessment and therapy will be a cornerstone of the treatment plan.
Substance abuse may involve minimizing one’s use, and an underestimation of the effect one’s use has on life areas as well as family members may be evident. However, these characteristics are typically interpreted as defence mechanisms (unconscious attempts to deal with what are perceived as attacks against one’s ego, or self), rather than, as in problem gambling, cognitive distortions in one’s belief system — misinterpreting the outcomes and cause-effect relationships involved in gambling.
Another aspect of treatment planning, and treatment where the two disorders vary distinctly, is in relation to the gambler’s financial situation. Treatment for pathological gambling typically includes a major focus on financial assessment, which includes issues like access to cash, cheque control, credit card control, debt resolution strategies, and financial planning (refer to Section 5.2, “Finances and the Gambling Client”). A financial crisis is often the issue that prompts a gambler to seek counselling. Because many gamblers are heavily indebted, attempting to deal with indebtedness by returning to gambling to win money (a cognitive distortion) can be a relapse factor if their financial crisis is not addressed and managed appropriately. It is not uncommon, particularly in the early stages of counselling, to suggest that the gambler surrender access and control of financial matters to his spouse, or another trusted person, as a preventive measure. Preventing or reducing access to money (and therefore eliminating the means to gamble) is considered good practice.
Counsellors must be completely comfortable discussing money management with clients, including incomes, net worth, financial liabilities (credit cards, mortgage, loans), and budgeting. This requires not only the knowledge to advise the client on these matters (or to refer them), but also being psychologically comfortable doing so.
Clients with substance abuse problems may also have some financial pressures related to the cost of their use, but money and financial issues do not take a central role in the treatment plan as they do with counselling gamblers. For many counsellors not accustomed to working with gamblers, this approach may represent a dramatic departure from how they might typically counsel alcohol- and drug-using clients. Accepting and dealing with the integral role of financial matters with gambling clients may require professional development for the substance abuse counsellor.
References
American Psychiatric Association. (1994). Diagnostic and Statistical Manual of Mental Disorders. (4th edition).Washington, dc: American Psychiatric Association.
Donovan, D. & Marlatt, A. (Eds.) (1988). Assessment of Addictive Behaviours. The Guilford Behavioural Assessment Series. New York: Guilford Press.
Griffiths, M. (1995). Towards a risk factor model of fruit machine addiction: A brief note. Journal of Gambling Studies, 11 (3), 343-346.
Jacobs, D., Marston, A., Singer, R.,Widaman, K., et al. (1989). Children of problem gamblers. Journal of Gambling Behaviour, 5 (4), 261-268.
Marlatt, G. Alan, Baer, J., Donovan, D. & Kivlahan, D. (1988). Addictive behaviours: Etiology and treatment. In Annual Review of Psychology, 39. Palo Alto, ca: Annual Reviews Inc.
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