case study of problem gambling

A Brief Review of Gambling Disorder and Five Related Case Vignettes

The loss of control over urges and behaviors may be the central component of gambling disorders, but there is so much more to consider. Individuals with these problems have exponentially higher rates of suicide attempts and completions.

Nearly 4% of the population has gambling-related problems, and 6% will experience harm from gambling during their lifetime-including financial, legal, relational, and health problems. 1 In addition, individuals with gambling problems have exponentially higher rates of suicide attempts and completions. One study found that 81% of pathological gamblers in treatment showed some suicidal ideation, and 30% reported one or more suicide attempts in the preceding 12 months. 2

DSM-5 criteria for gambling disorder represent the most common symptoms experienced by those with gambling problems. These symptoms characterize 3 heterogeneous dimensions related to gambling disorder: damage or disruption, loss of control, and dependence. The loss of control over urges and behaviors may be the central component of gambling disorders, and the inability to control gambling may be a component of a progressively worsening process in the life span of some gamblers.

Individuals who encounter gambling-related problems but who do not reach the diagnostic threshold (subthreshold gambling disorder meets only 1 to 3 criteria) are referred to as problem gamblers. For the most part, those with subthreshold gambling disorder continue to experience social, psychological, and health repercussions but to a lesser degree. They are also at increased risk for progression to gambling disorder compared with non-gamblers.

Gambling disorder is referred to as a hidden addiction because of the minimal signs and symptoms associated with this condition. 3 The level of severity can also be concealed and involve multiple components. For example, a gambler who “hits rock bottom” (or one who has lost everything, including financial assets and social relationships) may have stopped gambling because of the lack of finances, but he or she may be severely depressed and suicidal because of the ongoing repercussion. Other components of severity include gambling behavior (frequency, duration, amount gambled), extent of gambling desires (cravings, urges), repercussions (eg, employment, legal, relationships), level of control, and comorbid symptoms (eg, suicidality, impulsivity, depression). These factors help predict treatment outcome and determine the appropriate treatment (ie, brief intervention, intensive outpatient, hospitalization). In research, severity is usually assessed using the total number of criteria endorsed, which can also be a quick and straightforward method in the clinical setting.

Comorbidity

Gambling disorders are strongly associated with comorbid psychopathology. A meta-analysis of 11 population surveys found high mean prevalence for nicotine dependence (60.1%), a substance use disorder (57.5%), mood disorders (37.9%), and anxiety disorders (37.4%). 1 A longitudinal 3-year study also found that any mood, anxiety, or substance use–related disorder was more likely to develop in individuals with either subthreshold gambling disorder or gambling disorder than in those who did not gamble. 4

Clinically, it may be helpful to assess sleep. Those with gambling problems have an increased risk of difficulty in initiating sleep, maintaining sleep, and more and early awakenings. 5 Sleep disturbances can impair self-control and decision making, increase impulsivity, degrade cognition in executive functioning tasks, attenuate responses to losses, and increase expectations of gains that can affect gambling behavior.

There are no FDA-approved pharmacological treatments for gambling disorder, but several studies have evaluated the effects of medications on gambling behavior and comorbid symptoms. Grant and colleagues 6 reviewed 18 double-blind placebo-controlled studies that included antidepressants, antipsychotics, mood stabilizers, glutamatergic agents, and opioid antagonists. Although the results were mixed and conclusions were limited because of the small sample sizes, opioid antagonists and glutamatergic agents ( N -acetylcysteine) seemed to have the most promising results, especially for those with intense gambling urges.

A number of psychosocial strategies have shown promise in controlling aberrant gambling behavior, including self-help manuals, brief one-session interventions (motivational therapy), psychodynamic therapy, cognitive-behavioral therapy (CBT), and referrals to 12-step support groups. 7 Research findings indicate that the treatment for gambling disorder not only reduces gambling behavior but can also help reduce comorbid psychiatric symptoms, such as anxiety and depression; improve quality of life; decrease psychological stress; and decrease the likelihood of comorbid psychopathology. 8

CASE VIGNETTE 1

Jack, a 16-year-old 10th grader, is brought by his mother for evaluation of his “excessive online gaming.” Jack’s mother is concerned that her son plays casino-based “freemium” games 5 hours every day. (Freemium games are free to download but require tokens that are purchased with real money and gambled among players.) He buys approximately $30 worth of tokens every day and has spent more than $5000 on tokens in the past 6 months. He constantly argues with his parents regarding his playing time, his school work has deteriorated, and he no longer has any social interactions.

Jack admits that he lies to his parents about the extent of his playing-he sometimes plays more than 10 hours a day. He has a hard time stopping and usually plays until he loses all his tokens. He uses his mother’s credit card to buy tokens without permission. He is proud of his online accomplishments and enjoys the winning and competition with real adults. Although he now has no desire to interact with peers outside of school, he had enjoyed participating in a recreational sports league in the past.

Jack does not appear to suffer from any other disorder. He has never had problems with alcohol or drugs, and he has never seen a mental health professional or received psychotropics. His childhood and development have been without incident. Last year, his mother returned to work and Jack started taking care of his 7-year-old sister after school (during which he games the most).

During the initial session, gaming patterns and repercussions are discussed (financial, educational, and developmental). Recommendations are made that include changing passwords to the app store and limiting Internet access to supervised sessions, and Jack’s access to his mother’s credit card is cut off. After-school activities for both children are also highly encouraged, possibly restarting recreational sports competitions for Jack. Potential positive reinforcement methods for complying with clean Internet play are also discussed. The family is referred to a family therapist to continue working on family dynamics.

CASE VIGNETTE 2

A 19-year-old college sophomore is referred by student health for evaluation of his gambling problems. Michael’s gambling has become pathological in the past year: he either bets on sports online or spends about 6 hours at a local casino daily. Although he does not work, he lost $50,000 in the past year, using money from his sports scholarship and financial aid. His mother has bailed him out multiple times by paying his credit card bills. He still has a credit card debt and owes money to his friends, which totals $25,000. He usually chases his losses, has strong cravings to gamble during the day, and experiences anxiety trying to find money to use for gambling. The time he spends on academics and team practices has become significantly reduced.

His primary care physician (PCP) prescribed stimulants after a diagnosis of ADHD in middle school, which Michael took until 12th grade. He has never seen a mental health professional or taken any psychotropic medication. He started binge drinking at college parties (probably twice a month, enough to black out); in addition, he smokes one blunt of marijuana every week.

Michael started gambling recreationally with friends in middle school, but he acknowledges that his problem controlling gambling started last year. Although he is disheartened by his gambling problem (and its repercussions), he is not depressed, still enjoys hobbies (which he indicates is gambling), and has fun with his girlfriend. He seems intelli-gent and brags about knowing the poker odds. He is seeking treatment because he wants to control his gambling (make only smart bets or play the good hands). His biggest problem is “losing a few bets in a row and going on tilt!”

During the first session, gambling patterns and repercussions are discussed, which he had initially minimized (ie, the possibility of losing his scholarship and being kicked off the team). He agrees to restart treatment with a stimulant, to include his mother in the next session via phone, and to go to Gamblers Anonymous. He agrees to continue CBT at the student health center to work on his aberrant alcohol use.

During the second session (3 weeks later), he reports that he has restarted the stimulant, which helps his impulsivity and studying habits. He has completed 8 sessions of CBT at the student center. He went to a Gamblers Anonymous meeting but did not agree with their tenet for abstinence. His mother agrees to stop bailing him out, control his credit cards and scholarship checks, and provide a limited allowance.

For the next few months, his gambling decreases (both in duration and frequency), but he places larger bets and loses more. Since his mother stopped bailing him out, he borrows money from a loan shark. He is kicked off the team and his scholarship is terminated. He decides to contact a state-funded mental health professional for more regular therapy sessions. He also agrees to ask the loan shark for a repayment plan.

By the fifth session (4 months after his initial presentation), he has stopped gambling and has a part-time job. He is making regular payments to his loan shark, studying more, drinking less alcohol, and playing more sports recreationally. He still enjoys gambling but now is aware of the repercussions. He is more focused on raising his grade point average and returning to the sports team.

CASE VIGNETTE 3

James, a depressed 40-year-old poker player, is referred by his wife. He was laid off from work 8 months earlier. Since then he plays poker for 8 hours a day at a nearby casino. He gambles “out of boredom” and enjoys the social atmosphere. Although he is well-off financially, he has lost more than $200,000 in the past year. He now plays at higher-limit tables and chases his bets. He lies to his wife regarding his gambling and is on the brink of getting a divorce. He started playing poker as a teenager and had weekly poker games with his colleagues at work.

He lacks motivation, has stopped taking care of himself, and has gained 30 pounds in the past year. He has a hard time falling asleep and at times is restless in the mornings. James has had 3 episodes of depression in the past; he has been taking aripiprazole, citalopram, and bupropion (prescribed by his PCP) for the past 6 months. There is no his-tory suggestive of mania, hypomania, suicidality, or aberrant substance use.

During the first session with James and his wife, his recent gambling winnings/losses are reviewed, including bank statements that his wife brings in. He is surprised at the total amount of losses. He loves poker, but he does not want a divorce. He agrees to give all his bank cards to his wife, ban himself from local casinos, and work on saving his marriage. The couple are given a self-help workbook and listings for Gamblers Anonymous and Gam-Anon, and proper sleep hygiene is emphasized. The couple are also referred to the state-funded gambling provider network to receive therapy to work on their relationship.

Mirtazapine is started to help with depression, and aripiprazole is tapered. (Case report findings suggest a potential correlation between aripiprazole and excessive gambling, which is similar to the association between dopamine replacement therapy for Parkinson disease and gambling.9)

By the next session, James has stopped gambling because he no longer has easy access to money. He has also started attending Gamblers Anonymous several times a week and enjoys their camaraderie. He appreciates how attending Gamblers Anonymous has helped diminish his strong urges to play poker.

By the fourth session (third month), he has completed his rÃ©sumÃ© and started exercising again. His sleep is improved, he regularly attends meetings of Gamblers Anonymous, and he has a sponsor in addition to making a commitment to the group. He is also in the process of completing 12 sessions with the marriage and family therapist. He misses playing poker, but realizes how abstaining has improved his relation-ship with his wife.

CASE VIGNETTE 4

Jackie, a 34-year-old nurse, is referred by her coworker for gambling at work. Compelled by her colleague, Jackie came to the addiction clinic to receive help for her uncontrollable need to gamble at work. She plays online slots on her phone for about 6 hours during her night shifts; after work, she usually tries to win back her losses at the local casino. Although she has lost $50,000 in the past 6 months, with an annual salary of $150,000, she does not have any financial difficulties and is still well regarded at work.

Six months earlier, Jackie called off her wedding after discovering her fiancÃ©’s infidelity. Since that time, gambling has been a great escape for her, specifically helping with ruminations. She is sad, has almost daily crying spells, lacks motivation to care for herself, has problems falling asleep and sustaining sleep, and has some thoughts that she may be better off dead. She is also irritable, easily snapping at colleagues and difficult patients at work. She drinks several glasses of wine every day to “help her nerves.”

Jackie describes some history suggestive of hypomania (not sleeping for a few days, very energetic, happy, impulsively shopping, gambling, and having sex). She carries diagnoses of bipolar disorder, depression, borderline personality disorder, and ADHD. When she was 17, she had a psychiatric hospitalization after breaking up with her boyfriend; she had suicidal ideations and self-injurious behavior (cutting). Jackie saw a therapist for 3 years, went to an accelerated nursing school, and currently works full-time at the hospital. She sees a psychiatrist (about twice a year), who prescribes quetiapine extended-release. Her PCP also prescribes trazodone, fluoxetine, methylphenidate (twice daily), clonazepam (3 times daily), and zolpidem.

