Gambling

Gambling has become a major recreational activity in the United States. In the past, legalized gambling was confined to a few states, such as Nevada and New Jersey, but in the past two decades gambling opportunities have expanded. Some form of legalized gambling exists now in all but two states; 37 have lotteries, and 27 have casino gambling. A 1999 survey showed that nearly 90% of the adult population participates in some form of legalized gambling, especially instant lottery games, slot machines, office pools, and card games. In the 23 years from 1974 to 1997, gambling expenditures more than doubled as a percentage of personal income.

While most persons gamble responsibly, between 3.5% and 5% of the general population develops problematic gambling. Pathological gambling (PG), the most severe form of problematic gambling, may affect as much as 1% to 2% of the adult general population, which suggests that more than 2 million Americans suffer from this disorder, with roughly twice that many having gambling related difficulties without meeting the criteria for the disorder as described in Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV). PG is characterized by continuous or periodic loss of control over gambling.

Recognized for centuries, criteria for PG were first enumerated in 1980 in DSM-III. The criteria are patterned after those used for substance dependencies and emphasize the features of tolerance and withdrawal, both of which have been described in persons with PG and in those with substance dependence. The DSM-IV enumerates 10 specific maladaptive behaviors, and 5 or more are required for the diagnosis.

Research suggests that PG may be even more common among youth. Gambling itself is on the rise; a national survey reported that 82% of respondents had gambled at least once in the past year, with lottery and casino gambling showing the largest rates of increase from earlier surveys. The psychosocial costs of PG include financial, legal, employment, and relationship difficulties as well as psychiatric complications such as depression, substance misuse, and suicide.

Although PG is widely conceptualized as an addiction, its classification remains controversial. Some experts have included PG as part of an “obsessive-compulsive spectrum” of disorders, while others have linked it with impulse control disorders, such as compulsive buying and kleptomania, or even to the mood disorders.

One quarter to one third of all pathological gamblers are women. Women tend to begin gambling later in life, often in their early 30s, while men start in their late teens or early 20s. Women tend to have a more rapid progression to pathological gambling, a phenomenon known as telescoping. Special populations at risk for developing PG include adults with mental health or substance use disorders, persons who have been incarcerated, African Americans, and persons of lower socioeconomic status.

Persons with PG are highly likely to have comorbid mood and anxiety disorders and to misuse substances. Other impulse control disorders (e.g., compulsive buying, kleptomania), and attention deficit hyperactivity disorder are also frequently comorbid with PG. Lifetime drug or alcohol dependence has been consistently reported in persons with [Page 228]PG, and one survey showed that the rate of alcohol or other drug abuse was nearly 7 times higher among persons with PG than among nongamblers or recreational gamblers. From 30% to 50% of treatment-seeking pathological gamblers have histories of substance misuse.

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