​  Behavioral Health

Gambling disorder

Diagnosing the “hidden addiction”

By Bill Stein and Randy Stinchfield, PhD, LP

hen you meet with a patient, the topic of addiction is not typically top-of-mind. And on the rare occasions when you suspect that an addiction is playing a role in your patient’s condition, you’re probably thinking about drug or alcohol addiction. However, other, less obvious addictions can be causing distress and poor health. One such lesser-known addiction is gambling disorder.

Sometimes referred to as the “hidden addiction” because it has no visible symptoms, such as those associated with drug or substance use disorder, it’s estimated that two million Americans suffer from gambling disorder. In Minnesota, approximately one to two percent of the population meets the diagnostic criteria for gambling disorder while another one to two percent experience problems related to their gambling behaviors.

Gambling disorder as defined in DSM-5

According to DSM-5 diagnostic criteria, gambling disorder is defined as persistent and recurrent problematic gambling behavior leading to clinically significant impairment or distress. An individual with gambling disorder exhibits four or more of the following behaviors over the course of a 12-month period:

• The need to gamble with increasing amounts of money to achieve the desired excitement
• Restlessness or irritability when attempting to cut down or stop gambling
• Repeated, unsuccessful efforts to control, cut back, or stop gambling
• Preoccupation with gambling
• Frequent gambling when feeling distressed
• Repeat gambling after losing money in an attempt to get even (“chasing” losses)
• Lying to conceal the extent of involvement with gambling
• Jeopardizing or losing a significant relationship, job, or educational or career opportunity because of gambling
• Relying on others to provide money to relieve desperate financial situations caused by gambling

Gambling behavior that is not associated with a manic episode can be classified as episodic, persistent, or in remission. The disorder can be further specified as mild (when 4–5 criteria are met), moderate (when 6–7 criteria are met), or severe (when 8–9 criteria are met).

​Anyone is at risk for developing a gambling problem.

Consequences of gambling disorder

Gambling disorder can result in social, emotional, and financial devastation, including loss of relationships, residence, emotional or physical health, and career or educational opportunities.

Some individuals with a gambling disorder commit illegal acts to support their gambling or to pay off gambling-related debts. Some ultimately go to prison or are admitted to psychiatric institutions.

Sadly, it is not uncommon to hear about compulsive gamblers who attempt or commit suicide. In fact, studies have shown that the rate of suicide is higher among those with gambling addiction than for many other addictions.

Populations at risk

Anyone is at risk for developing a gambling problem, regardless of sex, age, religion, race, or socio-economic background. Individuals can develop a gambling addiction from participating in any type of gambling pursuit, whether traditional gambling activities such as horse racing, slots, lottery, pull-tabs, cards, and bingo or newer games and venues available online.

However, while anyone can become addicted to gambling, there are risk factors that can increase the chance of developing this disorder. Some of these risk factors are detailed below:

Age. Individuals under the age of 35 may be at higher risk of developing a gambling addiction. This is because younger people are more likely to act impulsively than older adults. The brains of young adults are less developed, leaving them predisposed to risk behavior. Younger people are also more likely to participate in the growing trend of online platforms and other venues.

A November 2018 National Gambling Attitudes and Experiences (NGAGE) study by the National Council on Problem Gambling found that admitted sports bettors and young men showed an elevated risk of gambling addiction compared to their peers who did not bet on sports. While this may not be a surprising find, it confirms that young men need more education about risk taking and that they be monitored for gambling disorder if they are exhibiting other mental health or addiction symptoms.

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Senior gamblers are also more likely to be vulnerable to gambling addiction. They may gamble as a way to relieve loneliness, depression, or anxiety. Dementia and other types of cognitive impairment may impact the ability of older seniors to make appropriate decisions when gambling. In fact, patients with Parkinson’s disease have been known to show problem gambling behavior due to the class of drugs called dopamine agonists prescribed for treatment.

Mental health issues. Individuals who suffer from depression, bipolar disorder, anxiety disorder, or attention-deficit disorder are at higher risk for gambling addiction. People with bipolar disorder often engage in high-risk behaviors during manic or hypomanic episodes. Patients with depression may gamble as a form of distraction to escape painful emotions.

Existence of other addictions. Comorbidity with other addictions is common. “Addiction switching” is also not unusual among those in recovery from alcohol or drugs. In these cases, gambling can become the next addiction.

The use of drugs may also play a role in addiction. For example, some gamblers use meth to keep them awake for hours. And the recent legalization of recreational cannabis in several states has created concern with how it may be connected to gambling disorder. However, it’s too soon to draw conclusions.