During the first session, Jackie is ambivalent about treatment for her gambling, but she does want help for her insomnia, irritability, and anxiety. She agrees to consolidate her prescriptions to one prescriber to optimize medications. She receives psychoeducation regarding the importance of sleep hygiene, especially the effects of smoking, alcohol, stimulants, and shift work. The repercussions of her gambling are also discussed, and she is given a self-help workbook with listings for Gamblers Anonymous meetings. She agrees to taper off most of her medications and to start lamotrigine.

During the second session (10 days later), she reports that her gambling at work has decreased significantly because she was being monitored by her colleagues, but her gambling outside of work has increased. She also started melatonin and diphenhydramine on her own to help with insomnia. Her passive suicidal ideations are stronger, because she thinks that she is not doing anything productive with her life. She does not have a specific plan to hurt herself; she believes that suicide is immoral; and she does not want to voluntarily admit herself to an intensive outpatient program, a residential treatment program, or an inpatient unit.

Jackie continues to be irritable and to have poor self-care and low self-esteem. She enjoys talking during the session and wants to come more often. She has not been to any Gamblers Anonymous meetings because she does not believe that she has a gambling problem. Medications continue to be optimized, and the benefits of sleep hygiene are reinforced. She is also referred to a state-funded therapist to help with her gambling problems.

During her third and fourth sessions (weekly), she reports that the new medication regimen is finally working and she feels less irritable. She has not gambled at work during the past week and feels good, and she has started working more shifts (about 90 hours per week). Consequently, she is usually exhausted af-ter work and does not have the energy to go gambling.

At the seventh session (about 10 weeks after intake), Jackie reports that her work shifts have become more irregular. She works subsequent day and night shifts, and then has a few days off. During her most recent off days, she accepted an invitation for free accommodations and a spa package at a casino/hotel. In those 3 days, she lost $30,000 and gambled for 40 hours. She maxed out her credit cards and emptied her savings account. She finally agrees that she has a gambling problem. She plans to remove herself from the casino’s mailing list, ban herself from the local casinos, close her online casino gambling accounts, schedule an appointment with the state-funded therapist, and ask her brother to start controlling her finances.

During the next 6 months (about 15 sessions), she stops gambling. She completes 10 sessions of gambling treatment with the state therapist and decides to continue the therapy out-of-pocket. Her sleep has improved, and her irritability and anxiety have decreased. Jackie also has started working only regular day shifts and has started exercising and socializing with old friends.

CASE VIGNETTE 5

Mrs Kim, a 60-year-old manic gambler, is brought to the emergency department by her daughter for bizarre behavior. For the past month, Mrs Kim has been gambling more than usual and today she returned from the casino after gambling for 48 continuous hours. She had maxed out her credit cards and emptied her savings account. A family friend saw her at the casino acting provocatively toward random strangers. Apparently, she has not slept for the past 3 days. Her family has never seen her act this way.

Mrs Kim has no psychiatric history other than complaining of boredom and lack of motivation to her PCP last month, who prescribed an antidepressant.

Gambling has been a significant part of her life for years; she has been going to the local casino at least once a week for the past 16 years and playing for 5 to 8 hours each time. Before this past incident, she has never gambled more money than she could afford or chased her bets. She has also never experienced gambling-related repercussions.

On evaluation, Mrs Kim is restless but alert and oriented. She is talkative with rapid speech. She reports that she feels “amazing”; her affect is labile-she cries when discussing her deceased husband and then suddenly starts making jokes. She is fixated on leaving the hospital and returning to Thailand to see her deceased mother (whom she believes is still alive).

She is admitted to the inpatient unit after a negative medical workup. Medication-induced bipolar and related disorder are suspected. Her antidepressant is discontinued and a low-dose antipsychotic is started. Fourteen days later, she is discharged: her delusions and manic symptoms have resolved, including her urges to gamble uncontrollably.

These fictional case vignettes represent samples of individuals with gambling problems that any practicing psychiatrist may encounter. Although each patient suffered gambling-related problems, treatments were unique and personalized. It is also not uncommon to include significant others to help control finances, professionals (eg, accountants, lawyers), and health care workers (eg, counselors, therapists) in treatment plans. Specifically, free resources are available and can be used as part of the treatment plan, including self-help manuals and referrals to state-funded provider treatments and 12-step support groups ( Table ).

Disclosures:

Dr Parhami, is a PGY 3 Psychiatry Resident at the Delaware Psychiatry Residency Program, New Castle. He has completed a postdoctoral research fellowship at UCLA and will start a Child and Adolescent Psychiatry Fellowship at Johns Hopkins, Baltimore, in July. Dr Fong is Associate Psychiatry Professor, Co-Director of the UCLA Gambling Studies Program, Director of the UCLA Addiction Medicine Clinic, and Program Director for the UCLA Addiction Psychiatry Fellowship. Dr Parhami reports no conflicts of interest concerning the subject matter of this article; Dr Fong has received funding from the California Office of Problem Gambling.

References:

1. Lorains FK, Cowlishaw S, Thomas SA. Prevalence of comorbid disorders in problem and pathological gambling: systematic review and meta-analysis of population surveys. Addiction . 2011;106:490-498.

2. Battersby M, Tolchard B, Scurrah M, Thomas L. Suicide ideation and behaviour in people with pathological gambling attending a treatment service. Int J Ment Health Addict . 2006;4:233-246.

3. Ladouceur R. Gambling: the hidden addiction. Can J Psychiatry . 2004;49:501-503.

4. Parhami I, Mojtabai R, Rosenthal RJ, et al. Gambling and the onset of comorbid mental disorders: a longitudinal study evaluating severity and specific symptoms. J Psychiatr Pract . 2014;20:207-219.

5. Parhami I, Siani A, Rosenthal RJ, Fong TW. Pathological gambling, problem gambling and sleep complaints: an analysis of the National Comorbidity Survey: Replication (NCS-R). J Gambl Stud . 2013;29:241-253.

6. Grant JE, Odlaug BL, Schreiber LR. Pharmacological treatments in pathological gambling. Br J Clin Pharmacol . 2014;77:375-381.

7. Hodgins DC, Stea JN, Grant JE. Gambling disorders. Lancet . 2011;378:1874-1884.

8. Fink A, Parhami I, Rosenthal RJ, et al. How transparent is behavioral intervention research on pathological gambling and other gambling-related disorders? A systematic literature review. Addiction . 2012;107:1915-1928.

9. Gaboriau L, Victorri-Vigneau C, GÃ©rardin M, et al. Aripiprazole: a new risk factor for pathological gambling? A report of 8 case reports. Addict Behav . 2014;39:562-565.

10. National Center for Responsible Gaming. Brief Biosocial Gambling Screen. http://www.ncrg.org/resources/brief-biosocial-gambling-screen. Accessed March 5, 2015.

11. Gamblers Anonymous. US meetings. http://www.gamblersanonymous.org/ga/locations . Accessed March 5, 2015.

12. California Department of Public Health. Freedom From Problem Gambling. http://problemgambling.securespsites.com/ccpgwebsite/help-available/publications.aspx . Accessed March 5, 2015.

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How gambling affects the brain and who is most vulnerable to addiction

Once confined mostly to casinos concentrated in Las Vegas and Atlantic City, access to gambling has expanded dramatically, including among children

Vol. 54 No. 5 Print version: page 62

Personality
Video Games

It has never been easier to place a bet. Once confined mostly to casinos concentrated in Las Vegas and Atlantic City, gambling has expanded to include ready access to lotteries and online games and video games with gambling elements for adults and children.

Sports betting is now legal in 37 states plus Washington, DC, with six more considering legislation, according to American Gaming Association data from early 2023. People can gamble around the clock from anywhere and, increasingly, at many ages, including teenagers and even young children who are well below the legal age for gambling.

As access to gambling has expanded, psychologists and other experts have become concerned not just that more people will give it a try, but that more will develop gambling problems. And while it is still too soon to know what the long-term effects will be, evidence is growing to suggest that young people, especially boys and men, are among those particularly vulnerable to gambling addiction—the same demographic most often participating in the newest forms of gambling: sports betting and video game-based gambling.

People in their early 20s are the fastest-growing group of gamblers, according to recent research. And many kids are starting younger than that. Nearly two-thirds of adolescents, ages 12 to 18, said they had gambled or played gambling-like games in the previous year, according to a 2018 Canadian survey of more than 38,000 youth funded by the government of British Columbia ( Understanding the Odds , McCreary Centre Society, 2021 [PDF, 1.1MB] ). Starting young carries a relatively high burden of psychological distress and increased chances of developing problems.

Researchers are now working to refine their understanding of the psychological principles that underlie the drive to gamble and the neurological underpinnings of what happens in the brains of gamblers who struggle to stop. Counter to simplistic assumptions about the role that the neurotransmitter dopamine plays in addictions ( Nutt, D. J., et al., Nature Reviews Neuroscience , Vol. 16, No. 5, 2015 ), research is showing variations in the volume and activity of certain areas of the brain related to learning, stress management, and rewards processing that might contribute to problematic gambling.

Understanding what makes certain people vulnerable to developing problems could ultimately lead to better strategies for prevention and treatment, and also elucidate the evolving health impacts of gambling, the consequences of starting young, and even the role that the government should play in addressing those issues.

As it stands, the National Institutes of Health has agencies dedicated to problem alcohol use and drug use, but there are no official efforts aimed at problem gambling, and there are no federal regulations against advertisements for sports betting, said social worker Lia Nower, JD, PhD, director of the Center for Gambling Studies at Rutgers University in New Jersey. That means kids can see ads, often featuring their sports heroes promoting gambling, at any time of day or night. “It’s the wild, wild west with regard to gambling,” Nower said.

Examining the risks

Most adults and adolescents in the United States have placed some type of bet, and most do it without problems. But a significant subset of people who start gambling go on to develop gambling disorder, defined in the Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) as a persistent, recurrent pattern of gambling that is associated with substantial distress or impairment.

Gambling problems, previously called pathological gambling, were considered an impulse control disorder until 2013, when the DSM-5 classified them as an addictive disorder. That made gambling addiction the first, and so far the only, defined behavioral addiction in the clinical section of DSM-5 (with some hints that video gaming disorder might ultimately follow, experts say). Like addictions to alcohol and drugs, gambling addictions are characterized by an increasing tolerance that requires more gambling as time goes on to feel satisfied. People with the disorder can also experience withdrawal that causes irritability when they try to quit.

Over the last 20 years or so, researchers have refined their understanding of how common gambling addictions are and who is most vulnerable. Among adults, the estimated proportion of people with a problem ranges from 0.4% to 2%, depending on the study and country. Rates rise for people with other addictions and conditions. About 4% of people being treated for substance use also have gambling disorder, as do nearly 7% of psychiatric inpatients and up to 7% of people with Parkinson’s disease. An estimated 96% of people with gambling problems have at least one other psychiatric disorder. Substance use disorders, impulse-control disorders, mood disorders, and anxiety disorders are particularly common among people with gambling problems ( Potenza, M. N., et al., Nature Reviews Disease Primers , Vol. 5, No. 51, 2019 ).

Vulnerability is high in people with low incomes who have more to gain with a big win, added psychologist Shane Kraus, PhD, director of the Behavioral Addictions Lab at the University of Nevada, Las Vegas. Young people, especially boys and men, are another susceptible group. Up to 5% of adolescents and young adults who gamble develop a disorder. And men outnumber women at a ratio of about 2 to 1 among people with gambling addictions, although there are a growing number of women with the disorder.

