Conceptualizing and Classifying PG: past, present and future. Peter Ferentzy & Nigel E. Turner Centre for Addiction and Mental Health

Transcription

1 Conceptualizing and Classifying PG: past, present and future Peter Ferentzy & Nigel E. Turner Centre for Addiction and Mental Health

2 Outline Trace the history of the conceptualization of disordered gambling going back to eighteenth century; Discuss the relationship between OCD, ICD and SUD from a historical perspective. Discuss how this all bears upon PG Discuss the concept of metaphors and examine the metaphors on which theories are built Discuss current difficulties and future directions.

3 Pathological gambling An addiction-like behaviour; similar to alcoholism. An impulse control disorder according to DSM-IV-TR. Main Symptom: Excessive gambling Associated with depression, impulsivity, anxiety, suicide, crime, substance abuse, family violence, etc., etc., etc.

4 Prevalence of problems 70% to 80% of people (including youths) report gambling in past year. Most gamblers do not have a gambling problem. 1% adults have severe gambling problems (pathological gamblers). Another 2% to 3% have moderate problems. 2/3 Males Disordered gambling accounts for a large percent of casino revenue. Similarly a minority of hard drinkers might consume 25-30% of alcohol products. Source: Wiebe, Mun & Kauffman, 2006; Turner et al., 2005; Room et al., 1998

5 DSM-IV-TR Criteria (paraphrased) 1. Preoccupied with gambling 2. Needs to gamble with increasing amounts of money in order to achieve the level of excitement you want. 3. Made efforts to control gambling, that have been unsuccessful.

6 DSM-IV-TR Criteria continued 4. Restless or irritable when attempting to cut down or stop gambling 5. Gamble as a way to escape from problems, or to relieve feelings of helplessness, or guilt, or anxiety or depression. 6. After losing money gambling, returns another day to get even; chasing losses 7. Lies to family members, or therapist, or others about the extent of involvement with gambling

7 DSM-IV-TR Criteria continued 8. Committed illegal acts such as forgery, fraud, theft or other embezzlement in order to finance gambling. 9. Jeopardised or lost a significant relationship, job, educational or career opportunity because of gambling. 10.Relies on others to provide money when in a desperate financial situation caused by gambling.

8 DSM-IV-TR summary 5 or more symptoms. Not accounted for by mania. Does not count for professional gamblers. Accurate description of the symptoms. Does not consider the causes (a-theoretical).

9 History, myths, stories, art, and sermons In the Mahabharata, Yudhishthira gambles away his kingdom, freedom, and wife. Hades ended up the master of the underworld from losing a gambling game In Roman law the term addictus referred to debt slaves, often the result of gambling. When Caligula lost at gambling, he d find a noble, arrest him, confiscate his wealth

10 History, myths, stories, art, and sermons Carmina Burana from the 13 th century describes the wheel of fortune (fate). an early version of the gamblers fallacy with those on high are dragged down into the mud and vice versa. The Tavern describes some people gambling away even their clothing

11 History, myths, stories, art, and sermons The Pardoner s Tale (Chaucer, 14 th century, Canterbury Tales) describes how excessive drinking, gambling and swearing are certain paths to death. Greed drives the characters to kill each other

12 History, myths, stories, art, and sermons The Rakes Progress (1735), a series of paintings by William Hogarth, depicts the decline and fall of Tom Rakewell. Wastes all his money on luxuries, prostitution and gambling. Ends up ultimately Bedlam.

13 History, myths, stories, art, and sermons Bernhard has shown that each symptom of PG can be found in old sermons In Jewish law habitual dice-players were not permitted to be magistrates or witnesses in courts

14 History, myths, stories, art, and sermons Stories illustrate an awareness of PG Do not differentiate problem and nonproblem gambling. Nor do they differentiate between pathological and predatory gamblers. Are moralistic rather than scientific Above all: being out of control, though understood to a point, was not singled out like it is today.

15 Older concepts Traditionally, all sins drunkenness, fornication, gambling were seen in a very similar way. Struggles with temptation were well known. Like today (since circa 1980) assorted addictions were viewed as a whole. E.g., they were progressive Abstinence was not the obvious answer, for example drunkards should drink moderately, in correct proportion.

16 Key Event: Discovery of Probability Combinatory math was first discovered in India over 2000 years ago Rediscovered in Europe by Cardano ( ) Developed further by Pascal ( ). Gets the credit. Lotto 3/6 20 combos Lotto 6/49-14 million Pascal s Triangle

17 Key Event: Discovery of Probability Pascal made practical use out of combinatory math. Today it s the basis of probability theory. Lead to more complex games. Better control over the house edge. The flourishing of casino table games. Pascal

18 History: 18 th century Disease = fluids out of balance No such thing as an specific disease The classification of diseases nosology started to gain acceptance in 18 th century. The concept of a disease as an entity, was just starting to emerge With industrial revolution, being out of control became a bigger issue than before

19 History: 18 th century Discovery of Gin lead to more alcoholism and the discovery of alcohol addiction first in Britain. Prompted a moral panic about the Gin craze. Similarly, the discovery of probability lead to more addictive gambling and ultimately to the discovery of PG

20 History: Turn of the 19 th century Benjamin Rush was arguably the first to medicalize chronic drunkenness in late 18 th century US Thomas Trotter early 19 th Century Britain was not too far Behind. Striking: each thinker worked Independently addiction concepts were a sign of the times Benjamin Rush

21 History: 19 th century Discovery of addiction New capitalist/industrialized world needed a different kind of citizen (and worker) Middle class industrialists pushed a moral agenda that disapproved of the excess of both nobles and the poor Needed sober workers

22 History: 19 th century Monomania (Esquirol ) first serious disease of the will Set the precedents for OCD, ICD and addiction concepts. Partial insanity insanity with insight Normal except for one problem. Before, insanity was viewed as stupidity new Brilliant Madmen Esquirol Captain Ahab & the White Whale

23 History: 19 th century Prichard (1822, 1835) moral insanity Moral had many meanings: e.g., emotional, affective but 19 th century psychiatric practice was often called moral therapy. Moral insanity, like monomania, was easy to dismiss as a catchall like ICD & addiction today.

