Gambling Addiction: Etiology, Treatment and Prevention

Transcription

1 Gambling Addiction: Etiology, Treatment and Prevention 6 CE Hours By: Deborah Converse, MA, NBCT Learning objectives Identify and explain five factors that determine classification of gambling addiction, according to the revised American Psychiatric Association DSM-5 criteria. Describe the prevalence of gambling addiction across age, gender, ethnic and socioeconomic status in the United States. List six signs and symptoms of a gambling addiction. Explain two forms of treatment for gambling addiction. Describe and give examples of three types of disordered thought patterns that are found among addicted gamblers. Identify and discuss four risk factors that may lead to gambling addiction. Describe four negative consequences that affect the addicted gambler s family and friends. Introduction An estimated $1 trillion is spent on gambling in the United States annually, according to one national study (Rose, 2010). Harmful effects of compulsive gambling on the individual include financial problems ranging from high debt, bankruptcy, poverty, legal problems, theft, prostitution, and attempting or completing suicide (National Council on Problem Gambling, 2011). Gambling addiction can have a multitude of negative effects on the family. Statistics indicate that families of compulsive gamblers are more likely to experience domestic violence, higher divorce rates and child abuse. Children of problem gamblers are at a significantly higher risk of suffering from depression, behavior problems and substance abuse (Skolnik, 2011). Gambling addiction is assuming alarming proportions, especially with the widespread popularity of online gambling. Problem gambling manifests itself in the form of various dysfunctional behaviors if not treated correctly. Gambling is the nation s foremost silent addiction. As one college counselor pointed out, pathological gamblers don t have track marks on their arms, their speech is not slurred and they are not staggering down the street. But on the inside, the emotional churn going on is equally as great as the substance abuser (Henry, 2003). Gambling addiction is a mental health problem that is one of many impulse-control problems. Types of gambling are as varied as the games available. Betting on sports, dog and horse races, lotto tickets, poker, slot machines, bingo, video lottery, power ball, blackjack or roulette are only a few of the activities in which compulsive gamblers engage. The venue of choice for individuals with gambling addiction varies as well. While many prefer gambling in a casino, the rate of Internet gambling addiction continues to increase. Gambling addiction is also called compulsive gambling or pathological gambling. Historical perspectives America has always been a nation of gamblers, from the colonial era horse-race bettors of the 19 th century and Mississippi riverboat card sharks to the millions who now annually gamble on the Las Vegas strip. Since the 1970s, legalized gambling has taken hold of the country as never before. Gambling has rooted itself in scores of cities and small towns in every region of the country, resulting in direct fallout from gambling addiction (Skolnik, 2011). Native American tribes have renegotiated compacts, and more than two dozen states allow casinos. State governments have joined, bringing private casinos, card rooms, video poker and slot machines by the tens of thousands into their jurisdictions. The national poker craze has led to the game s increased exposure on television. During one week in May 2010, 58 episodes of 14 different poker tournaments ran on eight different networks. This is in contrast to the mid-1990s, when a single network broadcast a one-hour-long poker show. (Rose 2010). Internet gambling is still on the rise, although Congress has deemed it quasi-illegal. Forty-three states, the District of Columbia, Puerto Rico and the U.S. Virgin Islands sponsor heavily promoted lotteries (Rose, 2010). According to experts, gambling becomes a problem when it disrupts or damages personal lives or careers. Problem gamblers often devolve into pathological gamblers when gamblers lose control over their betting, when they gamble more often and for larger amounts and continue to gamble despite adverse consequences (APA, 2010). Negative consequences resulting from gambling addiction not only affect family and friends, but also affect the workplace throughout a community. They run the gamut from increased absences, decreased work productivity, increased physical and mental health problems and a rise in divorce rates. Studies have also shown that pathological gambling has caused an increase in filings and claims for unemployment, welfare benefits and home foreclosures (Skolnik, 2011). Further research conducted over the last couple of decades concludes that unremitting expansion of legalized gambling has helped turn great numbers of Americans into problem and pathological gamblers. A comprehensive analysis of 120 gambling prevalence research studies that looked at gambling behavior in the United States and Canada between 1974 and 1997 concluded there was a dramatic rise in the adult problem and pathological gambling rates. Over that time, the study showed a sharp increase in the percentage of lifetime problem or pathological gamblers to nearly 7 percent of the population (Shaffer et al., 1997). SocialWork.EliteCME.com Page 1

2 In 2007, Americans lost more than $92 billion on gambling, about nine times what they lost in That is almost 10 times what moviegoers in the United States spent on tickets during the same year (Rose, 2010). Thirty-five years ago, casinos became legal in Nevada. As of 2010, a variety of gambling activities have been legalized everywhere in the United States except Utah and Hawaii. The majority of Americans now live within a three- to four-hour drive of a casino. Because of this growth, millions of Americans have for the first time been directly exposed to gambling (Rose, 2010). The result is a significant increase in the number of addicted gamblers around the country. There is a fairly obvious proposition at work: In communities where legalized gambling has been introduced, new problem and pathological gamblers have developed (Volberg, 2003). As gambling became more socially accepted and accessible during the past two decades, adults in the general population have started to gamble in increased numbers, the