Despite concerns, scientists have yet to document a consistent rise in the rates of gambling problems in recent years, said Jeffrey Derevensky, PhD, a psychologist and director of the International Centre for Youth Gambling Problems and High-Risk Behaviours at McGill University. Still, because more people now have access to gambling, evidence suggests that overall numbers of problems appear to have risen, Derevensky said. After Ohio legalized sports betting, for example, the number of daily calls to the state’s gambling helpline rose from 20 to 48, according to the Ohio Casino Control Commission. Other states have reported similar trends.

As evidence accumulates, it is important to examine the risks without overreacting before the data are in, said Marc Potenza, PhD, MD, director of Yale University’s Center of Excellence in Gambling Research. When casinos enter a region, he said, the area may experience a transient bump in gambling problems followed by a return to normal. Given how quickly gambling is evolving with digital technologies, only time will tell what their impact will be. “We don’t want to be overly sensationalistic, but we do wish to be proactive in understanding and addressing possible consequences of legalized gambling expansion,” he said.

From gaming to gambling

After years of studying the psychological effects of video game violence, psychologist James Sauer, PhD, a senior lecturer at the University of Tasmania in Australia, took notice when Belgium became the first country to ban a feature called loot boxes in video games in 2018. Loot boxes are digital containers that players can buy for a small amount of money. Once purchased, the box might reveal a special skin or weapon that enhances a character’s looks or gives a player a competitive advantage. Or it might be worthless.

On a Skype call after the news broke, Sauer, a psychological scientist and coexecutive director of the International Media Psychology Laboratory, talked with his collaborator, psychological scientist Aaron Drummond, PhD, of Massey University in New Zealand, about Belgium’s decision. Because loot boxes represent a financial risk with an unknown reward, Belgian policymakers had categorized them as a form of gambling, and those policymakers were not the only ones. Countries and states that have passed or considered regulations on loot boxes include Australia, the Netherlands, and Hawaii. But those regulations were contentious.

Sauer and Drummond discussed the need for more science to guide the debate. “We were trying to think about how we might contribute something sensible to a discussion about whether these in-game reward mechanisms should or should not be viewed as a form of gambling,” Sauer said.

To fill the evidence gap, the researchers watched online videos of players opening loot boxes in 22 popular and recently released games that had been rated by the Entertainment Software Ratings Board as appropriate for people ages 17 and younger. Nearly half of the games met the definition for gambling, the researchers reported in 2018, including Madden NFL 18 , Assassin’s Creed Origins , FIFA 18 , and Call of Duty: Infinite Warfare ( Nature Human Behaviour , Vol. 2, 2018 ). Among the criteria for qualifying as gambling was an exchange of real money for valuable goods with an unknown outcome determined at least partly by chance. Purchased objects had value that gave an advantage in the game and sometimes could be sold or traded to others for real money.

Loot boxes tap into the same psychological principles that draw people to slot machines, Sauer said. They may deliver a big payoff, but payoffs come at random intervals. Unlike rewards given after every repetition of a behavior, this type of variable ratio reinforcement, or intermittent reinforcement, exploits a cognitive distortion that makes a player or gambler view each loss as one step closer to a win and can lead to very rapid adoption of a behavior that can then be hard to extinguish, Sauer said. Animals exhibit the same patterns. “They feel sure that the reward is coming, but they can’t know when, so they keep repeating the behavior,” he said. “They continue even as rewards become less and less frequent and even stop entirely.”

After establishing that loot boxes, which generate billions of dollars in revenue for video game companies, are often in fact a type of gambling, studies by Sauer’s group and others since then have shown that people who spend more on loot boxes are often at higher risk of developing gambling problems, and that the connection is strongest in adolescence. Scientists are now working to untangle the question of whether buying loot boxes can cause gambling addictions, and at least some evidence supports this kind of gateway idea.

In one survey of 1,102 adults in the United Kingdom, about 20% of gamblers said that loot boxes were their first introduction to gambling and that their experiences with the game rewards made them think that other forms of gambling could be fun, according to a 2022 study ( Spicer, S. G., et al., Addictive Behaviors , Vol. 131, No. 107327, 2022 ). More than 80% of them had started buying loot boxes before they were 18. More recently, Canadian researchers surveyed hundreds of young adult video gamers at two time points, 6 months apart. Among those who were not gamblers when the study started, dozens went on to gamble over the course of the study, they reported in 2023, suggesting that loot boxes had opened the gambling floodgates ( Brooks, G. A., & Clark, L., Computers in Human Behavior , Vol. 141, No. 107605, 2023 ).

But the relationship can also go the other way. People who already gambled, the Canadian researchers found, spent more on loot boxes. And in the U.K. research, about 20% of people who started out with other types of gambling migrated to loot boxes—the same proportion that went in the other direction. Figuring out how loot boxes and gambling behavior influence each other remains a work in progress. “We just don’t have the data yet to understand the long-term consequences,” Sauer said.

Also contentious is the question of how loot boxes affect mental health. Sauer’s group has found a link between spending on loot boxes and severe psychological distress ( Scientific Reports , Vol. 12, No. 16128, 2022 ), while other research has failed to find the same association. Because kids are increasingly being exposed to gambling, it is an important question to sort through. “Some researchers have argued,” Sauer said, “that if we don’t want kids engaging with bona fide gambling behaviors, maybe we want to be wary about kids engaging with these...gambling-like reward mechanisms.”

Early exposure

Loot boxes are not the only avenue to gambling for kids. Online games that simulate gambling without financial risk are often available to very young children, said Derevensky, who once watched a young girl play a slot machine game on a tablet installed in an airport waiting area. She was earning points, not real money, and loving it. “She’s winning, and she’s saying to her dad, ‘I can’t wait until I play it for real,’” he said. “She must’ve been no more than 6 years old.”

By adolescence, about 40% of people have played simulated gambling games, studies show. These games often involve more winning than their real-world equivalents, Derevensky said. And that playful introduction without financial stakes can spark an interest. Work by his group and others has shown that teens who play simulated gambling games for points are at higher risk of having gambling problems later on ( Hing, N., et al., International Journal of Environmental Research and Public Health , Vol. 19, No. 17, 2022 ).

Seeing parents, siblings, or other members of the household gamble also normalizes gambling for kids, making them more likely to engage in gambling and other risky behaviors, including alcohol and drug use, Nower has found in her research ( Addictive Behaviors , Vol. 135, No. 107460, 2022 ). And the earlier kids get exposed to gambling through online games and other avenues, studies suggest, the more severe their gambling problems are likely to be later on ( Rahman, A. S., et al., Journal of Psychiatric Research , Vol. 46, No. 5, 2012 ).

“Kids as young as preschool are being bombarded with requests to buy things in video games,” Nower said. “A lot of kids move from betting on loot boxes in video games to playing social casino games that are free and then triage them to pay sites. You can’t really tell gambling from video gaming anymore. There’s so much overlap.”

The brain of a problem gambler

To understand why early exposure makes a difference, and why a subset of people develop gambling addictions, some scientists have been looking to the brain.

Studies have linked gambling disorders to variations in a variety of brain regions, particularly the striatum and prefrontal cortex, which are involved in reward processing, social and emotional problems, stress, and more. Some of these differences may be attributable to genetics. Twin studies and modeling work suggest that genes explain half or more of individual differences with gambling problems, specifically.

In people with gambling disorders as well as substance use disorders, a meta-analysis found that several studies showed less activity in the ventral striatum while anticipating monetary rewards ( Luijten, M., et al., JAMA Psychiatry , Vol. 74, No. 4, 2017 ). Along with other findings, those results suggest that this part of the brain contributes to impulsive behaviors for people with gambling problems.

Among other emerging insights, people with gambling problems also have smaller volumes in their amygdala and hippocampus, two regions related to emotional learning and stress regulation. Brain research might help explain why teenagers are particularly susceptible to gambling, Potenza said, including the observation that different parts of the brain mature at different rates in ways that predispose teenagers to gambling and other risk-taking behaviors. The prefrontal cortex, which regulates impulsivity and decision-making, is particularly late to develop, especially in boys.

Parsing out the details could lead to new treatments, Potenza said. For example, he and colleagues stimulated the prefrontal cortex of people with problematic gaming behavior and found improvements in their ability to regulate cravings and emotions ( European Neuropsychopharmacology , Vol. 36, 2020 ). The U.S. Food and Drug Administration has begun approving neuromodulatory approaches for using targeted brain stimulation to treat psychiatric conditions, including addictions, that could eventually help people with gambling problems, Potenza said.

New strategies for treatment would be welcome, experts say, as gambling is a particularly tricky addiction to treat, in part because it is easy to hide. As many as 90% or more of people with gambling problems never seek help ( Bijker, R., et al., Addiction , Vol. 117, No. 12, 2022 ).

For now, cognitive behavioral therapy is the most common form of treatment for gambling addiction, Nower said, and identifying pathways can tailor therapy to particular needs. She has proposed three main pathways that can lead to gambling problems ( Addiction , Vol. 117, No. 7, 2022 ). For one group of people, habitual gambling pushes them to chase wins until they develop a problem. A second group comes from a history of trauma, abuse, or neglect, and gambling offers an escape from stress, depression, and anxiety. A third group may have antisocial or impulsive personalities with risk-taking behaviors.

Betting on the game

For young adults who have grown up with video games and online gambling games, sports betting is the newest frontier—for both gamblers and researchers interested in understanding the consequences of early exposure to gambling.

Now legal in many states, the activity has exploded in popularity. An estimated 50 million people were expected to bet some $16 billion on the Super Bowl this year, according to the American Gaming Association, more than double the amount wagered the year before. (Official numbers are not yet available and are usually an underestimate because of “off the books” betting, Nower said.) At its peak, according to news reports, the betting platform FanDuel reported taking 50,000 bets per minute. Billions more were expected to be bet on March Madness.

Sports bettors trend young: The fastest-growing group of sports gamblers are between 21 and 24 years old, according to an analysis by Nower’s group of data from New Jersey, which legalized sports gambling in 2018. Compared with other kinds of gambling, the in-game betting offered during sports games is highly dependent on impulsivity, Nower said. There are opportunities to place bets during the game on everything from who will win the coin toss to which quarterback will throw 100 yards first to how long the national anthem will last. And impulsivity is particularly common in younger people and among sports fans caught up in the emotion of a game, Nower said.

Researchers are still collecting data to see if sports betting is causing a true surge in gambling problems, said Kraus, who is working on a longitudinal study of sports bettors that is following about 4,000 people over a year to see who is most likely to go from betting on a game to having problems with gambling. His group just collected their third wave of data and will be writing up a paper on their results in the coming months. “We’re going to be riding on this issue for years,” he said.

Early signs from Nower’s research in New Jersey suggest that people who engage in sports betting appear to develop gambling problems at particularly high rates and are at higher risk for mental health and substance use problems compared with other kinds of gamblers. About 14% of sports bettors reported thoughts of suicide and 10% said they had made a suicide attempt, she and colleagues found in one New Jersey study.

“Risk-takers who like action can get really involved in sports wagering,” Nower said. “Because of gambling on mobile phones and tablets, there’s no real way to keep children from gambling on their parents’, friends’, or siblings’ accounts. And they’re being bombarded with all these advertisements. This is a recipe for problems among a lot of young people.”

It takes time for a gambling problem to develop, and simple steps can interrupt the progression for many people, Kraus said. That might include placing a limit on how much they are going to spend or setting an alarm to remind them how long they have been gambling.

Education before people try gambling would help, Derevensky said, and plenty of prevention programs exist, including interactive video games designed by his group. But kids do not often get access to them. Teachers are not monitoring lunch tables for gambling activity, Nower said. And administrators are not screening for problems. Derevensky recommends that parents talk with kids about loot boxes and other gambling games and explain the powerful psychological phenomena that make them appealing.

