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Pathological Gambling: Diagnosis, Theories and Treatment

Gaming can be, for most of us, a recreational activity that does not have to involve any negative consequences.

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Gambling can be, for most of us, a recreational activity that does not have to involve any negative consequences. People can play in social gatherings as a form of fun or socialization with others or as a way to pass the time.

There are other cases in which the game goes from being a mere entertainment to being the central part of the person’s life, taking control of their life.

When the person can not stop thinking about the game, feels the need to lie or invests amounts of money that he can not afford to lose, he may have become a pathological gambler.

What determines that a game is pathological is the ability of the person to voluntarily control their involvement in the game. Generally, the person’s perception of their own capacity may be altered, being unable to recognize reality until the consequences become dramatic.

This bias, called the illusion of control, causes players to think that they control the situation and that they can stop whenever they want. On the other hand, the reality is not that and, frequently, the game gets out of hand, having important consequences at the economic, family, social and labor levels.

The DSM 5 relocated this diagnostic category within the chapter on Disorders related to substances and other addictions. What motivated the change was the similarity between the game and other addictions. In both entities the same brain mechanisms would be involved, particularly those that have to do with the reward system.

How is pathological gambling diagnosed?

To diagnose a patient’s pathological gambling, the DSM5 tells us that the game must be problematic, persistent and recurrent and cause a clinically significant deterioration or discomfort (the person starts playing so as not to feel bad; before the game, the rest of the reinforcers have lost value).

The patient must also present four or more criteria, out of a total of 9 during a period of 12 months. These criteria are the following:

  • Need to bet larger amounts of money to get the desired excitement.
  • He is nervous or irritated when he tries to reduce or abandon the game.
  • He has made repeated efforts to control, reduce or abandon the game.
  • He often has his mind engaged in betting.
  • He often bets when he feels restless.
  • After losing money in betting, he usually returns another day to try to win.
  • It lies to hide your degree of involvement in the game.
  • Has endangered or lost an important relationship, a job or an academic or professional career.
  • Count on others to give you money to alleviate your desperate financial situation.

This behavior should not be explained by any manic episode, since then we should attribute it to this diagnosis and not to the pathological game.

In addition to these diagnostic features provided by the manual of the APA, there are a number of cognitive distortions that we can find very often in these patients.

In addition to the illusion of control, it is normal for players to present the illusory correlation (consider that certain variables would covary when this is not the case: “if I speak fondly of the dice, I will obtain a higher score”), the fixation on the absolute frequencies ( they value their success based on what they have gained and do not take into account everything they have lost), flexible attribution (attributing successes to personal factors and external failures) or post-hoc explanations (believing that they predict the result once it has already happened).

Explanatory theories about the pathological game

Some theoretical perspectives that have tried to explain the pathological game are the following:

The model of the states of necessity

According to this theory, the game is seen as a behavior that satisfies some lack of the subject. The addiction would be acquired as an attempt to control this situation of chronic stress that this alteration entails.

The factors that predispose the game are: an altered level of aversive psychophysiological activation and an altered state of identity, such as having feelings of inferiority, disability or feeling rejected. Let’s say that in this sense, the game acts as a cover for all these unresolved deficiencies.

Brown’s reversal theory

It is based on arousal / activation and in Apter’s reversal theory. It proposes two systems that would lead the person to the motivation to play and an optimal level of activation.

From this perspective, we speak of a telephonic state (the subject is motivated and oriented towards a goal, enjoying his anticipation, but with a low activation) and the parathelic state (states of high activation and enjoyment with immediate sensations).

Let’s say that the person in a thetic state perceives the game with anxiety and those in the parathelic state are more attracted to the game. The thelic begins the game to induce a parathelic state, where the activation is not lived with anxiety, but with pleasure.

Let’s say that the player learns that if he keeps playing despite the anxiety, then reinforcers and winnings will come and that’s why the problem remains.

Dickerson and Adcock model

Explain how the game is maintained and focuses on activation as a key variable. The two factors that modulate the activation are: the mood and the illusion of control. This module explains that, the lower the mood, the longer the behavior of playing with the purpose of reaching the optimal level of activation with which the player feels comfortable.

Sharpe and Tarrier model

Explain the problem based on the typical reinforcement program of the game: the variable. Monetary gain is not something fixed. Sometimes it happens and sometimes it does not. This variability favors that the person remains hooked to the game, since he can not anticipate when he will win.

Treatment of pathological gambling

There are two therapeutic objectives: complete abstinence or controlled play. The choice of one or the other will be made according to the profile of each patient. However, the most used is complete abstinence. As treatments used we can find the following:

Self Help Groups “Anonymous Players”

They consider the game as a chronic and progressive disease on which they can intervene to stop their development, but not cure.

The group constitutes a social support network, but the dropout rates are high from the first sessions. It would not be useful in patients in the early stages, but rather in those with more associated problems.

Pharmacotherapy

Three types of approach can be used in this regard: mood stabilizers such as lithium carbonate with neuroleptics, SSRIs such as fluoxetine and even naltrexone because of its resemblance to substance addictions.

Multi-component programs

There are two ways to carry out these programs:

  • Internment. If the patient’s profile is of a person without social or family support, with ideas of suicide or behavioral disorganization. That is, serious patients.
  • Ambulatory. From this perspective we find two of the most famous. The Ladouceur y cols program and the Echeburúa y Baez program. The first includes more cognitive techniques such as restructuring, problem solving and relapse prevention. On the other hand, that of Echeburúa and Baez is more behavioral in nature, including strategies such as stimulating control and exposure with response prevention, as well as group therapy.

The treatment of pathological gambling, as it happens in other types of addictions, is not easy. First, it requires the person to recognize a problem, then he has to realize that he can not handle it on his own.

Finally, in many cases, having a good circle of support is the last push that encourages the person to go to consultation, which reinforces and consolidates the progress and also prevents relapse.

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