Those serving in the military. Several risk factors associated with members of the military may make them more vulnerable to develop gambling disorder. Some of these include a predisposition to take risk and act impulsively, involvement in extremely stressful situations that create anxiety, experiencing grief and loss, and substance use and abuse.

Warning signs

The vast majority of those who gamble do so responsibly. However, a small percentage develop problem behavior. While gambling addiction can be difficulty to identify, there are several warning signs physicians can watch for, including:

• Increased frequency of gambling activity
• Increased amount of money gambled
• Gambling for longer periods of time than originally planned
• Bragging about wins, but not talking about losses
• Pressuring others for money as financial problems arise
• Lying about how money is spent
• Escaping to other excesses
• Denying there is a problem

A misunderstood addiction

Gambling addiction is not well understood by the general public and in some areas within the medical community. Many people think it’s an issue of willpower or a moral weakness. However, gambling addiction is a disease, and while nothing is ingested into the body when one gambles, there are still measurable changes in activity in the ventral striatum. In fact, images of brain activity in people with gambling disorder and substance addictions show similar activity in the reward centers.

​Gambling addiction is a disease.

Because gambling disorder is not well understood, there remains a significant stigma attached to the condition, which serves as an unnecessary obstacle to getting treatment. Patients are reluctant to self-report the condition and they may not understand that treatment is available and that it can help.

Gambling trends

Gambling—and gaming activities that have the essential characteristics of gambling—are evolving. Whereas gambling was once limited to traditional forms, newer forms have emerged as technology has become more sophisticated.

Social casinos, which are apps or websites where people play popular casino games with friends, are experiencing rapid growth. Experts are concerned that these games can trigger desires to gamble with real money for vulnerable problem gamblers.

In some social casino games, players compete for virtual prizes, often using real money to make purchases of “loot boxes,” which may or may not have the “prize” they are seeking to help them advance in the game. Players don’t know the odds of receiving these prizes when they make a purchase, thus meeting the traditional definition of gambling: wagering money or something of value on an event with an uncertain outcome, with the primary intent of winning something of value.

The growth in video gaming is another trend. Compulsive use of video games, an impulse control disorder that’s similar to gambling disorder, can occur for those susceptible to addiction. Currently, these games are not regulated, making those who may be vulnerable to addiction even greater targets for gambling disorder.

We are also watching carefully to see if addiction to sports gambling increases as more states legalize this activity. Although it’s uncertain if Minnesota will legalize sports gambling, individuals seeking to gamble on sports have many other options, including online, that don’t involve the state.

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Resources

If you suspect your patient may have a gambling problem, there are several things you can do. The first is to administer a simple two-question gambling screen that will provide a quick read on whether a gambling problem might exist. The two questions (“Have you ever had to lie to people important to you about how much you gambled?” and “Have you ever felt the need to bet more and more money?”) trigger links to online resources. Look for it at www.NorthstarProblemGambling.org/quiz-results/. General information about problem gambling in Minnesota can be found at www.NorthstarProblemGambling.org.

This site also features a list of state-certified problem gambling treatment providers who  specialize in both assessment and treatment for gambling addiction. In Minnesota, treatment for gambling addiction is available at no charge, making it easy for anyone to obtain access. Many patients are still reluctant to enter treatment due to perceived stigma, while others fail to seek help until they have exhausted financial resources.

Treatment programs range from traditional one-to-one counseling to intense week-long programming to residential treatment. It’s important to understand that gambling treatment works and has turned lives around for many Minnesotans.

Addressing the problem

Ensuring that individuals with gambling disorder are properly diagnosed and treated is a responsibility that falls to a lot of people. It includes a variety of efforts, including those in education and public policy, prevention, consumer protection, research, and, of course, treatment.

Those working in health care, including physicians, have an important role to play. By asking the right questions, looking beyond the surface, and simply being aware that gambling disorder is real, you have the opportunity to spot a problem gambler. If you’re able to direct them to the help they need, you can make a significant impact on their lives.

Bill Stein is communications manager for Northstar Problem Gambling Alliance (NPGA), Minnesota’s state affiliate to the National Council on Problem Gambling.

Randy Stinchfield, PhD, LP, is a clinical psychologist, retired from the Department of Psychiatry at the University of Minnesota, and a member of the NPGA Board of Directors. Dr. Stinchfield conducted some of the earliest and most significant research on youth gambling, including the first youth gambling survey in the United States.