24 History: early 20 th century Advances in chemistry had produced more addictive drugs such as Heroin & Cocaine. Moral panic over drugs. A different social setting -- temperance movement finally acquired political power. Enacted the prohibition of drugs ( ), gambling (1902 and on), and last alcohol (1919).

25 History: early 20 th century The criminalization of addictions Addict perceived as psychopath no moral center Racial and other issues involved in this transformation the junkie model Aimed at SUD, but affected how all out-ofcontrol behaviors were perceived Adopted the idea that hitting bottom was the solution

26 History: early 20 th century Psychoanalysis Freud, Simmel (masturbation, anality, masochism) Bergler - the gambler is masochist who wants to lose Rejection of reality principle Bergler

27 History: 1950 to 1980 The discovery of intermittent reinforcement by B.F. Skinner The emergence of behavioral therapy Does not supposed a pre-existing disorder or psychopathy Late 1950 s cognitive revolution that views thoughts as scientific data The emergence cognitive psychotherapy Skinner

28 History: 1980 to PG is recognized as a mental disorder and included in DSM-III. Atlantic city gambling initiates the new age of legal gambling. By early 1980s lotteries become common place. Desperate governments needed cash without raising taxes. Electronic gambling machines were developed. Early 1990s the beginnings of wide open gambling.

29 History: 1980 to 2010 Major challenge to standard (AA/GA) disease concept: Public Health Model. Origins: based on epidemiological disease control host, agent, vector -- applied to insanity and other issues. Paul Lemkau mid-twentieth century psychiatrist headed a Dept. of Mental Hygiene.

30 History: 1980 to 2010 Challenges to Disease model Abstinence not only solution There is a continuum of harm Clinical vs. sociological perspectives Hitting bottom vs. readiness to change Not all addicts fit the same mold Disease model vs. harm reduction Often, this approach sidelines involvement of family & friends even though such support is often beneficial

31 Metaphor or literal? Is problem gambling literally a disease or is it a metaphor? Does it matter? Metaphors, analogies, & theoretical models are simply how thought works. Scientific theories are extended metaphors (e.g., the fabric of space, string theory, waves of light). Calling something a metaphor does not minimize its importance.

32 Metaphor or literal? Two major metaphors haunt our field Disease model hard pathological constructs. Public health model infection metaphor. Both are disease/medical conceptions What do these models reveal? And what do they hide?

33 Metaphor: Chronic disease model Source: Allergy, Diabetes, morality & religion. Proponents: AA, GA, Medical research. Popular in US where the Voluntary & free mutual aid fits in well with US health care. Embraced by popular culture since 1980s. Yet challenges emerged (e.g., Stanton Peele).

34 Metaphor: Chronic disease model Reveals/emphasizes Patient not blamed for illness Individual responsibility for recovery Avoidance abstinence -- is necessary Chronic & Lifelong Lifelong avoidance is the only solution View problem and non-problem gamblers as categorically different

35 Metaphor: Chronic disease model Hides Addiction viewed as primary, so other causes are ignored or downplayed Actual recovery is viewed as not possible Emphasizes life-long maintenance Ignores role of the games Rejects the potential for controlled or less harmful drinking or gambling

36 Public health model Source: Infectious disease; Toxin How the infection spreads through society Proponents: Epidemiology and disease control Also has links to moral ideas of contagion

37 Public health model Reveals: Importance of involvement of society Toxic or infectious aspects of exposure Exposure puts a person at risk Emphasizes prevention (hygiene) Emphasizes societal responsibility Anyone can catch the disease (not categorical) Features of the games may make some more toxic than others

38 Public health model Hides: Does not account for non-problem gamblers Assumes that gambling harms recreational gamblers Confuses current play with being at risk

39 Towards a Hybrid Model Some approaches to addiction are actually hybrids of these two Sometimes its confusing because both are disease based Science is often best served by using multiple competing metaphors (e.g., wave vs. particles models of light) Integration its a good thing

40 History: 2010 and beyond!!! In the past for SUD, dependence was invoked because addiction was thought to stigmatize not for scientific reasons. For PG, ICD was invoked partly because there was nowhere else to put it addiction was not a recognized term, and dependence was a poor fit for PG

41 Looking forward to DSM-V DSM-V is coming responding to criticism many (including us) have been making. Reclassification of pathological gambling (PG) from impulse control disorder (ICD) to Addiction and Related Disorders. Re-emergence of addiction as the operative term.

42 Issues in Transition ICD is a wastebasket category All addictions are disorders of impulse control but are acquired disorders PG and SUD are kindred affliction similar etiologies, natural histories, risk factors and symptoms Most PG inquiries rely on SUD concepts good fit with addiction.

43 Discuss current difficulties and future directions. Is abstinence the only solution? Viability of hard pathological constructs Harm reduction or hitting bottom? Is treatment the key solution, or should we focus on socioeconomics (housing, social support)? Is PG a unified disorder? How to classify?

44 Hitting bottom? With no other medical condition (save for those designated as addictions) do treatment professionals suggest (or insist!) that the disease must be allowed to get worse (and cause sufficient harm) in order to render treatment more effective.

45 Future Directions Unification of wave & particle theory offers example of how disease & PH models could be unified Full circle: all behaviors can be addictive in 1750 and a priest could have told you that.