“We educate our kids in our school systems about alcohol use, drug use, drinking and driving, and unprotected sex,” Derevensky said. “It’s very difficult to find jurisdictions and school boards that have gambling prevention programs.”

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The Association Between Problem Gambling and Suicidal Ideations and Attempts: A Case Control Study in the General Swedish Population

Affiliations.

1 Department of Psychology, Stockholm University, Stockholm, Sweden. [email protected].
2 Department of Public Health Sciences, Stockholm University, Stockholm, Sweden.
3 Department of Global Public Health, Karolinska Institutet, Solna, Sweden.
PMID: 33492582
PMCID: PMC9120086
DOI: 10.1007/s10899-020-09996-5

The association between problem gambling and suicidal behaviours is well established in treatment seeking populations, but less explored among sub-clinical problem gamblers in the general population. The aim of this study was to examine the association between problem gambling (including moderate risk gambling) and suicidal ideations/suicide attempts, in the general Swedish population. Another aim was to compare problem gamblers with and without suicide ideation/attempts. A case-control study nested in the Swelogs cohort was used. Both ideations and attempts were about twice as frequent among the cases compared to the controls. After controlling for socio-economic status and life-time mental health problems, suicidal ideation, but not attempts, remained significantly higher among the cases compared to the controls. The largest difference between attempters and non-attempters were on payment defaults and illicit drug abuse, whereas depression yielded the largest difference between ideators and non-ideators. Problem gambling severity (PGSI 8+) resulted in the smallest difference, compared to the other variables, between attempters and non-attempters. Even though no conclusion regarding the casual relationship can be drawn in this type of study, it seems like sub-clinical levels of problem gambling might have an impact on suicidal ideations whereas for suicide attempts to occur, other factors need to be present. In addition to mental health issues, financial difficulties may be such factors.

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Conflict of interest statement

Peter Wennberg declares that he has no conflict of interest. While Kristina Sundqvist has no current or past direct affiliations with the gambling industry, she has received funding from the Svenska Spel research council. This research council is financed by the state-owned gambling company Svenska Spel.

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Research article
Open access
Published: 28 July 2022

What to target in cognitive behavioral treatment for gambling disorder—A qualitative study of clinically relevant behaviors

Olof Molander ORCID: orcid.org/0000-0001-5348-051X 1 , 2 ,
Jonas Ramnerö 1 , 2 ,
Johan Bjureberg 1 , 2 &
Anne H. Berman 1 , 2 , 3

BMC Psychiatry volume 22 , Article number: 510 ( 2022 ) Cite this article

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From a clinical perspective, knowledge of the psychological processes involved in maintaining gambling disorder has been lacking. This qualitative study formulated hypotheses on how gambling disorder is maintained by identifying clinically relevant behaviors at an individual level, as a means to guide the development of new cognitive behavioral interventions.

Six individuals from a treatment study, diagnosed with gambling disorder and with diverse symptom profiles of psychiatric comorbidity, were recruited. Participants were interviewed using an in-depth semi-structured functional interview and completed self-report measures assessing gambling behavior.

Functional analysis was used as a theoretical framework for a thematic analysis, which yielded the following categories: 1) antecedents that may increase or decrease gambling; 2) experiences accompanying gambling; 3) control strategies; 4) consequences of gambling behavior; and 5) events terminating gambling behavior. Few differences were identified in relation to symptom profiles of psychiatric comorbidity, although some gamblers did not report experiencing abstinence when not being able to gamble.

Conclusions

Gambling is a secluded activity mainly triggered by access to money. Positive and negative emotions could be both antecedents and functions of gambling behavior. Avoidance-based strategies used to control gambling might result in a failure to learn to control gambling behavior. Anticipation, selective attention, and chasing could be important reinforcers, which should be addressed in new developments in cognitive behavioral treatment for gambling disorder.

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Introduction

Gambling, an activity “where something of value is risked on the outcome of an event when the probability of winning or losing is less than certain” [ 1 ], is a behavior that has generated increased interest in research and clinical practice. Gambling has been called a “pure” addiction from a behavioral perspective [ 2 ], in that it lacks any form of involvement from external chemical agents, and it was the first such state acknowledged as an addiction disorder. With the introduction of the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5; [ 3 ]), gambling was equated with substance use as an addiction. Gambling disorder (GD, previously called pathological gambling), includes behaviorally-based criteria such as loss of control, chasing losses, increased tolerance and gambling as an escape from aversive experiences. The past year prevalence of problem gambling , meaning gambling leading to any negative consequences, varies across countries between 0.3% and 5.3% in the general population [ 4 ]. Both problem gambling and GD are associated with severe negative consequences in important life domains such as finances, wellbeing, relationships and poorer mental and physical health, including higher rates of suicide ideation and attempts, for both the person with gambling problems and their significant others [ 5 , 6 , 7 ]. Furthermore, problem gambling and GD are highly comorbid with other psychiatric disorders [ 8 , 9 ]. Taken together, these recent developments indicate that increasing understanding of gambling as a behavior is a pivotal task, through basic research that can inform treatment development.

The phenomenon of learning and maintenance of unhealthy gambling habits has elicited a variety of attempts at explanation. It has been argued that gambling behavior has an intuitive fit to learning theories, in that gambling involves behavior under close control of rewards [ 10 ]. The phenomenon of gambling has been studied experimentally, with the investigation of several behavioral processes such as delay and probability discounting [ 11 , 12 , 13 ], reinforcement without actual winning [ 14 , 15 , 16 ], and rule-governed behavior [ 17 ]. Models of distinct gambling-related vulnerabilities have also been proposed. The Pathways model [ 18 ], suggests three subtypes manifesting impaired control over problematic gambling behavior: (1) Behaviorally conditioned gamblers who gamble due to learning processes such as conditioning and habituation; (2) emotionally vulnerable gamblers who gamble in order to relieve aversive experiences; and (3) impulsive/antisocial gamblers who gamble due to impulsive traits, substance use and antisocial behavioral tendencies. The Pathways model has gained increased prominence in the gambling field (e.g., [ 19 , 20 , 21 , 22 ]), but research has not shown whether the subtypes manifest different clinically relevant behaviors.

Treatment research on GD is a field still in its infancy. Currently, the only evidence-based treatments for GD are cognitive behavioral treatments (CBT). Clinical trials have shown CBT to be effective for reducing gambling behavior and related problems, but have failed to demonstrate differences between various treatment approaches (e.g., cognitive therapy, behavioral therapy, CBT and motivational interviewing), as well as between treatment and active control conditions [ 23 , 24 , 25 , 26 ]. Most current CBT approaches for gambling comprise a broad mixture of general CBT interventions found effective for other psychiatric conditions (for a review of treatment components, see [ 27 ]), but lack a solid theoretical base concerning the critical question of why gambling may persist despite obvious negative consequences [ 28 ].

Learning theory has served as a key inspiration for developing many psychological treatment models. However, behavioral treatment models and interventions for gambling have a less clear relation to basic experimental studies. On the other hand, experimental studies rarely involve clinical subjects or the natural environmental contingencies where the problematic gambling behavior occurs [ 29 ]. Behavioral principles are generally studied under strict observation and experimental control. In the prototypical clinical situation, i.e., talk therapy, the behaviors at hand are verbal descriptions of behavior given by the client, which may seem like a detour from a learning perspective. However, it could be argued that these narratives, in themselves, deserve attention as important data. Or as formulated by Foxall [ 30 ]:

“The testimony that people give us about their intentions, plans, hopes, worries, thoughts and feelings is by far the most important source of information we have about them” (p. 112).

A few existing qualitative studies were identified that examined gamblers’ subjective experiences in relation to their gambling, In her book, Addiction by design [ 31 ], the anthropologist Natasha Schüll interviewed members of Gambling Anonymous about their experiences of gambling. One striking feature in these subjective testimonies is that the role of winning money is downplayed as a motivating factor. Instead, a trancelike state that occurs with repetitive gambling, referred to as “the zone”, is more central. The zone is a state where the daily worries and concerns fade away in an almost dissociative manner. An interview study with a specific group of gamblers with schizophrenia found that they gambled specifically as a means to engage in a social activity, but also that their psychotic symptoms led to greater involvement in their gambling experience [ 32 ]. Finally, Hodgins & El‐Guebaly [ 33 ], interviewed recovered gamblers and found that they reported mainly emotional and financial reasons for quitting. Furthermore, the most endorsed actions taken in order to quit gambling were stimulus-control strategies, i.e., limiting access to gambling by avoiding gambling milieus or restricting access to money, and engaging in new, alternative activities. Starting with interviewing the afflicted is a clinically sensible strategy [ 34 , 35 ], but it is also in line with the American Psychological Association (APA) presidential task force on evidence-based practice in psychology [ 36 ] that advocated the use of multiple types of research evidence that can contribute to effective psychological practice, ranging from clinical observation and qualitative research to broad-scale randomized controlled trials.

In the present study we interviewed individuals with GD regarding their own perceptions of the functions of their gambling behavior, as part of our aim to develop a treatment model based on functional analysis of gambling behavior [ 28 ]. The gambling subtypes from the Pathways Model [ 18 ] were used to ensure a diverse sample of participants with GD. Self-report measures and a functional assessment interview were used to identify clinically relevant behaviors and formulate hypotheses concerning the maintenance of GD on an individual level, as a preparatory step to guide clinical interventions.

Participants

Theory-based clinical sampling was used in this qualitative exploratory study. Treatment seeking individuals with GD and other psychiatric comorbidities were purposively selected by a clinical psychologist from a separate CBT study at the Stockholm Center for Dependency Disorders [ 37 ], as representative for the gambling types delineated in the Pathways Model [ 18 ]. Participants were recruited to this study after completing all treatment sessions. To be included in our study the participant had to: (1) be identified as one of the gambling subtypes according to the Gambling Pathway Questionnaire (GPQ; [ 38 ]), (b) show a total score of >= 3 on the Problem Gambling Severity Index (PGSI; [ 39 ]), (c) be 18-85 years old, (d) read and write Swedish. Prior to inclusion in the original treatment study, participants were screened and assessed for GD and psychiatric comorbidity with the Structured Clinical Interview for Gambling Disorder (SCI-GD; [ 40 ]) and the Mini International Neuropsychiatric Interview version 7 (MINI-7; [ 41 ]). Although GD was not originally defined as an inclusion criterion, all participants in the study fulfilled GD diagnostic criteria. After six participant interviews, the representative clinical material was deemed sufficient, and no further interviews were conducted. No participants dropped out. Table 1 shows an overview of participant characteristics.

The Functional Assessment Interview [ 42 ] is an open-ended semi-structured assessment instrument for clinical behavior analysis. For the purpose of this study the Functional Assessment Interview was adapted for gambling (FAI-G). To test the feasibility of the adapted interview, it was first piloted with one participant (not included in the study). After the pilot interview, the interview was modified further and shortened to focus on key features of gambling behavior. The final FAI-G interview (see Supplementary material 1 ) consisted of the following sections: Topography of gambling behavior, Antecedents of gambling behavior, Experiences when not being able to gamble, Physiological responses, Strategies to control and/or continue gambling, Experiences during gambling and function of gambling behavior, Terminating events of gambling behavior, and Behaviors with similar functions to gambling.

