1) Problem Gambling

clinical terminology and history (3)

• pathological gambling was first introduced in DSM- III as an impulse control disorder

• in DSM 5 renamed to gambling disorder and moved to substance related and addictive disorders

• problem gambling is a more general term with no precise criteria

• gaming disorder new in ICD- 11

gambling disorder in DSM 5 (12)

• at least 4 of the following symptoms

• pre occupied with gambling

• needs to gamble with increasing amounts, tolerance

• repeated attempts to reduce or quit gaming

• restless or irritable when attempting to stop gambling, withdrawal

• gambles as a means of escape or alleviate low mood

• frequently returns to get even, loss chasing

• lies to conceal involvement

• jeopardised/ los relationship or job due to gambling

• forced to borrow money due to gambling debt

• dropped illegal acts to support gambling in DSM 5

• not better explained by manic episode

withdrawal to gambling (2)

• found that psychological withdrawal symptoms in gambling were common to other substance use

• 2/3 gamblers report more than 1 somatic withdrawal symptom

loss chasing (4)

• often regarded as the hallmark of when recreational gambling becomes problematic

• a sociological study describes a spiral of intensifying gambling until all financial options are exhausted

• chasing is a complex behaviour where gamblers can chase between both sessions, going back sooner and within sessions, increasing their bets

• gamblers also chase following wins

individual sensitivity of the diagnosis criteria (3)

• loss chasing is too sensitive where too many non problem gamblers also endorse it

• illegal acts is too insensitive where it is only endorsed by gamblers who already meet the diagnosis anyways so it doesn’t provide any leverage to the diagnosis

• withdrawal symptoms was just right where it increases with severity of gambling disorder

evidence for reclassification (5)

• symptom hallmarks (withdrawal, tolerance)

• co morbidities

• shared heritability/ genetics

• neuroimaging/ neurocognitive similarities

• effective treatments

what does a DSM diagnosis of problem gambling require

involves a face to face interview with a clinician as it requires their judgement to decide if they meet the criteria

what else do we also need to assess gambling problems (3)

• short self report instruments

• south oaks gambling screen

• problem gambling severity index

south oaks gambling screen (4)

• widely used and is translated into different languages

• based on DSM III

• probable pathological gambling score is more than 5

• binary ratings (yes/no) asking lifetime gambling

problem gambling severity index (3)

• current gold standard measure

• pre DSM 5

• problem gambling is a score between 20- 27

2014 prevalence survey (3)

• PGSI: 0 is non problem, 8+ likely problem gambling

• 3.3% moderate or likely problem gambling

• 3.7% report online gambling

2024 online survey (2)

• 27% reported online gambling, increased x9

• 15% reported moderate risk of likely gambling problems, major increase

2026 BC prevalence survey (5)

• legal survey commissioned by BC independent gambling control office

• around 4000 online and 600 telephone survey

• 19% report moderate or high risk problem gambling

• from 2020 to 2026, there is a two times increase in online gambling

• more gambling now done on mobile device rather than on laptop

but what matters in how data is collected

the survey mode matters

why does survey mode matters (5)

• survey done on phone show 3% of moderate to high risk

• but survey done on web show 19% of moderate to high risk

• question of what the true value is, 3% or 19%

• on the phone, people may be more prone to social desirability, don’t want to be seen as a gambler so they underestimate

• but online may overestimate as people who are part of online panel may do everything online so online gambling is a high risk format

how are the prevalence rates changing over time (2)

• one argument is the total consumption model where as gambling increases at a population level, becomes more accessible, rates of problem gambling will rise (broadly agreed)

• another argument is the adaption hypothesis where PG rates appears to drop in canada in 1990s- early 200s despite increased availability and society adapts to new technologies

demographic predictors of problem gambling is increased among (6)

• males/ men (unsure if it is sex or gender)

• younger age, ppl in 20s

• lower socioeconomic status

• racialised groups including indigenous peoples, asian community in BC, migrant communities

• people experiencing other mental health problems

• but these are all correlations

household survey done in the US (6)

• conducted DSM survey and asked when they first gambled

• 78% report lifetime gambling

• 2.3% report any lifetime gambling problems

• those with gambling problems start gambling at an earlier age

• earlier age of onset gambling is a correlate of future gambling problem

mental health problems and problem gambling (same survey done in the US) (4)

• 0.6% have pathological gambling

• among people diagnosed with pathological gambling, 96% report at least one co- existing disorder

• common for co- morbidity with mood disorder, anxiety disorder, impulse control disorder and substance use disorder

• mood and anxiety disorder often occur before gambling problem

what can gambling disorder and drug addictions be regarded as

developmental disorders

psychodynamic theory (4)

• Bergler talked about problem gambling as masochism, the unconscious desire to lose

• gambler is driven by underlying motive to punish themselves, opposes the idea that humans are motivated by reward and avoid punishment

• driven by denial or rebellion against parental authority

• recognises that problem gambling is not necessarily about winning money

pathways model of problem gambling (3)

• pathway 1: behaviourally conditioned problem gambling

• pathway 2: emotionally vulnerable gambler

• pathway 3: antisocial impulsive gambler

• 3 pathways are not independent route but every person with a gambling addiction go through the basic model

process of the basic pathways model (6)

• at the start of the process there is an ecological factor, have to have the availability and accessibility of gambling

• then there is conditioning or experience where there is excitement, arousal or irrational beliefs

• depending on their experience, they keep going back to it but it is still recreational

• but with repeated use, there is habit formation and tolerance starts to build

• as it becomes repeated, they will start losing and chasing will occur where they start recover losses

• symptoms of problem gambling emerge

pathway 1 (5)

• termed the behaviourally conditioned problem gambling

• subtype of gambler for whom this sequence is all that happens

• characterised by an absence of any apparent vulnerabilities

• people in pathway 1 may exhibit depression and anxiety but these symptoms would be in response to the financial costs of gambling rather than preceding their gambling

• entry into this subgroup may occur at any age, precipitated by exposure to gambling by chance

evidence for pathway 1 (2)

• anecdotally, many people seeking help for gambling problems report early big wins in their first experiences with gambling

• early big wins could be a powerful one trial conditioning event and/ or could skew expected value calculations

pathway 2

• termed the emotionally vulnerable gambler

• negative emotionality that predisposes some people to gambling engagement and persistence

• includes depression, anxiety, childhood trauma, poor coping, life stresses

• people in pathway 2 use gambling for escape or to cope with these negative emotions, negative reinforcement

• thought to intersect between ecological factors and conditioning but unsure

evidence for pathway 2 (3)

• 129 casino visitors played 300 spins on a fake slot machines then answered questions about their level of flow

• flow is a deep state of absorption

• gamblers with higher depression scores reported higher flow scores

pathway 3 (4)

• termed the antisocial impulsive gambler

• individuals in pathway 3 have a background history of impulsivity, ADHD, anti-sociality and/ or difficulties with executive function

• these individuals engage in a wide array of high risk behaviours besides gambling, e.g. substance use, suicidality, criminal acts

• their gambling often commences at an early age, rapidly escalates in intensity and may occur in binge episodes

are pathway 2 and 3 together

no they are independent routes

why did the pathways model take so long (3)

• measuring all components of the original model was tricky

• they spent years developing the gambling pathways questionnaire in order to do the study

• statistic for testing the testing type theories are complex and require large samples

what analysis did they use (5)

• latent class analysis

• 3 cluster model showed best fit compared to 2 or 4 clusters

• 44% in pathway 1

• 40% in pathway 2

• 16% in pathway 3