The prevalence of pathological gambling is between 1 and 3 percent of the population in the United States. Problem gambling represents roughly another 5 percent. These numbers have risen with the widespread legalization of lotteries and casino gaming. Men outnumber women by a ratio of about two to one. At least half of pathological gamblers are also addicted to alcohol, and studies show that a family history of alcoholism may predispose a person to pathological gambling.

Ten percent of the men who are admitted to alcohol and drug treatment meet screening criteria for pathological gambling.

The diagnosis of pathological gambling is based on the presence of several typical patterns of behavior, including gambling to escape stress, spending money that is needed for living expenses, lying about gambling, engaging in illegal acts to obtain money, becoming tolerant to the stimulating effects of gambling, a feeling of restlessness when one is not gambling, and “chasing losses,” or betting more in order to cover losses. Problem gamblers are those who may have gambled away needed money or used gambling as a coping strategy but who do not have all of the features asssociated with pathological gambling.

Pathological gambling typically progresses through three stages. First is the winning stage, in which the gambler focuses on how much money is being gained. Self-esteem is linked to winning and to the amount that is won. Next, in the losing stage, the pathological gambler feels insulted and responds as though to a challenge. During this stage, gamblers will begin to chase losses and take inordinate risks with money they can’t spare. The desperation stage is third, and involves depletion of resources, complete preoccupation with gambling, and serious psychological consequences. Suicides are common during this phase.

The coexistence of other psychiatric problems is common in pathological gamblers. Major depression is seen in over two-thirds of those identified. Antisocial, narcissistic, and borderline personality disorders are also common.

Pathological gambling is both underrecognized and undertreated. Most gamblers are destitute by the time treatment is sought; many are no longer employed and have no insurance. (Many insurance carriers will not cover treatment for pathological gambling when it is the primary diagnosis even if the gambler still has insurance.) Few professionals are experienced and certified in treating pathological gambling, although their numbers are increasing, especially in states with legalized casino gambling.

Because of the coexistence of depression or alcoholism, pathological gamblers frequently seek treatment in hospital settings. But they often do not recognize or mention that gambling is a problem. Screening for pathological gambling on admission to an alcohol and drug treatment facility or psychiatric hospital is becoming more common, and should probably be routine. The addition of appropriate intervention for the gambling problem can then be provided.

The treatment of pathological gambling is similar to the treatment for other addictions but has some important differences. When the alcoholic or addict goes through “detox” and begins to think clearly, productive changes in attitude often follow. The pathological gambler, however, often does not experience craving and loss of control away from the place where gambling occurs. Discussion of the problem can become merely an intellectual exercise, and no opportunity exists for putting realistic changes into action. Long-term follow-up is therefore essential.

Gamblers Anonymous is a 12-step program based on Alcoholics Anonymous and can provide ongoing support.

GA meetings, however, are not as widely available as AA and NA meetings. Groups facilitated by counselors are helpful but also not widely available. Individual and family therapy is useful, especially in unraveling the secrecy and manipulation associated with the gambling behavior. As problem and pathological gambling become more widespread, treatment centers and government agencies are developing more treatment alternatives.

The presence of major depression is a strong risk factor for the development of pathological gambling and for later relapse. Comprehensive treatment of depression or other coexisting psychiatric problems is essential, as is treatment for any other addictions that might be present, such as alcoholism.

Elizabeth Connell Henderson, M.D.

Glossary

Appendix A: Regulation of Addictive Substances

Appendix B: Sources of Additional Information