Self-report measures consisted of the Gambling Pathways Questionnaire (GPQ; [ 38 ], a 48-item self-report measure for assessing etiological gambling types according to the Pathways Model [ 18 ]; the revised version of Gambling Functional Assessment (GFA-R; [ 43 ]), a 16-item self-report measure developed to assess whether gambling behavior is maintained by positive reinforcement or escape; and lastly, the Centre for Addiction and Mental Health Inventory of Gambling Situations (CAMH-IGS; [ 44 ]), a 63-item self-report measure developed to assess high risk situations in the last 12 months that may have led to gambling behavior.

Participants were recruited from a separate treatment study. After completing an informed consent form and self-report measures online, they were contacted to arrange a face-to face FAI-G interview at a location of their own choosing. Three interviews were conducted at the Stockholm Center for Dependency Disorders clinic, two at the Center for Psychiatry Research, and one in the participant’s home. All FAI-G interviews except the pilot interview (not included) were carried out by the author OM, who took field notes. The interviews were audio recorded and subsequently transcribed and pseudonymized using a study id number. The interviews lasted between 60 and 90 minutes. Participants were given two movie vouchers as compensation.

Data analysis

Qualitative analysis.

Functional analysis as a theoretical framework (e.g., [ 45 ]) was used to review and analyze the transcribed FAI-G interviews. In the first step, two raters (authors OM and JB), independently reviewed and coded each FAI-G section in the transcribed interviews into short sentences or phrases. The raters, blinded to GPQ scores, also made independent clinical assessments regarding gambling type according to the Pathways Model [ 18 ], based on each participants FAI-G responses. In the next phase, the coded sentences and phrases were condensed further and coded into single words or short phrases. Any sentence or phrase bearing individual meaning and coded by either of the raters was added into a data pool, which also included information on the FAI-G section and participant id number. After this, each coded word or short phrase in the data pool was reviewed and categorized using theoretical thematic analysis [ 46 ]. Functional analytic themes were chosen that best described the most important concepts highlighted by the participants under each FAI-G section. The categorization and interpretation were done by authors OM and JR. Frequencies of endorsed constructs and phrases were summarized for all participants, as well as for each clinically assessed Pathways subtype [ 18 ]. In the last step, the results were triangulated among all authors. Results were reported in alignment with the Consolidated Criteria for Reporting Qualitative Research (COREQ) 32-item checklist [ 47 ].

Researchers’ competence

The researchers had complementary competences within different disciplines of clinical psychology. Author OM is a clinical psychologist, PhD, and researcher with experience of CBT development. Author JR is a clinical psychologist, PhD, and associate professor, with expertise in behavioral analysis and CBT. Author JB is a clinical psychologist, PhD, and researcher with experience of emotion regulation and CBT development. Author AHB is a clinical psychologist, PhD, and professor, with expertise in addiction. Variation in coding between raters were highlighted and discussed in detail, safeguarding that all perspectives were vocalized before consensus was reached. We are satisfied that this process ensured credibility and trustworthiness in interpretation and analysis.

Quantitative analysis

Descriptive statistics were used to present participant characteristics. Measure scores (GPQ, GFA-R, CAMH-IGS) were calculated for individual participants, as well as means and standard deviations for clinically assessed Pathways subtypes. Unweighted Cohen's κ for two raters [ 48 ] was used to calculate inter-rater reliability regarding Pathways subtypes by assessor 1 (first author) and assessor 2 (third author), as well as between clinical assessments and GPQ score. Quantitative analyses were performed using R Studio version 1.1.456 [ 49 ].

The mean participant age was 34 years (Sd=9.12), with 2/6 women. Casino online was the most frequent gambling type, played by 4/6. On average, participants reported onset of gambling problems 6 years and 7 months prior to inclusion. The mean number of fulfilled GD diagnostic criteria was 7 (Sd=1.72). Participants had an average of 1.7 additional DSM-5 psychiatric diagnoses, where anxiety disorders were most common. See Table 1 for individual participant characteristics, and Table 2 for self-report measures assessing gambling behavior.

Gambling Pathways subtype assessments

Two participants were clinically assessed as conditioned (Behaviorally Conditioned Subtype 1), two as emotional (Emotionally Vulnerable Subtype 2) and two as impulsive (Antisocial, Impulsive Risk-taking Subtype 3). Compared to clinical assessment, GPQ differently identified one conditioned participant as impulsive, one emotional as conditioned, and one emotional as conditioned. Perfect agreement was achieved for clinical assessments of Pathway gambling subtype between assessors 1 and 2, κ = 1, z = 3.46, p = 0.000. Agreement between clinical assessments and GPQ result was fair, κ = 0.25, z = 0.866, p = 0.386. The clinician-assessed Pathway subtypes were used for analysis of the results.

Self-reported gambling behavior

Self-report measures indicated that gambling as a function of negative reinforcement was more common among clinically assessed emotional and impulsive gamblers, compared to conditioned gamblers. Similar results were found for positive reinforcement, but not for impulsive gamblers (see Table 2 ). In a similar vein, three antecedent high-risk situations for gambling behavior were above the clinical CAMH-IGS cut-off score, irrespective of clinically assessed gambling Pathway subtype: Negative emotions, urges and temptations, and winning and chasing.

Functional assessment of gambling behavior

Coding of participant FAI-G interviews yielded 330 phrases, of which 258 were unique. Eight phrases were categorized as “Other: Not categorizable”, and were excluded from analysis. The thematic analysis yielded 23 functional analytic themes, within the FAI-G sections. See Table 3 for examples of coding and categorization, and Table 4 for frequency of these functional themes, as coded in the participants’ interviews.

Antecedents of gambling behavior

Antecedents refer to events that occur prior to gambling behavior, that may increase or decrease the actual behavior.

All participants reported emotional events that were perceived to increase the likelihood of gambling. Emotional events were coded irrespective of their descriptive value into one theme (i.e., emotion), as the distinction between positive and negative emotional valence was far from clear cut. Thus, emotional antecedents could be described in positive terms, as when participants expressed that they often gambled after “feeling good” or “satisfied in life”. Indeed, all participants expressed that they could experience a positive emotional state of anticipation, excitement or exhilaration prior to gambling. Some, but not all, participants described negatively valued emotional antecedents. All but one participant expressed that negative emotions triggered their gambling, for example feeling “bored”, ”anxious”, “worried”, “stressed”, “sad”, or ”restless”. Others reported pre-gambling rumination, for example thinking that they ought not be gambling, or being displeased with relationships or other areas in their life. Overall, however, few participants expressed that specific gambling-related thoughts triggered their gambling, and when they did, it was often in conjunction with a positive emotional experience. Only two participants described thinking of gambling losses as a trigger for gambling. Emotional events were also reported as antecedents that could decrease the likelihood of gambling. Half of the participants described positive emotions, such as “feeling good”, “happy” or “life going in the right direction”. Two participants described that when being in a negative state, such as feeling “down”, “depressed”, “hopelessness”, or “seeing no opportunities”, they seldom gambled. Thus, emotional events could be considered as a functional theme in understanding conditions that govern gambling, whether positive or negative, and whether they increased or decreased the likelihood of gambling.

Another prominent pattern was that all participants reported that available resources (i.e., access to money) were a critical antecedent condition. For example, participant 3 described a monthly pattern where he gambled using all his salary as soon as the amount was transferred to his bank account. From there on, he lived without money for a couple of weeks feeling pretty good at not gambling and often thinking that he did not want to gamble again. However, as soon as the new salary was transferred to his bank account, he started to gamble online again until the salary was spent, often gambling the whole night long.

Social antecedents were also described by all participants. Social stimuli that were reported to increase gambling were mainly being alone (absence), while decreased gambling was mainly associated with being in contact with others (presence). However, exceptions to gambling alone were noted, for example when friends suggested gambling. Time of day was reported by all but one participant as an antecedent that might increase (mainly evenings) or decrease (mainly daytime and nights) the likelihood of gambling. In the same vein, specific locations were noted by all participants as antecedents that would increase gambling (e.g., “home”, “in my room”, “at public transportations”, or “at work”), but only 3 participants reported locations that were associated with decreased likelihood of gambling (e.g., “outside home” or “outside bedroom”).

A majority of the participants described specific preceding behaviors that either would increase or decrease the likelihood of gambling. Typical activities that would facilitate gambling included for example “browsing gambling Facebook groups”, “ruminating”, or “reading gambling statistics”. Behavior that influenced in the opposing direction typically had the character of competing responses or activities (i.e., behaviors incongruent with gambling). Further, three themes of antecedents were identified with sole functions of increasing gambling. Two participants reported specific discriminative stimuli; that is, events that would clearly signal the availability of reinforcers following gambling behaviors (e.g., gambling commercials). Losses were reported by two persons as antecedents that would increase the likelihood of gambling. Also, use of substances (alcohol and prescribed drugs) was reported by two persons.

Experiences when not being able to gamble

Participants were asked to describe their experiences of not being able to gamble. Two main functional themes were identified. One theme identified was frustrative non-reward, for example “frustration” and “irritation” or “can’t focus”. The second theme concerned the more common response which was to describe an essentially non-problematic response, such as “no anxiety or depression”, “I can interrupt gambling”, or “I can focus on other things”.

Accompanying responses

The participants were asked to identify physiological responses that would occur regularly when gambling. Three participants described positive or negative emotional arousal-related responses, such as “itchy fingers”, “pumping”,”endorphin-kick”, “fear in the body”, “excitement”, or “itchy body”. The other three did not report any such responses.

Strategies to control or continue gambling

Loss of control is a key criterion for GD [ 3 ]. The participants were asked to describe their attempts or strategies for controlling their gambling behavior. The main functional theme described concerned avoidance-based strategies, such as not owning a smartphone or a bank card reader, handing over control over their economy to significant others, blocking gambling accounts or credit cards, or extracting money in cash to prevent themselves from gambling.

“During a one-year period I handed over my finances to my brother. I also got help with budget and… making calls and so forth. I didn’t gamble for...surely one and a half years. Everything was great, but then I got it back [control over my finances]. After that I started to gamble again pretty fast.” (Participant 3)

The other strategies for controlling gambling were labeled either social strategies, for example scheduling non-gambling activities with friends, or telling their friends they had gambling problems and prohibiting them from lending them money; or monetary-based strategies, such as ceasing to borrow money for gambling, depositing only small sums in gambling accounts, or saving money to cover other minimum living expenses.

In contrast, gambling also involves using a variety of strategies that serve the opposite function: deliberate planning that enables or facilitates gambling. These responses were categorized either under the heading of enabling or securing resources, or as different kinds of planned and deliberate behaviors, for example taking out loans to gamble or cover other expenses, waiting for salary, selling possessions, lying or gambling to win, or to win back money.

Consequences of gambling

Participants were asked to describe the experiences and events that would either accompany or occur subsequent to their gambling behavior, in order to identify the possible reinforcing properties of gambling and its contextual factors. These were identified as either different emotional properties or tangible reinforcers (i.e., money).

“There were different stages. (...) First it felt like a big development for me, that I had found something (...) it was a feeling of great… a good feeling. I was happy with myself and felt I was going somewhere. Then, when the winnings were replaced with losses, and the bettings became wilder (...) I remembered my first feeling, that I had won (...) In the next step I betted more aggressively, to, sort of like, catch up to what I potentially thought I should have won (...). It became a straitjacket pretty fast when the losses mounted up and I started to chase them.” (Participant 6)

Overall, participants described that they experienced a range of emotional states while they gambled; these we categorized as positive (Emotional positive). Common descriptions were “excitement”, “kicks”, “euphoria”, “satisfaction”, or feelings of “being in control”, “being on the right path”, “invincibility”, or “growing ego”. Another functional theme was that gambling was described as serving a function to avoid aversive emotional experiences, for example “getting a break”, “escaping reality”, avoiding “responsibility”, “social interaction”, “boredom”, or “bad conscience”, or avoiding hard thoughts of “debts”, “betrayal against family” or “social failures”. All but one participant described that anxiety was fulfilling different functions in their gambling experiences. By gambling, participants avoided symptoms of anxiety, for example post-mortem ruminations on social situations, or post-traumatic memories. Interestingly, anxiety was also described as a part of the gambling activity in itself. Participants described that gambling “is a mixture between excitement and anxiety”, and “relieves anxiety in the short term, but increases it in the long term”, or “relieves gambling-related anxiety in the short term”, but it was also described as “a relief when the money's gone”, and there being a point where “it gets calm in the head”.