Volberg study concluded. Other prominent studies back up this notion. The gambling behavior survey carried out by the National Gambling Impact Study Commission determined those who live within 50 miles of a casino were more than twice as likely to develop significant problems as those who live between 50 and 250 miles from the establishment. Within the 50-mile zone, the pathological gambling rate was 2.1 percent; outside of that zone it was 0.9 percent (Welte, et al., 2003). The conclusion was that proximity to gambling venues spurs higher problem gambling rates and has been supported repeatedly by other independent studies. A review of the problem of pathological gambling in Nevada, which has the most extensive legal gambling market in the United States, will be reviewed in a later section. Definition Gambling addiction is gambling behavior that causes disruption in any major area of life, psychological, physical, social or vocational. The term gambling addiction includes the condition known as pathological or compulsive gambling (APA, 2010). A progressive gambling addiction is characterized by: Increasing preoccupation with gambling. A need to bet more money frequently. Restlessness or irritability when attempting to stop. Chasing losses. Loss of control manifested by continuation of the gambling behavior in spite of mounting serious, negative consequences. There is a certain shame attached to confessing a gambling addiction in our culture, in some cases even more so than being an alcoholic or cocaine addict. Many still believe that people gamble excessively because of a lack of willpower or because they re simply immoral. These antiquated beliefs are beginning to fade as doctors, scientists and researchers are increasingly concluding that pathological gambling is a behavioral addiction that affects the brain in much the same way as substance dependencies. Research suggests that about one in two problem gamblers suffer other types of addictions (Goudriaan et al., 2006). Beginning in 1980, modern psychiatry redefined gambling addiction. The publication of the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III) marked the first time pathological gambling was included (APA, 2010). This resulted in a major shift in how gambling addiction was seen by those in a wide range of fields, from doctors to judges, social workers and religious leaders. The condition began to be accepted by many as a medical disorder, as opposed to moral failing or sinful transgressions that stem from personal weakness. The DSM listing changed gambling addictions from vice to disease. As the DSM-III and DSM-IV were released between 1987 and 2000, the definition of pathological gambling continued to evolve. It remained classified as an impulse control disorder, as such conditions of pyromania or kleptomania, rather than directly defined as an addiction (APA, 2010). Under the most recent definition, pathological gambling is described as persistent and recurrent maladaptive gambling behavior indicated by five or more of 10 symptoms. As the perception of problem gambling changed dramatically in 1980, so did the perception of the disorder. In February 2010, a DSM-5 workgroup recommended that a new category of behavioral addictions be formed for the first time and suggested that pathological gambling be included as the sole disorder on the list. In psychiatry, only disorders involving substances such as alcohol and drugs have been considered full-fledged addictions. This proposed change would put gambling addiction on par with them. Final publication of the DSM-5 has been released as of May The DMS-V workgroup has proposed that gambling addiction be reclassified from impulse control disorder not elsewhere classified to substance-related disorders, which will be renamed addiction and related disorders as described below: Gambling disorder A. Persistent and recurrent maladaptive gambling behavior as indicated by five or more of the following: 1. Is preoccupied with gambling, reliving past gambling experiences, handicapping or planning the next venture, thinking of ways to get money to gamble. 2. Needs to gamble with increasing amounts of money in order to achieve the desired excitement. 3. Has repeated unsuccessful efforts to control, cut back or stop gambling. 4. Is restless or irritable when attempting to cut down or stop gambling. 5. Gambles as a way of escaping from problems or relieving negative moods, such as feelings of helplessness, guilt, anxiety or depression. 6. After losing money gambling, returns for another day to get even ( chasing one s losses). 7. Lies to family members, therapists or others to hide the extent of involvement with gambling. 8. Has jeopardized or lost a significant relationship, job, educational or career opportunity because of gambling. 9. Relies on others to provide money to relieve a desperate financial situation caused by gambling B. The gambling behavior is not better accounted for by a manic episode Gambling severity Dr. Iman Parhami, M.D. (2010), summarized an article submitted by Rosenthat et al. to the Journal of Addiction in March He noted that reduction of symptoms associated with gambling behavior and pathological gambling might not be meaningful because a single Page 2 act, event or slip-up could be catastrophic. Absence or reduction of gambling behavior may not mean improvement per se, but may be due to extrinsic factors, such as lack of funds, incarceration or social ultimatums. SocialWork.EliteCME.com

