Experts Struggle to Define Problem Gambling

4 December 2001

by David Strow

LAS VEGAS, Nevada – Dec. 4, 2001 --In the 1950s, problem gamblers were lumped into the same category by psychologists as "racketeers, dope peddlers and prostitutes." It wasn't even called problem gambling then, but "dishonest gambling."

Today, that viewpoint has changed dramatically. Psychologists now view problem and pathological gambling as a legitimate illness, one that can be diagnosed and treated.

The advancement of this emerging science -- and the methods for diagnosing it -- are the focus of a scientific conference that began Sunday at the Mirage hotel-casino. The conference, co-sponsored by the National Center for Responsible Gaming, the Harvard Medical School Division on Addictions, and the Nevada Council on Problem Gambling, continues through Tuesday.

The goal of the 140 scientists, clinical professionals, gaming industry executives and regulators is to discuss what, exactly, problem gambling really is, how to diagnose it more effectively, and how to structure its treatment.

"We know what the problem is when we see it, but it is very difficult to define," said Howard Shaffer, director of the Division on Addictions at Harvard Medical School.

"What is it we're evaluating? It could be anxiety, depression, or an inability to control responses. This conference will deepen our scientific understanding."

Once the disease is understood better, Shaffer said it could be possible to move to a stage where problem gambling can not only be treated, but prevented, much like physicians can now identify patients are at risk of cardiovascular disease long before a heart attack.

"My hope is to develop a method of identifying this problem before they (problem gamblers) lose their shirt," Shaffer said.

Currently, the clinical method for diagnosing a "pathological gambler" is through the use of the fourth edition of the Diagnostic and Statistical Manual (DSM), the American Psychiatric Association manual for diagnosing psychiatric disorders.

But it isn't a perfect system, said Thomas Widiger, professor of psychology at the University of Kentucky, who is helping conduct preliminary research for DSM-5.

One difficulty is the high hurdle the test uses in defining problem gambling. Five or more symptoms result in a diagnosis of pathological gambling -- four or less result in a negative, though clinicians often refer to such borderline cases as "problem gambling," considered less severe than pathological gambling.

Shaffer has estimated that about 1.1 percent of the American adult population has been an active pathological gambler in the past 12 months.

"Erring in favor of avoiding false positives ... clearly leads to many false negatives," Widiger said. "Most likely, the prevalence (of problem gambling) is higher."

Goals for the scientists who develop the next version of DSM, Widiger said, should include identifying and using laboratory tests that can help diagnose problem gambling.

But even if scientists can come up with a "gold standard" for diagnosing compulsive gambling, it won't make treating the disease a cinch, said Dr. John Renner, a clinician and professor of psychiatry in Boston University's School of Medicine.

"Even the most accurate diagnosis doesn't solve our problems," Renner said. "It doesn't guarantee success (in treatment)."

The problem for those who treat problem gamblers, Renner said, is that those who seek treatment rarely have problem gambling alone. Often, problem gambling exists in concert with other psychological problems -- and is often a symptom of a deeper problem.

As an example, Renner pointed to the case of a recent patient, 31-year-old "Fred W."

Fred came in for treatment after losing his job and his girlfriend because of a gambling habit. The initial diagnosis was pathological gambling, but his clinician became concerned when she noted growing anxiety and depression despite treatment.

After further investigation, it was found that Fred -- a veteran of the Gulf War -- had seen combat. Nightmares about combat had led him to use gambling as an escape in college. When the war in Afghanistan began, the nightmares and flashbacks of combat returned, as did anxiety and depression. Fred's problem gambling was then linked to post-traumatic stress disorder.

Later, Fred revealed a history of sexual abuse by a relative, who had introduced him to gambling. Now the picture changed again. The gambling, Renner concluded, was a coping device for dealing with the abuse, and helped Fred identify with the aggressor.

This example, Renner said, is proof that diagnosing problem gambling alone isn't the answer. Clinicians must still be able to sort out the web of related problems a patient might have, and plan treatment accordingly.

Those people with stand-alone problem gambling often never seek treatment, Renner said, and the problem usually eases without any intervention. And with the limited resources available for treating problem gambling, "we couldn't afford to treat all these people even if we wanted to."

But, obviously, the disease is harmful. A solution for controlling the problem, Renner said, is a program of education in high school and college, structured along the same lines as substance abuse programs. To be effective, Renner believes a gambling education can't focus on prohibition, but on how to gamble without getting into trouble.

"General prevention activities are cost-effective, and don't get you in the area of trying to treat every person," Renner said.

Related Links
National Center for Responsible Gaming 2nd Annual Conference on Gambling and Addiction