“Nowadays I see my gambling as a form of deliberate self-harm. Uumm … Because now I don’t gamble to… I know that I can win a lot of money. But if I win a lot of money, I will use it to gamble anyway. I rarely gamble to win, I only gamble to shield myself from reality.“ (Participant 4)

A third functional theme, “the zone”, involved participants’ experience of a state of selective attention, or focus, while they gambled. This state was described mainly in positive terms as “focus”, “being able to concentrate”, “entering a bubble”, or “all thoughts on gambling”, and was often associated with a feeling of escaping reality (sometimes also avoiding aversive thoughts or feelings), tunnel vision, lost perception of time, as well as continuing to gamble until all money were gone. For example, Participant 3 expressed that:

“I get totally stuck. I know situations where I gambled for, what I perceived as half an hour, fifteen minutes, twenty minutes. But instead… well, one and a half hours had gone by. What? I sort of like lose perception of time (...) when I win and… perceive that it goes well, and later, when you click and click, then... Well, out of money. But it went well fifteen minutes ago (...) Often when I gamble, I feel best.”

As expected, money was identified as a tangible reinforcer for gambling behavior. However, while all participants described emotional consequences, only four of them explicitly reported money as an important consequence. Overall, participants described that winning was associated with “a great feeling”, “a kick” or “euphoria”, but also that winnings resulted in “feelings of unreality”, and that the money they won lost its value and became “just numbers on the account”. Two participants described that they “chased wins”, “chased absent wins”, or “demanded absent wins” when they gambled. Participant 1 expressed that he knew he could not win money by gambling, but that these thoughts were “blocked in the brain somehow” while he gambled. Overall, participants described that losses during gambling were associated with feelings of “anger”, “frustration”, “anxiety” and “a lust for revenge”. Half of the participants described that they continued to gamble to “win back money” or “chase losses”.

Terminating events of gambling behavior

The participants were asked to identify circumstances that would terminate a period of gambling behavior. We identified two broad functional themes. The first was depleted resources, which included running out of money. All participants reported this. But it could also be physical or temporal resources, such as continuing to gamble until becoming exhausted and falling asleep or running out of time.

The second theme mainly consisted of different behaviors that served the function of terminating gambling. For example, participant 5 described that gambling sessions usually ended according to her pre-decided plan. Notably, only participant 6 described a specific time as a terminating event for gambling. This participant was the only one who gambled on the stock market (day trading) which was not accessible around the clock, as were other gambling types played online by the remaining participants.

Behaviors with functions similar to gambling

Finally, participants were asked to report other behaviors that they had engaged in, that resembled the experience of gambling. Four participants described various behaviors and activities, i.e., computer games, other games, sex, deliberate self-harm, and work tasks. However, we decided that these behaviors were too disparate to constitute a functional theme and they were therefore excluded from the thematic analysis.

Pathways Model subtypes

When comparing the clinically assessed Pathway subtypes, few clear differences in the functional properties of gambling were found. Instead, a more general gambling pattern was identified which seemed to include all participants, irrespective of subtype categorization. However, two differences were noted. First, the only participants who described frustrative non-reward responses were the two participants clinically assessed as emotionally vulnerable. Secondly, somewhat surprisingly, three participants, assessed as emotionally vulnerable and impulsive Pathway subtypes, described behaviors that enabled them to stop gambling. For example, participant 2, assessed as an impulsive gambler, described that he could stop gambling while still having money in his account if:

“(...) someone wants to go out and do something fun. If something else is happening, not just going out to drink beers. To go bowling, we go and do this, do you want to come and bathe in the sauna or go swimming. To do things.”

This study used a functional assessment interview and self-report measures to identify clinically relevant behaviors and formulate hypotheses on the maintenance of GD on an individual level, as a preparatory step for guiding clinical interventions. The Pathways model subtypes [ 18 ] were used to obtain a diverse sample of participants with GD. The study was driven by an overarching interest in clarifying the functional aspects of gambling, from a subjective participant perspective.

When investigating the context of gambling behavior, a striking feature was that study participants often reported commonplace antecedents, such as being alone, time of the day (e.g., evenings), and being at home. The most prominent antecedent reported, indeed, was access to money. This suggests that gambling could be viewed as a secluded activity, mainly triggered by access to money. For our participants, who mainly gambled online, it was possible to gamble everywhere and at any time, with the only hindrance that money was not equally available. Depleted financial resources were, consequently, described as the main terminating event of gambling by the participants. Some also described physical exhaustion or running out of time. Loss of control is often regarded as a defining feature of GD [ 3 , 18 ]. Our results indicates that it could be more complicated. All participants in this study described that they had used stimulus control strategies in order to refrain from gambling. While stimulus control strategies are endorsed among recovered gamblers [ 33 ], and typically employed as a first intervention in many treatment protocols [ 27 ], they are essentially avoidance-based strategies. One drawback with such strategies may be that the person fails to learn control of behavior in the presence of the antecedents that tend to result in gambling behavior.

Gambling is often described as an escape from negative emotions and aversive experiences [ 3 , 18 ]. Our results indeed indicated emotional antecedents for gambling. However, the link to negative emotions was not exclusive. Some participants described that positive emotions preceded their gambling, and others that negative emotions did so. Conversely, some participants expressed that positive emotions decreased the possibility for them to gamble, and others that negative ones did so. However, it should be noted that all participants expressed that they experienced an emotional state of expectancy prior to gambling. Gambling-related physiological arousal and subjective excitement is consistent with the theoretical Pathways Model [ 18 ], and has been examined in several experimental studies e.g., [ 50 , 51 , 52 ]). For example, Rockloff and Greer [ 53 ] concluded that high arousal can increase subsequent gambling behavior among at-risk players, as long as the arousal is not perceived as a negative emotion. Thus, future etiological and treatment models may consider affective antecedents regardless of valence.

The participants’ descriptions of the relationship between gambling and winning or losing money were not unanimous. While all participants but one scored above clinical cut-off at “Winning and Chasing” on the CAMH-IGS, only four of them explicitly reported money as an important consequence of gambling. Two participants described that they chased wins, and three participants that they continued to gamble to win back money they lost. The gambling activity itself was also described in relation to emotional events, where placing a bet was associated with excitement, winning with euphoria and a kick, and losing with anxiety and a lust for revenge; findings that are in line with a functional magnetic resonance imaging study by Campbell-Meiklejohn et al. [ 54 ]. Chasing, in particular chasing losses, has been proposed as a key symptom of GD [ 55 ], although experimental studies investigating this phenomenon seem rare [ 29 ]. Our results suggest that tangible reinforcers; i.e., money, might be important for gambling behavior, but probably do not account for the whole clinical picture of GD.

A more striking feature in the participants’ narratives was that they all reported a positive state of selective attention, or focus, while they gambled. While this “zone” typically is not part of existing gambling treatment protocols [ 27 ], nor of the Pathways Model [ 18 ], it is not a novel finding. As previously noted, Schüll [ 31 ], downplayed winning money as a motivating factor, and instead described the slot machine as a “zone”, where events occurring outside the gambling experience become less relevant to gamblers, as they grow completely absorbed by the game. Similarly, Dixon et al. [ 56 ] coined the expression “dark flow”, a flow-like state which has been investigated in experimental studies and found to be associated with multiline slot gambling and GD [ 56 , 57 ]. Findings from the present study are in line with the presumption that this state might be an important reinforcer for gambling behavior.

Inherent in the idea of an addiction lies the idea of craving, coupled with experiencing abstinence when access to the drug is hindered. In parallel with this, abstinence is a diagnostic criterion of GD [ 3 ]. Somewhat surprisingly, two participants in this study reported not being able to gamble as entirely non-problematic, i.e., other activities enabled them to stop gambling fairly easily despite having access to money. They experienced no negative symptoms, such as anxiety, depression or concentration problems. It should be noted that both participants were assessed as impulsive gamblers according to the Pathways Model [ 18 ], which may indicate a unique feature of this theme.

This study had several strengths. Gambling has been investigated in previous qualitative studies, but not from a clinical perspective. As previously noted, this is a sensible strategy, as treatment interventions ideally should emanate from ideographic models. Interviewing “sufferers” is often conducted to identify hypotheses of maintenance for problem behaviors, when developing novel CBT (34,35, personal communication Edna Foa). These qualitative and clinical based assessment procedures are, however, rarely published as formal systematic studies. The current paper is thus an important exception in the clinical treatment literature. This study used theory-based clinical sampling. Participants from a CBT study were purposely selected by a clinical psychologist. This ensured both richness of data and that participants were familiar with the behavioral constructs in the FAI-G interview and self-report measures.

Limitations of the study included the lack of validation of results and conclusions by reporting them back to the participants. Also, we did not use a predefined procedure to assess whether saturation was reached. However, we found that code saturation was achieved following recruitment of six participants, in line with findings by Henning et al. [ 58 ], who have studied the saturation process and found that over 80% of coding can be expected after six interviews. The first interviews generated a rich range of coding, and for the purposes of this study six participant sufficed. The use of a semi-structured interview format, based upon a predefined theoretical framework, delimited possible conclusions in the thematic analysis, and created difficulties, for example, in differentiating themes from constructs. Also, theoretical (i.e., functional, and behavioral) terms were used throughout the data collection, which might have hindered the participants’ understanding of the questions being asked. However, as the participants had undergone a recent cognitive behavioral treatment study [ 37 ], where individual clinical behavioral analyses were continuously performed, they were familiar with the theoretical constructs employed in the current study. Overall, the study was a preparatory step for developing a CBT treatment protocol, so other methodological approaches would probably have been of less clinical relevance.

With regards to the functional aspects of gambling, this study has merits from a heuristic perspective since it identified several potential processes which might be clinically relevant for GD, but typically have not been part of gambling treatment protocols (e.g., [ 27 ]). In terms of clinical implications, a treatment model and an internet-based cognitive behavioral protocol was developed, based on the results of the study. The treatment was disseminated into routine addiction care and is currently being evaluated in a feasibility study (see 28 for a study protocol). The interviews and results of the current study were completed before the treatment development and feasibility study was initiated.

In sum, the aim of the current study was to assess the subjective functions of gambling, within a diverse sample of participants with GD, ultimately with the goal of informing treatment development. The considerations could be important to address in future CBT models and treatment protocols for GD. First, access to money might be a critical antecedent for GD, and we question the use of avoidance-based control strategies in treatment if the objective is to achieve long-term control over gambling behavior. Secondly, treatment needs to address both negative and positive antecedent emotions for gambling behavior (e.g., anticipation), and not only negatively reinforced gambling behavior. Third, the gambling activity in itself seems to include emotional functions. In particular, an absorbing experience of selective attention during gambling might be an important reinforcer, and should accordingly be addressed in CBT protocols. Finally, gamblers in the impulsive subtype did not report experiencing abstinence symptoms when not being able to gamble, despite presence of critical antecedents, such as access to money. Future clinical studies could investigate this phenomenon further, using targeted interventions, such as behavior replacement.