3 A subjective method to assess severity may be based on recognizing the central component for addictive and self-distracted behaviors, which Parhami and Rosenthal believe to be the progressive loss of control. Progressive loss of control may be the most meaningful classification for severity and pathological gambling, but might be the most difficult to determine because it requires following the gambler for a period of time. Clinicians have previously described this process as a three- to fourstage progression of losing control. These models have been modified into a new triangular model with four phases. A triangular model is used because gamblers can shift back and forth to any of the other three phases at any time, as described below (Rosenthal, et al, 2010): 1. In the first phase, ego-systonic, many gamblers plateau and reduce and control behavior or periodically get in trouble. There are big wins or fantasies of success with enhanced self-esteem. Gambling is not to solve problems in this phase. Some gamblers value the avoidance of feelings and the distracting aspect of gambling, and many emphasize how alive and special they feel. 2. In the second phase, referred to as out of control, they have a series of losses and discover that losing is intolerable to them. They abandon previous strategies and limits they made for themselves, and take increasingly greater risks in order to win back their losses all at once. There is an urgency to borrow money, lie to conceal what happened, and there is a clear loss of control. They hope to get even to cancel out their feeling of loss and guilt. It is as if they have never gambled, and the thought is two wrongs can make a right. 3. The third phase is ego-dystonic and begins when gamblers realize they will never get even. They stop caring and keep gambling even knowing they will lose. Their sloppy play, even when they have the right horse or the winning hand, serves to guarantee it. They insist that just playing is all that matters, and that it is no longer about winning. They want to feel action or excitement for its own sake. As this phase progresses, there is no longer any rationalization of why they gamble or attempt to undo problems. They just want to lose their money as quickly as possible, not because they are masochistic, but because it is only then that they will be able to stop and sleep. This phase is named the ego-dystonic phase, because the gambling seems to take on a life of its own, and the individual feels driven to do something that no longer makes sense or is in their control. 4. In the fourth phase, which is exhaustion, gambling behavior is halted due to added extrinsic/intrinsic factors such as exhaustion of funds, physical or psychological stress, social ultimatums or incarceration. In this phase, the gambler does not stop having urges or does not stop enjoying the gambling; rather he or she is not able to gamble. This may also explain why some researchers report gamblers stop due to natural causes without treatment. It also might explain why there are a high number of relapses after people seemed cured initially. Time is not relevant for this process because gamblers can stay in phases from minutes to years. For example, with the enhancement in technology and accessibility gamblers can lose their entire savings and max out their credit cards in minutes with online gambling and electronic money transfers. It is important for mental health providers to recognize this model and emphasize therapy as a way to prevent shifting to the severe phases. Because the DSM-5 is a proposed revision and is still under consideration by the APA, it is important to consider information presented by other organizations dedicated to the prevention and treatment of gambling addiction. The National Council of Problem Gambling is the national advocate for programs and services to assist problem gamblers and their families. It represents a cross-section of clinicians, researchers, problem gambling service administrators, the gambling industry and policymakers. Its mission is to increase the public awareness of pathological gambling, ensure the widespread availability of treatment for problem gamblers and their families, and encourage research and programs for prevention and education (NCPG, 2010). As an advocate for problem gamblers, the NCPG does not take a position for or against legalized gambling but concentrates on helping those with a gambling problem. Its 38-year history of independence and neutrality makes NCPG a credible voice on problem gambling issues (Whyte, 2010). Keith S. Whyte, executive director of the National Council on Problem Gambling, submitted the following comments and information to the APA for consideration in April Here are some excerpts from a letter to Dr. David Kupfer, Chair, DSM-5 Task Force, as summarized below: Please accept these comments on the proposed changes to the classification of gambling problems in the DSM-5 on behalf of the Board of Directors of the National Council on Problem Gambling. The Board appreciates the significant work undertaken by American Psychiatric Association to improve the classifications of disorders, including gambling addiction, in DSM-5, and is pleased to provide additional information on four specific issues: 1. The importance of the criterion has committed illegal acts in the diagnosis of pathological gambling. 2. The impact of changing the diagnosis threshold. 3. The need to recognize a broader spectrum of gambling problems by adding a subclinical category of problem gambling analogous to alcohol and substance abuse or developing severity criteria. 4. The need to make provisions for sub-typing of problem and pathological gamblers to recognize different pathways into the disorder. Illegal acts. The NCPG Board questions elimination of the diagnostic criterion has committed illegal acts such as forgery, fraud, theft or embezzlement to finance gambling. The DSM-5 website references only one source for this proposed change (Strong & Kahler, 2007). In population surveys, researchers have found that while illegal acts is the DSM-4 criteria least likely to be endorsed, this item is the most reliable discriminator between individuals who score at the highest level of pathological gambling severity (endorsing 8 to 10 criteria) and those who endorse fewer criteria. Changed diagnostic threshold. Under DS-5, a diagnosis of pathological gambling requires endorsement of five out of 10 criteria (50 percent). Under the new proposal, diagnosis would require endorsement of five out of nine criteria (55.5 percent). In addition, the DSM-5 website lists several published references that support lowering the threshold to 4 out of 10 criteria. There are no references provided in support of increasing the threshold. Subclinical/severity classification. In addition to the need to lower the threshold for a pathological gambling diagnosis, the NCPG believes there is a need for a subclinical category of problem gambling that more accurately reflects the full spectrum of gambling involvement in the population. Internationally, there is a large body of research supporting the view that gambling occurs on a continuum that ranges from no gambling to social gambling to problem gambling to pathological gambling (Gambino, 2009; Korn, Gibbons, & Azmier, 2003); (Ministry of Health, 2008). We believe that it is essential that the different levels of severity of gambling involvement be reflected in the DSM-5 classifications. We recommend severity specifiers be developed for moderate and severe gambling disorders, mirroring the proposed substanceuse disorder criteria. Sub-typing. Finally, while it might not be relevant to the diagnostic criteria, the NCPG Board believes that the evidence DSM-5 information on gambling disorders should reflect sub-types SocialWork.EliteCME.com Page 3

