Pathological Gambling Pathological gambling (PG) represents the end spectrum of gambling behaviors. It is characterized by constantly recurring gambling behaviour which is maladaptive. Preliminary neuro-biological studies implicate serotonergic dysfunction in pathological gamblers.
Other neurotransmitter systems implicated include the Dopaminergic and the Nor-adrenergic systems. While the former may mediate positive and negative rewards, and is important for aberrant substance seeking or impulsive addictive-compulsive behavior, the latter possibly mediate selective attention.
The accessibility and availability of gambling outlets is an important factor in the number of people being adversely impacted by gambling. Early exposure to an environment of heavy gambling appears important too as excessive participation in gambling frequently results from social pressures. Gambling is often used by certain individuals to cope with crisis and major stresses as the building up and release of tension associated with risk taking can be thrilling, cathartic and pleasurable. Mere occasional gambling can therefore become pathological.
Development of gambling addiction proceeds in stages as illustrated by this case. She appeared predisposed in terms of the familial history, her lack of social support and her boredom. Her initial stagewas characterized by a series of initial gains and encouragement from peers of a similar gambling background. As she entered the developing stage, her self-esteem soared as she saw herself as a smart and lucky gambler, and thereby increasing her bets and frequency of gambling.
The thrill associated with winning propelled her into the losing phase when she began to lose money and suffer a blow to her self esteem, which led to chasing and acceleration of the losses. When she presented during the desperation phase, social and psychiatric complications with more bail-outs and impairment in her control were apparent.
Being a complex bio-psycho-social phenomenon, PG is associated with high rates of other clinical and co-morbid conditions such as affective disorders, anxiety disorders and phobia, substance abuse and suicidality. There are also higher rates of other impulse control disorders such as compulsive buying, compulsive sexual behavior, kleptomania and attention deficit disorder. However these were absent in this patient. On the other hand, she did exhibit alexithymia, which is found to be increased in PG and may be a risk factor for PG in some population.
The fact that PG is multi-factorial in etiology means that its treatment has implications far wider than just the activity of gambling. It also involves that person’s entire lifestyle and the impact of social factors, particularly public policy on gambling. In a clinical setting, treatment has to be carried out in stages and often face limitations. Assessment should be detailed and the need for honesty set right from the start as the patient tended to develop a pattern of dealing with problems by untruthfulness.
Cognitive behavior therapy has been found to be effective in reducing the frequency of gambling behavior in clients as well as maintaining the therapeutic gain. On the other hand, aversive therapy and covert / imaginal-desensitization have not been found useful. Involvement of family is essential.
Social assistance such as dealing with marital problems, leisure activities and legal assistance may also be indicated. A warm, empathic, non-judgemental and enthusiastic therapist with a strong sense of treatment boundary plays a pivotal role in moving the patient through the steps of change. With better therapeutic alliance, other relevant aspects of management such as dealing with low self esteem, ambivalence and fluctuating motivation to stop gambling; and applying the appropriate intervention based on the stage of gambling habit become easier.
Treatment of pathological gambling is very much in its infancy stage locally. Self-help groups may need to be developed with increased awareness and service demand. This case illustrates that though treatment can be long and frustrating, success is possible with appropriate approach in treatment and support.
Pathological gamblers exhibit complex impairments in decision-making and executive function processes associated with the prefrontal cortex of the brain, according to research that was presented at the American Academy of Neurology 57th Annual Meeting in Miami Beach, Fla., April 9 -16, 2005.
Researchers learned that decision-making functions and inhibitory control in chronic pathological gamblers appear to be altered and may influence the trade-off between short-term reward and the long-term negative consequences of gambling on employment, social relationships, and family life. Better understanding of these processes could lead to the development of more effective strategies for treating pathological gamblers.
The study, led by Dr. Maria Roca, investigated the decision-making processes and executive functions in pathological gamblers. Executive functions encompass a variety of processes and are defined as the ability to abstract, plan, organize, shift set, and adapt current and past knowledge to future behavior, said co-author Facundo Manes, MD, of the Raul Carrea Institute for Neurological Research (FLENI) in Buenos Aires, Argentina. Decision-making involves assessment of possible reward and punishment outcomes from the various response options, and the selection of the option that one thinks will be best.
Dr. Roca’s study examined 11 pathological gamblers and 10 control subjects, using decision-making tasks, inhibitory control and attention tasks, and other measures. In the decision-making tasks, the gamblers made more disadvantageous choices. In the inhibitory control and attention tasks, the gamblers made more errors.
We think that the results of our study are important for two reasons, said Manes. First, our findings add more evidence to the possible role of the prefrontal cortex in the pathophysiology of this neuropsychiatric disorder. Second, the characterization of executive deficits involved in chronic pathological gambling has clear implications for rational pharmacological and rehabilitative treatment strategies. The study was supported by the Raul Carrea Institute for Neurological Research in Buenos Aires, Argentina.
Robert Mittiga (Addiction Specialist)
GATS Counselling & Treatment Services (GATS)
The GATS Program
P.O. Box 6411 Halifax Street, Adelaide SA 5000
Ph 08 8223 4555 or Mobile 0400 801 557
Web http://www.gatscounselling.com
