Problem and Pathological Gambling

Review byNK Cooper Lt Col RAMC & Dr JP Hammes MMed(Psych) MRCPsych, to appear in Journal of the Royal Army Medical Corps, 2008Within the psychology of addictive behaviours, significant to severeproblems due to their gambling activities are experienced by some 5%to 9% of adults depending on the population surveyed. (The BritishGambling Survey1 estimated the prevalence of problem gambling to be0.8% in British adults.) Although an ancient, some might say timeless,feature of human life pathological gambling behaviour has only reallybeen seen as a psychopathology in recent decades.Authored by a trio of psychology professors, two from the Universityof Memphis and the third from Indiana Wesleyan University, this shortbut solidly priced text in the publisher's Advances in Psychotherapy -Evidence-Based Practice series gives the reader a surprisingly broadintroduction to the problem. In DSM-IV-TR2 Pathological Gambling(312.31) is categorised as "an Impulse Control Disorder Not Elsewhere Classified" with at least 5 out of 10 diagnostic criteria met, these being drawn from the 3 symptom clusters of disruption to the individual's life, loss of control and dependence. (ICD-103 ategorisesit among Habit and Impulse Disorders - F63.0.) In both classificationsystems it is not deemed to be form of obsessive-compulsive disorder.Although the term "problem gambling" is included in the title of thebook, authors regard it to be a "somewhat more ambiguous term thanpathological gambling and generally reflects the experience ofsignificant negative consequences due to gambling." However"problem gambling" seems to be used more often than "pathologicalgambling" during the rest of the text.The overview of vulnerable populations and demographic correlates isrelevant in a military population. Pathological gambling is morecommon below the age of 30 years with a significant malepredominance. Males who seek treatment are younger and have higherincomes. Substance use and mood disorder are the main co-morbiddisorders, which are common presentations in military psychiatry too.Although the impact of gambling availability is discussed, what isperhaps not made explicit is that "because of the nature of gambling,we are all vulnerable to take gambling to excess."4The main theories are explained and integrated into a model ofproblem gambling, which guides clinical assessment and provides thefoundation for a treatment approach called Guided Self-Change forGambling (GSCG). The principles of GSCG are: harm reduction,rapid change response, self-change and a motivational approach. Fordiagnostic assessment DSM-IV-TR3 or RDC4 criteria are used mostlyin practice, because most clinicians would not have access to theDiagnostic Interview for Gambling Severity (DIGS) or self-administered South Oaks Gambling Screen (SOGS) discussed.Further clinical assessment examines the variables that affect GSCGincluding gambling behaviour, possible treatment mediators, systemicfactors and co-morbid psychopathology. Alternative or adjunctivetreatments to GSCG are reviewed briefly emphasising the value ofcombining cognitive and behavioural components. Pharmacotherapyfor problem gambling is regarded "largely experimental" at this stage.("No drug has been approved for use in the UK or USA to treatpathological gambling."5)The five phases and components of GSCG are explained clearly in aseparate chapter. These are: running start assessment, motivationalfeedback, triggers and consequences, options and action plan, relapseprevention. The following chapter is a case vignette demonstrating howthese phases work in practice. There are nine appendixes that "may bereproduced by the purchaser for clinical use." These would beparticularly useful for clinicians who already have experience in the use of problem-solving techniques, motivational interviewing and cognitive-behavioural interventions, who want to use GSCG. However theappendixes should also give other clinicians and even potential patients an idea what will be addressed during a course of GSCG.From the military Occupational Medicine viewpoint NKC sees the textas being of use to any Service MO faced with the question "To P8S8discharge this indebted individual or not." There is a fine istinction to be made between the QRs 9.405(3) administrative dischargerecommendation for a persistently indebted individual for whomgambling may be one of several causes of their financialembarrassment and the long-term psychiatrically unwell case whereP8S8 grading is recommended by a Service psychiatrist. The UKGambling Commission has identified the number of problem gamblersas about 250,000 hence one is likely to come across the soldier ormilitary family so affected from time to time.References1. Sproston K, Erens B, Oroford J. (2000). Gambling Behaviour in Britain: Results from the British Gambling Prevalence Survey. London: National Centre for Social Research.2. American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed text revision). Washing DC: Author.3. Cooper JE (ed). (1994). Pocket Guide to ICD-10 Classification of Mental and Behavioural Disorders: With Glossary and Diagnostic Criteria for Research DCR-10 (Paperback). Oxford: Churchill Livingstone.4. Moran E. (2007). The Royal College of Psychiatrists Submission to the Secretary of State for Culture Media & Sport on the implementation of the Gambling Act 2005. London: Royal College of Psychiatrists.5. George S, Murali V. (2005). Pathological gambling: an overview of assessment and treatment. Advances in Psychiatric Treatment. 