4 of problem and pathological gamblers There is a substantial and growing evidence that disordered gamblers are not a homogeneous group but instead are heterogeneous. There are clearly diverse pathways into problem and pathological gambling as well as the range of motivations for gambling involvement such as the need for action or escape. Sub-typing of problem and pathological gamblers would be particularly helpful in making decisions on medication usage where gambling driven by urges, related to difficulties inhibiting behavior, may respond differently to different pharmacotherapy. If the criteria remain as proposed, the NCPG Board questions the necessity of changing the label from pathological gambling to disordered gambling. However, if proposed severity criteria are adopted or an abuse/dependence distinction is made, the Board supports the label of gambling disorder or gambling abuse and gambling dependence. Thank you for the opportunity to share our views. We would be happy to amplify any of these comments and answer any questions you might have (Whyte, 2010). As noted above, in the current DSM, pathological gambling is defined as a persistent and reoccurring behavior, and repeated studies have shown that gambling addiction is difficult to treat, reflected by the fact that relapse rates for such gamblers are high. Signs and symptoms Gamblers can have a problem without being totally out of control. Unpleasant feelings such as stress, depression, loneliness, fear and anxiety can trigger compulsive gambling or make it worse. After a stressful day at work or after an argument with a spouse or coworker, an evening at the track or the casino can seem like a fun, exciting way to unwind. Here are some myths and facts about gambling addiction and problem gambling often held by gamblers and their family and friends (Department of Mental Health & Addiction Services, 2011): Myth: Someone has to gamble every day to be a problem gambler. Fact: A problem gambler may gamble frequently or infrequently. Gambling becomes a concern if it causes problems in other areas of the person s life. Myth: Problem gambling is not really a problem if the gambler can afford it. Fact: Problems caused by excessive gambling are not just financial. Too much time spent on gambling can lead to relationship breakdown, loss of friendships and problems at work. Myth: Partners of problem gamblers often drive the person to addiction. Fact: Problem gamblers often rationalize their behavior. Blaming others is one way to avoid taking responsibility for their actions, included treatment needed to overcome the problem. Myth: If a problem gambler builds up debt, family and friends should help take care of it. Fact: Quick-fix solutions may appear to be the right thing to do. However, bailing the gambler out of debt may actually make matters worse by enabling problem-gambling behaviors to continue. Families and friends might recognize the following signs as indicators of a gambling problem (MHAS, 2011): The individual becomes increasingly defensive about his or her gambling. The more a problem gambler is in debt, the more the need to defend gambling as a way to get money. The person may become secretive, defensive or even blame other family members for the need to gamble, telling them that it is for the family and that they need to trust that the big win will happen. The individual suddenly become secretive over money and finances. He or she might show a new desire to control household finances, or there might be an increasing lack of money despite the same income and expenses. Savings and assets might mysteriously dwindle, or there may be unexplained loans or cash advances. The individual may become increasingly desperate for money to fund the gambling. Credit card bills may increase, or the gambler may ask friends and family for money. Jewelry or other items easily pawned for money may mysteriously disappear. The following list contains some common signs and symptoms of pathological gambling. The following symptoms are not the result of other mental health problems in the cases of pathological gambling (MHAS, 2011 and Jordan, 2009). The person: Gains a thrill from taking big gambling risks. Takes increasingly bigger gambling risks. Is preoccupied with gambling. Relives past gambling experiences. Gambling as a way to escape problems or feelings of helplessness, guilt or depression. Takes time from work or family life to gamble. Conceals gambling. Feels guilty or remorseful after gambling. Steals to gamble. Has failed efforts to cut back on gambling. Lies to hide gambling. Needs more and more money for gambling to achieve the desired level of gambling enjoyment. Returns to gambling after losing money in an effort to recoup losses. Commits crimes such as embezzlement, fraud or forgery to finance gambling. Depends on others for money to resolve dire financial situations that result from gambling. Risks important relationships, employment or other opportunities because of gambling. Compulsive gambling typically begins in the late teen years, and on rare occasions, gambling becomes a problem with the very first wager. More often, a gambling problem progresses over time, and many people spend years enjoying social gambling without any problems. More frequent gambling or life stresses can turn casual gambling into something much more serious. During periods of stress or depression, the urge to gamble may be especially overpowering. Eventually, a person with a gambling problem becomes completely preoccupied with gambling and getting more money to gamble (Mayo, 2011). For most compulsive gamblers, betting is as much about money as it is about excitement. Sustaining the thrill gambling provides involves taking increasingly bigger risks and placing larger bets, which may involve money the gambler cannot afford to lose. Unlike most casual gamblers, compulsive gamblers are compelled to keep playing to recoup their money, a pattern that becomes increasingly destructive over time. Compulsive gambling can have profound and lasting consequences including: Failed relationships, loss of family and friends. Financial problems, including bankruptcy. Legal problems or incarceration. Job loss or professional stigma. Development of associated problems, such as alcohol or drug abuse. Suicide. Page 4 SocialWork.EliteCME.com

