Download Position Statement 45 Pathological/problem gambling

Position Statement 45
Pathological/problem gambling
June 2009
Definition
The diagnosis of ‘pathological gambling’ was accepted by the World Health Organisation and introduced
into the International Classification of Diseases (ICD) system in 1977. The diagnosis as a disorder of
impulse control was introduced into the Diagnostic and Statistical Manual of Mental Disorders (DSM) III
by the American Psychiatric Association in 1980. Although some modifications to the criteria for the
diagnosis have occurred, subsequent editions of the DSM continue to classify pathological gambling in
this manner, despite the argument for its similarity to drug and alcohol problems.
The term ‘pathological’ was accepted as being more correct than the lay term ‘compulsive’ as the
element of resistance necessary for a compulsion is rarely seen.1 Recent times have seen the wider use
of the term ‘problem’ to emphasise the view that gambling behaviour moves along a continuum.
According to this view, it is difficult to distinguish regular gamblers from a discrete group for whom
gambling has become a serious problem.
The Ministerial Council on Gambling, comprised of the Ministers responsible for gambling in each State
and Territory Government and the Australian Government, aims to minimise the adverse consequences
of problem gambling and in 2005 recommended the following national definition: “Problem gambling is
characterised by difficulties in limiting money and/or time spent on gambling which leads to adverse
consequences for the gambler, others, or for the community.” In New Zealand, problem gambling has
been defined as “patterns of gambling behaviour that compromise, disrupt or damage health, personal,
family or vocational pursuits”2.
Psychiatrists have a role in the diagnosis of underlying pathology and confirmation that pathology is
absent or present. Problem gambling will often coexist with psychological problems of anxiety and
depression. These will usually be a consequence of the gambling behaviour and improve when the
behaviour is controlled or stopped. In other instances, gambling may be a way of dealing with preexisting anxiety or depression and both conditions will require appropriate treatment. Other psychiatric
illnesses that may rarely be seen to contribute to problem gambling include mania, hypomania and
schizophrenia. While delusional ideas and command hallucinations associated with a schizophrenic
illness may precipitate gambling behaviour, more commonly the gambling behaviour becomes a way of
dealing with the negative symptoms of schizophrenia. Physical illnesses such as migraine, hypertension
and other stress-related problems can also be associated with gambling. In these instances, gambling
should be considered as a contributory factor.
Evidence
The Ministerial Council has adopted the Canadian Problem Gambling Index (CPGI) as the national
screening measure and recent surveys show ranges of 0.4% to 0.97% of the Australian population in the
various States and Territories having gambling problems. This group has the most serious difficulties
due to gambling behavior (divorce, suicidal thoughts and acts, illegal acts, bankruptcy) and may require
treatment and assistance although longitudinal studies suggest many will change without seeking such
assistance. It should be noted that this group is determined by a cutoff point on the scale, but some
scoring below the level, while not being regarded as cases, would be deemed to be “at risk” and may still
have problems, albeit at a lower level. Community education and responsible gambling policies put in
place by the industry should assist most of these gamblers. Problem/pathological gambling is highly
comorbid with other diagnoses. Depression, as discussed earlier, is the most frequent but studies, both
local and overseas, show that hazardous alcohol use and smoking are very prominent also. Personality
Position statement 41 – Pathological/problem gambling
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disorders are commonly seen, most often from Cluster B and C. Treatment for one condition should
involve assessment and possible concomitant treatment for these comorbid conditions.
Recommendations
•
Questions about gambling behaviour should form part of every routine patient history.
The following approach is recommended:
o
Ask if the patient gambles at all. If so, what is the type of gambling? (Forms such as
lotteries rarely cause problems).
o
What is the frequency of gambling? (Those who gamble weekly are more likely to develop
problems).
o
Ask the patient if gambling is a problem for them. If a problem is found then assistance
may include referral to a specialist gambling treatment agency.
It is further recommended that these questions be put to the patient when asking about the
consumption of alcohol and other drugs, given the general acceptance that there is a
substantial overlap between these behaviours.
It is important to remember that it may be the spouse, partner or other family member that
has a gambling problem leading to distress for which the patient is seeking help. The patient
may not reveal this information unless specific questions are asked.
•
The College is concerned about the negative impact of gambling in the community. Accordingly,
the College urges Government and industry bodies to work together with community
representatives to find responsible levels of gambling activity which minimize the harmful impact
on the community.
•
The College recommends the following action in response to the current situation:
o
o
o
o
o
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that information about gambling odds for all avenues of gambling is promoted;
that gamblers are advised of possible harm due to excessive gambling;
that gamblers are advised where help may be obtained;
that the availability of counselling services and other help is ensured; and
that research into treatments and outcomes is encouraged.
The College is aware of the importance of relating with the industry in such a manner that does
not contribute in any way to the harm of pathological gambling. The College will be mindful in
selecting venues for conferences that it does not create the impression that it is supportive of the
industry or gambling. At the same time it recognises that it has an important role in working with
the industry for research, advancing treatment of problem gamblers and supporting harm
minimisation. It recommends:
o
That the College's relationship with the industry is purely in an advisory role to assist the
industry and the community reduce any harm that might arise from gambling
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o
•
The College takes precautions so it does not act in a manner that is perceived as
condoning gambling in its many forms.
No one treatment is considered to be most efficacious although current research suggests that
cognitive behavioural approaches are the most effective treatment for pathological/problem
gambling.3-6 Within the behavioural therapies, evidence exists which suggests that imaginal
desensitisation may be the most successful. Support also exists for Gamblers Anonymous and
more in-depth counselling.
It should be noted that good randomised controlled trials of
treatment outcomes are sparse. However, many studies are under way and future findings may
influence therapeutic practice, including the possible development of medications for the
treatment of some problem/pathological gamblers. Psychotherapy and pharmacotherapy should
be considered, when appropriate, for depression and anxiety.
References
1
Moran E. Pathological Gambling. British Journal of Psychiatry Special Publication No 9: Contemporary
Psychiatry 1975.
2
Ministry of Health New Zealand, Preventing and Minimising Gambling Harm: Strategic plan 2004-2010.
2005.
3
DeCura CM, Hollander E, Grossman R. Diagnosis, neurobiology and treatment of pathological gambling. .
Journal of Clinical Psychiatry 1996; 57: 80-84.
4
McConaghy N, Armstrong M, Blaszczynski A, Allcock C. Controlled Comparison of aversive therapy and
imaginal desensitisation in compulsive gambling. British Journal of Psychiatry 1983; 142: 366-372.
5
Walker M. Treatment Strategies for problem gambling: a review of effectiveness. In Eadington W,
Cornelius J (ed) Gambling Behavioural and Problem Gambling: Reno: Institute for the study of Gambling
and Commercial Gambling, 1993.
6
Ladouceur R, Sylvain C, Boutin C, Lachance S, Doucet C, Leblond J, et al. Cognitive treatment of
pathological gambling. Journal of Nervous and Mental Disease 2001; 189: 774-780.
Adopted: May 2003 (GC2003/1.R29)
Amended: May 2009 (GC2009/2 R31)
Currency: Until withdrawn
Owned by: Section of Addition Psychiatry
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