Subjective functions of gambling behavior were identified among a sample of participants with gambling disorder, as a means to guide new developments in cognitive behavioral interventions.

Access to money might be a critical antecedent for gambling and should be addressed using non-avoidance interventions.

Treatment should address positive and negative emotions both as potential antecedents and functions of gambling behavior.

Anticipation, selective attention, and chasing might be important reinforcers for gambling.

Availability of data and materials

The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.

Abbreviations

Anne H Berman, last author

The American Psychological Association

Cognitive Behavioral Treatment

The Centre for Addiction and Mental Health Inventory of Gambling Situations

The Consolidated Criteria for Reporting Qualitative Research

The Diagnostic and Statistical Manual of Mental Disorders, 5th edition.

The Functional Assessment Interview

Gambling Disorder

The Gambling Functional Assessment

The Gambling Pathway Questionnaire

Johan Bjureberg, third author

Jonas Ramnerö, second author

The Problem Gambling Severity Index

The Structured Clinical Interview for Gambling Disorder, version 7

Olof Molander, first author

Responding to and Reducing Gambling Problems Studies

The Structured Clinical Interview for Gambling Disorder

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Acknowledgements

The authors would like to thank the participants in the study. The authors would also like to thank Viktor Månsson at the Center for Psychiatry Research who recruited the participants and conducted the FAI-G pilot interview, as well as the editor and the reviewers.

Open access funding provided by Karolinska Institutet. The study was carried out within the frame of the “Responding to and Reducing Gambling Problems Studies” (REGAPS program grant), financed by the Swedish Research Council for Health, Working Life and Welfare (Forte), grant number 2016–07091; as well as development funds from the Stockholm Health Care Services, Stockholm County Council, for identification and treatment of problem gambling. The funding sources had no role in study design, data handling, writing, or submission of the article.

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Olof Molander, Jonas Ramnerö, Johan Bjureberg & Anne H. Berman

Stockholm Region Health Services, Stockholm, Sweden

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Author OM conducted all interviews, except the pilot interview. OM and JB reviewed and coded the transcribed interviews. Author OM and JR did the categorization and interpretation and wrote the first draft manuscript. Author AHB provided expert knowledge in qualitative methods. All authors contributed to the process of finalizing the manuscript. The authors read and approved the final manuscript.

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Correspondence to Olof Molander .

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All parts of this study were approved by the Regional Ethics Board of Stockholm, Sweden (ref. no. 2017/1479-31). All participants were approached on a voluntary basis and provided written informed consents for participation in this study, including publication of results.

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All participants provided consent for publication in the written informed consent.

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Functional assessment interview for gambling (FAI-G).

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Molander, O., Ramnerö, J., Bjureberg, J. et al. What to target in cognitive behavioral treatment for gambling disorder—A qualitative study of clinically relevant behaviors. BMC Psychiatry 22 , 510 (2022). https://doi.org/10.1186/s12888-022-04152-2

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Gambling disorder
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A Case Study of Binge Problem Gambling

Published: 26 October 2006
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To examine the rarely reported phenomenon of binge problem gambling via a case study.

A male 31-year old “fruit machine addict” was interviewed three times over a three-month period. The participant was diagnosed as a pathological gambler using both the South Oaks Gambling Screen and the DSM-IV criteria.

The male gambler displayed a very unusual pattern of problem gambling that would best be described as binge gambling. The participant’s gambling binges were typically caused by very specific ‘trigger’ incidents (e.g., relationship break-up). Gambling problems appeared to be related to low self-esteem coupled with feeling depressed and having nothing else to do. Gambling problems were usually linked to other underlying problems. When these are dealt with, his problem gambling all but disappeared.

Conclusions

Binge problem gambling appears to be less serious than chronic problem gambling but can still cause significant problems in the lives of people it affects.

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Griffiths, M.D. A Case Study of Binge Problem Gambling. Int J Ment Health Addiction 4 , 369–376 (2006). https://doi.org/10.1007/s11469-006-9035-7

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Issue Date : October 2006

DOI : https://doi.org/10.1007/s11469-006-9035-7

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Communities and Vulnerable People

A case study - Matthew’s story

Not long ago, Matthew wouldn’t have thought twice about buying a car seat for his daughter’s baby. Today, it’s more than he can afford.

Just 2.5 years ago, Matthew was earning more than $150,000 a year, after 21 years of hard work in the same company.

He enjoyed a bet. Sometimes he’d go past the local bookmaker on the way home from work, or head to the casino with friends after dinner, and he didn’t think much of it at the time.

Then he was made redundant, and handed a payout worth $178,000.

“Suddenly, I finished work, I was angry about it, and I had too much time on my hands,” Matthew said.

“I’d plonk myself in front of a computer at night, and with the combination of medication and alcohol, I wouldn’t even know until the next day what I’d done.

“I’d log on the next morning to find I’d placed $40,000 at 2.30am on some random race in Europe.

“Three weeks later, I had blown the whole lot.”

Even though Matthew began a responsible gambling case against the online wagering service provider, who agreed to pay him back the money he had lost, the ability to easily open another account meant his online wagering activity didn’t stop there.

“I opened an account with another online gambling company. It was almost a blueprint of the first time around—in three to four weeks it was all gone.

“It just shows the enormous pit online gambling is. You couldn’t put that much money inside a poker machine. You can’t walk into a TAB at 2.30 in the morning.

“Online gambling will keep taking and taking until there is no more to take.

“If I didn’t contact them, they would text, email, and ring. They’d say, if you put $5,000 on this race, we’ll match it, or they’d offer me bonus bets, or make me a gold class customer.”

After losing everything, Matthew excluded himself from online gambling sites, but because the system is state based, he had to go to each site individually. He thinks there are better ways to protect people.

“Safeguards need to be in place,” Matthew said.

Matthew says he thinks measures are needed to force people to set a limit before they start, and to only allow people to deposit a certain amount in their account.

“If you want to add more than $10,000, you should have to justify that. I had no limit. It is ridiculous that I could spend $60,000 in one night.

“In the light of day, my own gambling behaviour didn’t make sense at all. You have these moments every morning when you wake up and tell yourself, ‘this stops now’, but then a few beers on a Friday afternoon, and you’re off again.”

At 54, Matthew is bankrupt and living on a Newstart Allowance. He takes Coles bags to get food parcels every week, so that his son doesn’t know where the food is from.

He has found a support network to help him get through the week. But he hasn’t told his friends and family.

“My gambling has had an enormous impact on everyone around me,” he said. “It’s all consuming. You tend to push people away. You become a very good liar.”

“I worked all my life, 6.5 days a week, 10 hours a day to get where I was. I should have a house; I should be able to help my daughter buy a house. Instead, I can’t even afford a car seat for her baby.

Last updated: 28 August 2020 - 2:58pm

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Indian J Psychiatry
v.61(3); May-Jun 2019

A case of pathological gambling

Neha sharma.

Department of Psychiatry, INHS Sanjivani, Kochi, Kerala, India. E-mail: [email protected]

Anindya Kumar Gupta

1 Department of Psychiatry, Command Hospital, Bengaluru, Karnataka, India

T. Hannah Jane

2 Medical Officer, INS Garuda, Kochi, Kerala, India

Pathological gambling is an entity recognized centuries ago and has remained a menace from the social and economic viewpoint. The recognition of medical nature of this vice is, however, a recent phenomenon, with current views placing it parallel in nosology to substance use disorders. Long-term effectiveness of available modalities of treatment still elude us, and the disorder remains an enigma for Psychiatrists and Behavioral Therapists alike. There are no systematic studies of this disorder in India. Our case is unique, as unlike most pathological gamblers, our patient actively sought treatment and showed good response in early follow-up period.

Our patient, a 23-year-old male, with family history of problem gambling in his grandfather, premorbid novelty-seeking traits, self-reported for psychiatric evaluation with depressive symptoms of 5 months’ duration, in the background of progressively increasing engagement in online gambling with consequent heavy financial loss over the past 1 year.

A year ago, when, while surfing the internet, he came across an advertisement about huge profit with little investment in online rummy, and tried with an initial bet of 15 rupees. Initially, he won and started increasing the bet gradually, both regarding money wagered per game and number of games per day, in an attempt to increase the profit. Thus, he reached a bet of 5000 rupees per game within the next 2 months, playing up to 1–2 h every day. Subsequently, he started betting an entire day's winnings in a single game, for the thrill he experienced on betting “all he had.” The patient started losing thousands of rupees in a day, purchased a credit card, took a personal loan and eventually borrowed money from friends, citing false financial crises, to fuel his habit and to chase his losses. Soon, his debt stood at 4.5 lakh rupees, paid off by his father, to whom he promised he would never gamble again.

He exercised restraint for the next 3–4 months, but again started gambling and by the end of next 6 months; he was in a debt of 15 lakh rupees. He once again fell back on his father, who curtailed his access to money, as a precondition to clear his debts. However, he would often remain preoccupied with guilt, started remaining low, reduced his social interaction out of shame, lost his confidence and self-esteem and often wished he was dead. After one failed attempt at committing suicide by hanging, he sought psychiatric treatment.

Evaluation on admission revealed a dejected looking individual with slow, monotonous speech, depressed mood and constricted affect, guilt and worthlessness, with deranged bio drives. Investigations revealed normal hematological and biochemical profile, euthyroid status, negative viral markers and drug screen and normal neuroimaging. Psychometry scores were Beck Depression Inventory: 13 (mild depression), modified Yale–Brown Obsessive Compulsive Scale (YBOCS): 34 (severe), NORC Diagnostic Screen for Gambling Disorders (NODS) loss of Control, Lying, and Preoccupation (CLiP): 9 (positive for pathological gambling (PG)), Beck's Suicide Intent Scale (BSIS): 2 (no suicidal intent).

He was managed with capsule fluvoxamine 150 mg and tablet Naltrexone 50 mg. He was given individual psychotherapy on the lines of motivation enhancement therapy, cognitive behavioral therapy (CBT) for depression and coping skills training. Contingency management was explained along with high-risk situations for relapse and relapse prevention strategies, aiming at complete abstinence. His family members and employer were included in treatment as “significant other” and were provided psychoeducation about nature of illness, prognosis, and measures for external control as part of relapse prevention. He responded well to treatment and was found to be maintaining remission at 3 months follow-up.

Global prevalence of PG is not known. A Romanian study calculated prevalence of 2.6%–4% among children and adolescents using south oaks gambling screen-revised adolescent (SOGS-RA) and 20 GA-RA.[ 1 ] A recent Indian study on the prevalence of PG among patients with substance use disorders found an occurrence rate of 6.1%–12.3%, using International Classification of Diseases (ICD)-10 and Diagnostic and Statistical Manual of Mental Disorders (DSM)-5 criteria and SOGS as screening instrument.[ 2 ]

A bio-psycho-social model of causation is proposed, with such biological factors as right-dominant lateralized correlations between brain-derived neurotrophic factor and beta and theta power reflecting right-dominant brain activation,[ 3 ] psychological risk factors such as negative emotions, motor impulsivity, gambler's fallacy, and gambling self-efficacy and the role of “variable ratio schedule of reinforcement” and social factors as availability of gambling platforms.

In the classificatory systems, DSM-5 has placed gambling disorder among the rubric of addiction, and ICD-11 is expected to do the same. Comorbidities are common in PG especially Depression.[ 4 ]

There are various instruments available for PG, of which the ones used in our case were NODS-CLiP and modified YBOCS. Treatment modalities include both pharmacological and nonpharmacological measures. A combined approach is considered better than individual methods of treatment, as was employed in our case.[ 5 ] Internet-based interventions such as “Deprexis” and Internet supported CBT may be a useful adjunct to standard treatment.[ 6 ]

In our patient, no comorbid substance use disorder, and active help-seeking were positive markers of prognosis. However, male gender, young age of onset, family history of gambling, novelty seeking, and impulsive personality traits were unfavorable. In addition, nature of this relapsing illness, comorbid depression and history of suicidalty does not indicate good prognosis.