5 Gambling terms The UCLA Gambling Studies Program (2010) identified a list of gambling terms as follows: Action Amount of money gambled. Banker The dealer that the players gambler against. Bankroll, access Total amount of money the player has available to gamble. Chase When the gambler increases his wagers to recover losses. Comps Gifts given by casinos to attract gamblers. Juice, rake Commission given to the house or sports book after a wager or hand is played. Parlay, teaser A wager involving more than one selection; player is given increased odds because all teams selected must win. Straight up A wager on a sports game without a spread. Rack A plastic container to transport or count large denominational coins, slot machine tokens and casino plastic chips Tilt After losing a wager or hand, the player has a wild, uncontrollable reaction. Prevalence According to recent research, about 2.5 million adults in America are pathological gamblers, and another 3 million of them are considered problem gamblers. Fifteen million adults are at risk of problem gambling, and about 148 million are low-risk gamblers. Gambling addiction statistics show that more than 80 percent of American adults report having gambled at some point in their lives. Gambling addiction statistics reveal that more than $500 billion is spent annually on wagers. The statistics show that during any year, 2.9 percent of U.S. gamblers are considered to either be pathological or problem gamblers. Gambling addiction statistics of co-occurrence of gambling and alcohol dependence revealed problem drinkers are more likely to have a gambling addiction percent of pathological gamblers were also addicted to smoking cigarettes. (Skolnik, 2011), (Shaffer, 2010) and (Rosenthal, 2010). Mood and anxiety disorders 37.9 percent of pathological gamblers were also diagnosed with mood disorders percent of pathological gamblers were diagnosed with anxiety disorders (Rosenthal et, al. 2010). Gender Although more men than women suffer from pathological gambling, women are developing this disorder at a higher rate, now making up as much as 25 percent of pathological gamblers. Women s symptoms of gambling addiction tend to worsen faster once compulsive gambling develops. Men tend to develop this disorder during their early teenage years, while women tend to develop it later. Gender-based differences in gambling addiction include the tendency for men to become addicted to more interpersonal forms of gaming, like blackjack, craps or poker, whereas women tend to gamble on slot machines or bingo. Men with pathological gambling tend to receive counseling about issues other than gambling less often than their female counterparts. (Shaffer, 2010) Ethnicity Gambling addiction is seen more among Caucasian Americans than African-Americans and Hispanic Americans (UCLA, 2010). In 2000, the U.S. Census Bureau defined Hispanic ethnicity as being of Mexican, Mexican-American, Chicano, Puerto Rican, Cuban or other Spanish/Hispanic origin or heritage. Census data for the year 2000 indicated that more than 35 million residents in United States were Hispanic, which constituted 12.5 percent of the total U.S. population (UCLA, 2010). Data indicates that nearly 83 percent of individuals of Hispanic heritage have gambled in the past year. Little research has been published on gambling problems among Hispanics, in fact, only two prevalence studies using national samples have examined the rates of gambling problems among Hispanics. Both studies suggest that when the prevalence of pathological and problem gambling is combined, the prevalence of gambling problems among Hispanics is similar to other groups. Examining the prevalence of pathological gambling among Hispanics suggests that pathological gambling may be more common among Hispanics relative to national prevalence rates. Very little research has examined gambling behavior among significant variables related to gender, acculturation, country of origin and immigration history among Hispanics. Further research and understanding of gambling problems among Hispanics could help target prevention efforts, identify risk and protective factors relating to gambling problems, and help design culturally tailored treatment modalities. Asian Americans, especially those of Chinese, Vietnamese and Korean origin, gamble at a higher rate than Americans from other ethnic backgrounds and suffer as problem gamblers at a higher rate (Skolnik, 2011). One possible explanation is that there are no religious prohibitions that warn against gambling in Asian cultures as there are in several Christian denominations, Islam and other faiths. In fact, gambling and religion in China are often part of the same general belief system. In some Asian communities, gambling is considered a rite of passage, an activity tacitly or explicitly encouraged. Numerology is important in many Asian cultures. Many Chinese, for example consider the numbers 6 and 8 lucky. Conversely, the number 4, which when spoken in Cantonese and Mandarin sounds like the word for death, is considered unlucky. As the novelist Amy Tan wrote in her book, Saving Fish from Drowning, the Chinese kind of Buddhism entails strong desires for riches, fame, and a large number of sons, as well as good luck at gambling (Skolnik, 2010). If these beliefs fade when Asian immigrants or refugees make their way to the United States, they do so slowly. Indeed, the gambling bug appears almost as strong in second and third generation Asian Americans as it does in those who made the trip to America. SocialWork.EliteCME.com Page 5