11: 450-456.PsycCRITIQUES, Vol. 53, issue 31, 2008, reviewed by Carrie H. Kennedy:Gambling is a popular pastime and comes in a variety of forms. Bingo,state lotteries, friendly neighborhood poker games, slot machines,casinos, raffles, sports betting, and on-line gambling can be readilyaccessed by practically anyone. Americans gamble over a half trilliondollars annually (National Research Council, 1999). It is estimated that 86 percent of American adults have gambled at some point in theirlives, with 63 percent gambling in the past year and 16 percentgambling in the past week (Volberg, 2001). Opportunities for gamblingcontinue to expand: it appears that gambling may be on course toeventually become legal but probably with restrictions, as seen withcigarettes and alcohol.While gambling may be considered recreation for most, a minority is significantly challenged by it. Within the book series Advances in Psychotherapy and in conjunction with Division 12, the Society of Clinical Psychology of the American Psychological Association, Whelan, Steenbergh, and Meyers strive to provide a desk reference, as well as continuing education opportunities (not yet available at the time of this review), for psychologists and therapists who are working with gambling patients. Beginning with a concise background of the disorder, its prevalence, risk factors, and comorbidities, and finishing with an illustrative case vignette, this brief but fulfilling handbook delivers. Whelan, Steenbergh, and Meyers cite a 1.1 percent prevalence rate for pathological gambling and a 2.8 percent rate for problem gambling. Despite these rates, it is not a widely researched phenomenon, and insufficient resources exist to address it clinically. The diagnosis itself is somewhat of a conundrum. Pathological gambling is without a true home in the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 2000) given its characterization as an impulse control disorder but its predominant conceptualization and treatment as an addiction. The concept of problem gambling is not addressed diagnostically. This 90-page book manages to incorporate the most significant aspects of pathological gambling theory, as well as a detailed description of one form of psychotherapeutic treatment. Whelan, Steenbergh, and Meyers provide suggestions for a variety of screening instruments and key diagnostic rule-outs. The authors emphasize the theoretical models of the disorder and discuss a variety of treatment approaches, with a focus on the empirically supported strategy of guided self-change for gambling (GSCG). While allowing the treating provider to choose between an abstinence-based or a harm-reductionbased treatment, Problem and Pathological Gambling presents practice guidelines and includes a reproducible appendix with patient homework assignments and exercises. GSCG objectives include conducting an examination of the gambling behavior, choosing treatment goals, learning about triggers and consequences, avoiding risk, implementing alternative behaviors, and maintaining changes. A primary focus is on having the patient take responsibility for goal setting, and the GSCG treatment strategy incorporates behavioral techniques, motivational interviewing, relapse prevention, and patient education. To describe the technique, the authors conclude the volume with a detailed case example that serves to provide the reader with an excellent understanding of the treatment. While succinctness is the greatest strength of the book, there are some key components that might have been added. The lack of an some key components that might have been added. The lack of an index makes navigating the book somewhat cumbersome, particularly when one is searching for something specific. The book also focuses on only one primary method of treatment, which may or may not benefit each patient. Refractory cases and alternative or augmented methods are not discussed, presumably given the purpose and need for brevity of the handbook.For example, although this book covers what psychotherapists may need to know to treat pathological gambling, it shortchanges theconsultation role that psychiatry may play. Reference to possiblemedication is briefly mentioned as experimental despite significantemerging research into the area (e.g., Black, Shaw, Forbush, & Allen,2007; Dannon, Lowengrub, Gonopolski, Musin, & Kotler, 2005). Whilethere continue to be no established protocols for treating pathological gambling with medication, a section discussing the possibilities, particularly when one has a difficult case, might prove useful. In addition, the length prevents it from covering much information related to treating comorbidities, a significant issue for many pathological gamblers. Although this book cannot stand alone as a gambling resource, it does manage to provide all of the basics for a psychologist to get started with a gambling patient and addresses many issues that may arise in the course of treatment. It is a quick read with no wasted space and provides a highly valuable and concise introduction to both problem and pathological gambling.In summary, this book is an excellent resource for new psychologists, psychologists inexperienced with gambling patients, substance abuse counselors who are treating patients with comorbid gambling problems, graduate students, and even motivated patients who are proactive in their own treatment. This volume successfully distills a complicated topic into an easily readable primer, making it a first-line reference for gambling treatment.