Current availability of online platforms and ease of transaction combined with covert marketing through apps have made gambling widespread. Our society at large needs to recognize the problem and take corrective measures both at organizational and individual levels.

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his clinical information to be reported in the journal. The patient understands that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

There are no conflicts of interest.

With more gambling cases likely, Ohtani debacle is a lesson to MLB

Los Angeles Dodgers' Shohei Ohtani, right, and his interpreter, Ippei Mizuhara

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Shohei Ohtani’s former interpreter has pleaded guilty to stealing millions from him to feed a sports gambling habit. The man who took Ippei Mizuhara’s bets entered a guilty plea to running an illegal bookmaking operation.

Major League Baseball has closed its investigation into the matter. And the Dodgers are delighted that Ohtani is putting up Hall of Fame numbers at the plate.

But the federal criminal probe that targeted Mizuhara and Mathew Bowyer, his Orange County-based bookmaker — and cleared Ohtani of any wrongdoing — is ongoing, even as MLB has been forced to deal with more forbidden gambling.

In Bowyer’s plea agreement, prosecutors allege that two current or former ballplayers placed bets with him. In the meantime, MLB banned another player for life and suspended four others after finding they bet on baseball, an offense that has been considered a mortal threat to the game since the Black Sox scandal of 1919.

Mathew Bowyer, a Southern California bookmaker, stands outside federal court in Santa Ana on Aug. 9.

The league is likely to face more allegations of illicit betting by players, especially since the sport’s partnerships with legal gambling enterprises have sent conflicting signals about its disdain for wagering. MLB insiders and experts on sports ethics say the handling of the Mizuhura affair is a case study in how not to deal with such a challenge. They describe the episode as a public relations fiasco that at one point had tied Ohtani himself — falsely, prosecutors say — to payments made in the bookmaking underworld.

Both the Dodgers and MLB have remained mostly silent about their actions during the days before The Times broke the story about Ohtani’s name surfacing in the federal probe and the theft allegations against Mizuhara. In a statement to the paper earlier this month , league spokesman Glen Caplin said, “Just like in other cases, MLB immediately began its due diligence upon learning of allegations from the news media.” Caplin declined to provide any specifics.

After The Times began inquiring about the investigation in March, the Dodgers and MLB left it to Ohtani’s agent and a New York-based crisis public relations manager to deal with the newspaper’s questions and similar queries later by ESPN.

ESPN reported that an unnamed spokesman for Ohtani offered up Mizuhara for an interview — and the interpreter told ESPN that the ballplayer had paid Mizuhura’s gambling debts to an illegal bookmaker. MLB prohibits players and other employees from betting on any sport with an illegal bookmaker. The rule does not specifically address paying the debts of others from unlawful wagering.

In the end, and with little time to spare as ESPN prepared to publish the interpreter’s claim, Ohtani had to head off a punishing blow to his image and reputation by privately questioning Mizuhura, who then confessed that he had covered the debts by stealing from the Japanese slugger.

Several sports communications experts told The Times that MLB and the Dodgers should have tried to keep Ohtani out of such a precarious position. That viewpoint was underscored by Mizuhara’s guilty plea in federal court in June — an admission that he siphoned off nearly $17 million in bank account transfers from Ohtani. But the plea didn’t stop unfounded speculation on social media and elsewhere over whether fans have been told the full story.

By failing to take the lead in responding to queries from The Times and ESPN, before the Mizuhara allegations burst into public view, MLB and the Dodgers did damage to the institution of baseball and the fans who revere it, the insiders and experts say.

“It’s bad for baseball,” said Maurice Schweitzer, a professor at the Wharton School of the University of Pennsylvania whose specialties include effective decision making. ”It’s bad for the Dodgers. It’s certainly not helpful for Ohtani.”

Shawn Klein, an Arizona State University professor whose work focuses largely on sports ethics, said: “I could understand why the Dodgers would be shaking in their boots. They were probably really nervous that something bigger was going to explode on them.”

“But transparency, honesty and being up front is the right thing to do,” he said. “Otherwise, you look like you’re hiding something. And from a moral perspective, it looks like you’re breaking faith with your fans.”

To Klein and others, the way the Mizuhara drama was handled reflects a longstanding pattern of teams taking a passive approach to such player troubles: Franchises typically either defer to MLB or allow the players’ union or personal representatives to address media queries about bad news. That is particularly so when the player is a superstar on the order of Ohtani, the biggest name in baseball, who had left the Angels and been signed by the Dodgers to a record $700 million, 10-year contract in December.

The Times received a tip in mid-March about Ohtani’s connection to the federal investigation. After the paper began asking questions, Ohtani’s agent, Nez Balelo of Creative Artists Agency, told Dodgers executives that his camp would field the inquiries, according to two sources who requested anonymity because they’re not authorized to speak publicly. The Dodgers already had been consulting with Balelo and Mizuhara for PR-related situations regarding Ohtani, the sources said. It’s unclear if or when Balelo informed the Dodgers that he had enlisted the New York-based PR manager Matthew Hiltzik to respond to The Times.

The news of Ohtani’s potential involvement in the probe caught MLB by surprise. One league representative expressed shock in the form of an expletive after learning of The Times’ reporting on the federal inquiry and Ohtani.

The league had encountered Balelo and Hiltzik in tough times before. They represented Ryan Braun when the Milwaukee Brewers outfielder was fighting allegations of testing positive for a prohibited level of testosterone in 2011. Braun appealed the finding and suggested that the man who collected the testing specimen might have mishandled it. He won the appeal and publicly thanked Balelo and Hiltzik for their support.

Later, however, Braun’s name appeared in the records of a clinic that dispensed performance-enhancing drugs and the player admitted to a “huge mistake” in using a “banned substance.” He apologized to the specimen collector and accepted a lengthy suspension.

With Balelo and Hiltzik in charge that week in March, the ESPN story on Mizuhara’s assertion that Ohtani paid the gambling debts began to take shape, ESPN reported. Mizuhara, a Dodgers employee, gave that account in an ESPN interview that the anonymous spokesman arranged, according to the outlet. And then the Dodgers called a clubhouse meeting during which Mizuhara gave the same version of events to the players and staff.

Afterward, Ohtani said he felt uncomfortable with what he understood of Mizuhara’s remarks in the clubhouse and, in a meeting later that day at the team hotel, the interpreter admitted to him that he stole the money, according to court filings and the ballplayer’s statements.

The fast-moving federal prosecution of Mizuhara has gone a long way to defuse suspicions that Ohtani might have known more about the interpreter’s associations with illegal bookmakers than what had been revealed. But there has been no public explanation for why those around Ohtani did not do more to protect him from the unverified story.

Scott Boras, the sports mega-agent who sought to represent Ohtani before the player signed with CAA, said once Ohtani’s representatives knew that Mizhuara had admitted to gambling illegally, he should not have been the source of any story about Ohtani, let alone a negative one that was uncorroborated.

“I would have never allowed the interpreter go to the press,” Boras said. “Why would I trust anything he says? I would have had him arrested on the spot.”

Steven Fink, a long-time communications specialist who has written several books on the topic, agreed that feeding the story to ESPN made no sense. “You don’t go public unless you’re sure of the facts,” said Fink, who is based in Southern California but has worked on PR campaigns around the world, including for the Soviet Union’s response to the 1986 Chernobyl nuclear reactor meltdown.

“I don’t know of anyone who would go public with a story unless they verified it was true,” he said.

Hiltzik declined to be interviewed or to otherwise comment. Balelo did not respond to requests for an interview or comment.

The Dodgers and MLB also declined to be interviewed or to answer written questions from The Times about why they deferred to Balelo and Hiltzik and whether they knew of Mizuhara’s original account to ESPN before he disavowed it.

The Times first contacted Balelo on March 15 while the Dodgers were in Seoul, where the team was playing its season-opening series against the San Diego Padres. Balelo did not reply to a phone message or a subsequent email, but Hiltzik did on the agent’s behalf. The Dodgers were not consulted about bringing in Hiltzik, according to the two sources with knowledge of the team’s actions.

The Dodgers should have taken command at that point, including by going directly to Ohtani, said Don Heider, executive director of the Markkula Center for Applied Ethics at Santa Clara University, where his areas of concentration include leadership and communications.

He acknowledged that if the team did quiz Ohtani, they might have been misled by Mizuhara’s untruthfulness. But the Dodgers should have used other Japanese speakers on the staff — and kept fans in the loop by issuing a statement, Heider added.

“Apparently, nobody was asking any hard questions,” he said.

For several days, Hiltzik provided no answers to the questions The Times put to him, and he eventually said Ohtani had no comment.

On March 20, after the Dodgers beat the Padres in the season opener, team co-owner Mark Walter and other executives alerted players at the clubhouse meeting of an imminent story about Mizuhara and his gambling debts. Mizuhara then told the gathering that Ohtani had paid off the bookmaker for him. Ohtani was at the meeting, but no one translated Mizuhara’s remarks for him.

The mood in the clubhouse shifted from celebratory over the victory on the field to a seriousness bordering on somber, according to several people present at the meeting. As the executives spoke, some players were in the middle of changing and others emerged from the showers in towels, surprised to encounter such an awkward scene.

Like Ohtani’s outside advisers, the Dodgers apparently took Mizuhara’s word about Ohtani — the claim that he funneled millions of dollars to an illegal bookmaker. The team did not immediately remove Mizuhara from the clubhouse or the payroll; he interpreted for Ohtani shortly after the meeting when reporters asked the player about the game.

MLB policy bars nonplayers like Mizuhara, who was a Dodgers employee, from betting on baseball or gambling illegally. One section states: “Any player, umpire, or Club or League official or employee who places bets with illegal book makers, or agents for illegal book makers, shall be subject to such penalty as the Commissioner deems appropriate in light of the facts and circumstances of the conduct.”

The abruptness of the reversal in Mizuhara’s account — that he stole from Ohtani — raised doubts about his new story at the time, some of which have lingered, the experts say.

“Mixed messages just create more fodder and more intrigue,” said Schweitzer, the Wharton School professor. “You’re letting social media and talking heads tell the story.”

Mizuhara and Bowyer are awaiting sentencing in federal court.

Times staff writers Jack Harris and Dylan Hernandez contributed to this report.

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How gambling affects the brain and who is most vulnerable to addiction

Examining the risks

From gaming to gambling

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The brain of a problem gambler

Betting on the game

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What to target in cognitive behavioral treatment for gambling disorder—A qualitative study of clinically relevant behaviors

Conclusions

Introduction

Participants

Data analysis

Researchers’ competence

Quantitative analysis

Gambling Pathways subtype assessments

Self-reported gambling behavior

Functional assessment of gambling behavior

Antecedents of gambling behavior

Experiences when not being able to gamble

Accompanying responses

Strategies to control or continue gambling

Consequences of gambling

Terminating events of gambling behavior

Behaviors with functions similar to gambling

Pathways Model subtypes

Availability of data and materials

Abbreviations

Acknowledgements

Author information

Contributions

Corresponding author

Ethics declarations

Consent for publication

Competing interests

Additional information

Supplementary Information

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BMC Psychiatry

A Case Study of Binge Problem Gambling

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Conclusions

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Considering Gambling Involvement in the Understanding of Problem Gambling: A Large Cross-Sectional Study of an Australian Population

Are There Riskier Types of Gambling?

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A case study - Matthew’s story

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