6 Gambling is inextricable part of the mix of life in San Francisco s Chinatown, the largest and oldest Chinese settlement in the Western United States. According to Kent Woo, executive director of the Chinese Health Coalition in San Francisco, there are more state lottery outlets in Chinatown per capita than elsewhere in the state. They re sold in bakeries, dime stores, groceries. They re everywhere, he said (Woo, 2011). Gambling operators, especially in the casino business, have for decades been aware of the value of building a strong base of Asian gamblers. In recent years, their efforts have influenced the way casinos are designed and which games are offered. Casinos send fleets of buses to any nearby Chinatown to shuttle Asian gamblers to the casino. They created special Asian-themed high-roller clubs with private gambling and dining rooms, and some Las Vegas mega-casinos avoid calling the 4th and 40th hotel floors by those numbers because of the negative connotations of the number four in Chinese (Rivlin, 2007). The phenomenon of Asian gambling addiction has come to the awareness of social workers, researchers and community activists around the country with increasing emphasis in recent years. Asian health groups for the first time are training counselors to deal with the problem. Activists infuriated at what they call the predatory efforts of gambling businesses to entice Asians to their establishments and equally aggravated with politicians for legalizing gambling in their communities in the first place are starting to fight back (Woo, 2011). Native American teens and adults were found to have higher percentage of gambling addiction at percent of the population compared to 2.2 percent of the Caucasian population studied. Native American males and females are at equal risk of developing a gambling addiction. Among American Indians treated for alcohol dependency, 22 percent also experienced gambling addiction, compared to 7.3 percent of Caucasian patients treated for alcohol and gambling addiction (UCLA, 2010). Since 1988 with the passage of the Indian Gaming Regulatory Act (IGRA), Native American Indian tribes rapidly opened up casinos, and Indian participation in recreational gambling increased. This led to increasing problem and pathological gambling among Native Americans. Researchers identified factors related to the increased predisposition of Native Americans to develop pathological gambling. These included economic status, unemployment, increased alcohol use, depression, history of trauma and lack of social alternatives (UCLA, 2010). Age The young are especially at risk for developing gambling problems. Compared to drugs and alcohol, which have been around colleges for decades, the addiction of gambling is a relatively new addiction on campuses. It is one of the most widespread and serious concerns affecting students today. A gambling network in a school can be disguised as a group of students getting together. In this Internet age, bets can be made online or via cell phones. This addiction can involve an entire school and be undetected. Because the rewards are something that resonates with almost everyone, it seems very harmless and is very tempting to make quick money. According to the Annenberg Public Policy Center s 2005 National Center of Youth: There are 2.9 million Americans ages 14 to 22 who gamble on cards once a week. About 50.4 percent of male college students gamble on cards once a month percent of female college students gamble on cards at least once a month. This is half of the entire male student body and a quarter of the female student body. Gambling is particularly tempting to college students because risktaking behaviors are common. The legal age for gambling is 18 years old in many states, making it a socially permissible behavior. The forms of gambling among students vary greatly depending on the individual states being surveyed. Among the common gambling activities for college students are (Jordan, 2009): Casino activities. Cards at casinos. Gambling machines. Playing the lotto. Formal card games with friends for money. Internet gambling Poker tournaments. The Internet has provided unprecedented access to online gambling. Currently there are more than 2,000 gambling websites that take in over $4 billion annually (Aire, 2003) Here is an example of on-line gambling as described by one collegeaged compulsive gambler: Page 6 It s 2 a.m. I ve got an economics exam very early in the morning. I can stay on for just one more tournament. This time I can win, I can feel it. I need to make up for what I lost today. I absolutely have to. Maybe I can buy a new outfit for this weekend or put a little bit of money toward my credit card bill. I can feel it. This is the one. Come on. Aces, aces I am an addict. I m not alone. This is a new addiction, and my 2 a.m. pre-econ exam, late-night binging is what I call the gambling me. The reason I didn t connect this directly to myself is because I never knew I was capable of an addiction. I ve never smoked or used drugs and only drink socially. I was the last person in the entire world that I thought could be addicted to anything. - Lauren Patrizi, Loyola University, 2005, at a Gambler s Anonymous meeting. (Jordan, 2009) Problem gambling involves more than one symptom but less than five symptoms required to qualify for the diagnosis of compulsive or pathological gambling. Binge gambling is a subtype of compulsive gambling that involves problem gambling but only during discrete periods of time. That is different from a gambling addiction, which tends to involve excessive gambling behavior on an ongoing basis and includes persistent thoughts or obsessing about gambling, even during times when the person is not engaged in gambling (UCLA, 2010). Sports wagering, beginning in high school and increasing in college, is done by 50 percent of student athletes (Engwall, Hunter, and Steinberg, 2003). Lesieur (1991) reported 85 percent of college athletes had participated in betting, and 23 percent surveyed showed evidence of pathological gaming behavior. Physically and psychologically tied to a campus, college students are more interested in the outcomes of sporting events, and when combined with easy access to alcohol and high-speed Internet, many post-secondary institutions find their students engaging in gambling at much higher rates than the general population (Henry, 2003). The University of Kansas director of counseling services noted gambling allows students to feel intimately involved in the game (Aire, 2000). The gambling recovery counselor stated, The more someone knows about a given sport, the more they believe their decisionmaking gives them a significant advantage. This develops a level of emotional invincibility in the addiction (Henry, 2003). With easy access to gambling and a need to feel part of the larger organization, SocialWork.EliteCME.com

7 pathological gambling associated with betting on sporting events has risen significantly in the past 10 years. (Jordan, 2009). In one extreme case, a student at the University of Wisconsin murdered three roommates because he owed them thousands in gambling debts. The trio had helped him place bets with an offshore gambling company. He had lost $15,000 gambling and withdrawn $72,000 from his bank account to support his habit before he committed the murders (Wexler and Isenberg, 2002). Robert L. Custer, M.D. discusses the four phases of gambling and developed an Adolescent Chart of Compulsive Gambling, which can apply to adults as well: The first phase: Winning The start of the compulsive gambling is that of immediate gratification when a gambler likely wins more than he loses. The wins reinforce his love of the sport. During the winning phase, a gambler may develop the illusion that he or she is skilled at the game. This phase is usually the first three years of gambling. This phase is characterized by: Occasional gambling and fun. Excitement before and during gambling. Increasing the amount of money that is wagered. Frequently winning. More frequent gambling. Fantasizing about winning. Lying to parents about gambling. Fantasy thinking. The second phase: Losing The gambler s luck does not run forever, and after a while, he starts losing more money. Paradoxically, a losing phase does not discourage the gambler. During the losing phase, the gambler feels tempted to gamble more and with larger amounts of money. He is convinced that he is simply on a losing streak and merely needs one win to get back his momentum. He invests on the long shots that, while having low odds of winning, will pay big, according to his thought process. He may engage in a behavior called chasing losses. This means increasing gambling with larger bets in hopes of winning back the losses. In the phase of chasing losses, the lies begin, and the gambler lies to maintain the façade that he is winning. He maintains that he is still financially viable and competent at the game. He continues to boast about his gambling skills, talks about his winning but rarely about his losses. When he suffers his first major setback, which places him in deep financial trouble, he makes up a lie to get a loan. He considers a bailout as a win and is back in action and gambling even more feverishly then before. In this phase, he seems to lose almost all the time, and his life has become unmanageable. It is impossible to persuade others to provide a loan, and relationships with his family and friends are rapidly deteriorating. This phase is characterized when the gambler: Is obsessed with gambling and cannot stop. Has debts that pile up. Is careless about family and friends. Brags about wins. Blames losses on bad luck. Covers up gambling. Loses time from school or work. Is irritable, restless, depressed. Drops extracurricular activities (social activities for adults). Experiences a drop in grades drop (or work performance drops). Increases the money and time spent gambling. The third phase: Desperation This is the point when the gambler becomes obsessed with gambling and feels compelled to carry it through. Even though he knows he will lose, he still gambles. His life becomes completely out of control, and when others don t believe his lies, he becomes angry, blaming them for his problems. He must obtain money to gamble at all costs, and illegal activity may occur through embezzling or stealing money. He will consider these as loans, which will be paid back from the big win he believes he will have. The gambler often has an outward appearance of being in total control. He is still convinced that everyone believes his lies and becomes angry when they don t. Outwardly, he blames everyone but himself for the unfortunate circumstances now occurring. Inwardly, the gambler is in severe anguish, truly loves his family and wants things to be like they used to be. He wants to correct the instability but is compelled to gamble though he does not know why. This phase is characterized when the gambler: Sells personal belongings. Is unable to pay debts. Drops out of school (or work for the adult). Sells family valuables. Has thoughts of crime. Feels out of control. Feels remorse, shame or panic. Withdraws from family or friends. Blames others. Feels guilty. Is involved in legal action. The fourth phase: Hopelessness Until recently, only three phases of pathological gambling have been noted. Many clinicians and experts who treat pathological gambling now say a fourth phase exists for both action-seeking and escape gamblers (Parhami, 2010). Once the gambler has been through the desperation phase, it would seem that everything bad had occurred. However in the hopeless phase, pathological gamblers have given up. They believe nothing can help; they don t care if they live or die, in fact many believe suicide is the only way out and they consider that during this phase. Most will commit actions that could place them in jail or prison. Clinical depression is a given and they believe no one cares and no hope is available. The hopeless phase is the time when the pathological gambler either gets help or attempts suicide or suffers extreme depression. This phase is characterized by the gambler s: Despair. Thoughts or attempts of suicide. Arrest. Use of drugs and alcohol. Emotional or physical breakdown. Elderly Sam Skolnik (2010) reports the following statistic on elderly gamblers: Individuals over 65 are the fastest-growing group to become addicted to gambling. With the elderly population growing, 80 percent of the over-65 population had gambled in percent of all revenues in Atlantic City casinos come from elderly gamblers. Studies found that elderly women gambled 249 percent of their monthly income. Many stopped taking meds, skipped meals, stole money from others, gambled with credit cards, and gambled away their mortgage, retirement, insurance, savings and homes. They are a particularly vulnerable group because they re living on fixed incomes with few ways to recoup the money they have lost. Many casinos aggressively market to the 50-plus crowd, providing cheap buffets, coupons, drug discounts sometimes up to 50 SocialWork.EliteCME.com Page 7

8 percent, and bus the elderly from nursing homes and retirement centers. The elderly are often victims of lottery scams and other individuals who prey upon their vulnerability. Many elderly individuals have to turn to their families for assistance, but many are too ashamed to seek help, and the rate of suicide among elderly gambling addicts is alarmingly high, nearly three times the national average. Military personnel The Pentagon operates several thousand slot machines on U.S. military bases abroad. These machines raise revenues of $130 million per year, which goes toward recreation programs for the troops, including movie theaters, concerts and swimming pools. According to a 2007 CNN story, there are 3,000 slot machines posted at Army and Marine bases. The number of machines at Air Force and Navy facilities wasn t immediately disclosed. The Pentagon confirmed it has 8,000 slot machines on 94 overseas bases. The Army also runs bingo games on U.S. bases, which are comparatively modest, profiting the military at least $7 million annually. Young soldiers, often competitive, risk-takers by nature, are at a high risk for developing gambling problems. John Kindt (2007) of the University of Illinois studied the issue and found that about 2.2 percent of military personnel indicated they are pathological gamblers, significantly higher than the percentage of adult civilian Americans (Skolnik, 2011). A statement by an undersecretary of defense said the slot machines provided controlled alternatives to unmonitored off-base gambling venues and offers a high payment percentage, making it more entertainment oriented than found in typical casinos (CNN, 2007). The CNN story centered around Aaron Walsh, a decorated Apache helicopter pilot with the Army who became addicted to slot machines he found in bases in Germany and South Korea. He received treatment through the military s only gambling treatment facility at Camp Pendleton in California, but it didn t help. He was kicked out of the military in A year later, after a visit to a casino in Bangor, Maine, he killed himself. (CNN, 2007). Etiology As with other mental health issues, compulsive gambling may result from a combination of biological, genetic, social and environmental factors. Gambling addiction, like other emotional conditions, may be the result of a combination of biological factors, thought patterns and social stressors. Compulsive gambling affects both men and women and cuts across cultural and socioeconomic lines. Although most people who play cards or wager never develop a gambling problem, certain factors are often associated with compulsive gamblers and elements that increase the likelihood that the individual will develop a gambling addiction. Risk factors for developing pathological gambling include schizophrenia, mood problems, antisocial behavior, personality disorder, bipolar disorder, and alcohol or cocaine addiction as described below:(mayo, 2011) Behavior or mood disorders. People who gamble compulsively often have mood disorders such as anxiety and depression, as well as attention-deficit/hyperactivity disorders. Family influences. If a parent had a gambling problem, chances are greater that children in the family will develop gambling problems. Personality characteristics. Individuals who are highly competitive, restless, or easily bored have an increased risk to develop a gambling problem. A diagnosis of bipolar disorder. Exorbitant spending in the form of compulsive gambling may be a symptom. Parkinson s disease or restless leg syndrome. Medications used to treat these disorders have been observed to develop compulsive gambling in some individuals. Alcohol and cocaine addiction are risk factors for pathological gambling. Biochemical factors. In some individuals, compulsive behaviors can be connected to increased activity of the chemical messenger dopamine in the brain or low serotonin levels. For the last decade, researchers have studied how biochemical substances such as dopamine work in the gamblers brain. Dopamine is the neurotransmitter that helps assess awards such as food. When the body experiences pleasurable things, anything from a tall glass of lemonade to a slot machine win, dopamine neurons fire. They help the brain learn about pleasure, including predicting when the sensation my return (Goudriaan et al). Addicted gamblers are different from non-addicted ones in the ways their dopamine systems function. Some researchers believe that during the first gambling experience of some pathological gamblers, a huge dopamine rush can occur that gets planted in their memory. When that happens, the addicted gamblers, like cocaine addicts, develop reward systems that respond to pleasing stimuli differently than non-addicts. An increasingly high level of reward has to be given for many addicted gamblers to continue to feel pleasure (APA, 2010). Studies have noted that the rush that gamblers crave is the high they feel when they make a bet, and sometimes when just anticipating the bet. Blood surges to the face and the mouth dries up. Concentration narrows, as time seems to slow. The high is fleeting, but is repeated as soon as the gambler makes the next bet. The feeling exists whether the bet is won or lost, but can spike, especially if it s more than expected. The experience has been compared to snorting a line of cocaine (Skolnik), 2011). Using an MRI scanner, neurologists in Hamburg, Germany, gauged the responses of 12 gambling addicts and 12 non-addicts to a card guessing game. When participants picked the correct card, they won a euro. The non-addicts picked the right card, which increased their blood flow to the ventral striatum, a portion of the brain with dopamine receptors that measures rewards. Comparably, the addicted gamblers brains had far less blood flow to the area, indicating they needed a price much larger than a single euro to become excited (Lewis, 2006). People who suffer from compulsive gambling have a tendency to be novelty seekers. Individuals who have a low level of serotonin in the brain are at higher risk for developing pathological gambling. Which came first, the gambler or the casino? The casino industry created the National Center for Responsible Gaming (NCRG) to try to establish the idea that pathological gambling is caused by gamblers who suffer from addictive personalities. Under this theory, casinos and other gambling operators are not responsible in any way for getting gamblers hooked. This not only aided the industry and its state-by-state legalization fights, but it also established a ready-made defense against potential lawsuits. Many NCRG-issued grants study genetic, neurological and chemical causes Page 8 SocialWork.EliteCME.com