An introductory powerpoint on Gambling Use Disorder for Process or Behavioral Addiction Classes

1. Leigh Falls Holman, Ph.D., LPC-S, RPTS, NCC, CSC
President-Elect, International Association of Addiction
and Offender Counselors (IAAOC)

2.  “To play games of chance for money or other
rewards” (Cambridge International Dictionary,
1996).
 “Any activity that has an uncertain outcome and
involves risking something of value with the hope
of increasing one’s wealth, status, or security”
(Chamberlain, 2004, p. 129).

3.  “Maladaptive form of gambling behavior associated with impaired
functioning, reduced quality of life, and high rates of bankruptcy and
divorce” (Grant & Odlaug, 2014).
 “Gambling behavior that causes disruptions in any major area of a
persons life” (National Council on Problem Gambling, 2000).
 The compulsion of gambling increasingly takes over an individual’s
resources (time, money, energy etc.) and intrapsychic life (thoughts &
dreams).

4. Symptoms of Behavior Alcohol & Other
Drugs
Compulsive
Gambling
Cravings Yes Yes
Denial of problem’s severity or existence Yes Yes
Disruption of families Yes Yes
Effects on specific neurotransmitters Yes Unknown
High relapse rate Yes Yes
Loss of control Yes Yes
Lying to support use/activity Yes Yes
Preoccupation with use/activity Yes Yes
Progressive disorder Yes Yes
Tolerance developed Yes Yes
Used as a means of escaping problems Yes Yes
Withdrawal symptoms common Yes Yes

5.  Choice:
◦ How easily it can be used with a client
◦ The type of info the assessment provides
◦ Appropriateness for use with a client
 WASTE-Time Quick Screen:
◦ Paper and pencil or verbal
◦ Can be used in a general counseling setting if a client
endorses behaviors consistent with problem gambling.

6.  Withdrawal
◦ “What happens to you when you are unable to engage in _______?”
 Adverse Consequences
◦ “What negative consequences resulted from _______?”
 Inability to Stop
◦ “Have you attempted to cut back or stop ______ without success?”
 Tolerance
◦ “Have you found it necessary to increase the amount or intensity of ______ to
achieve the same effect?”
 Escape
◦ “Do you _____ to escape from negative moods?”
 Time Spent
◦ “Do you find yourself spending a lot of time preparing, engaging, and recovering
from ______?”
 Time Wasted
◦ “Have you spent more time and/or resources on _____ than you intended?”

7.  Screening instrument
 20 item
 Self-report
 Lifetime gambling activity or Last 3 months
 Score ≥ 5 indicates possible problem & need for further
assessment
 http://www.addictionrecov.org/southoak.aspx
 SOGS-R for Adolescents:
 http://www.southwestern.org/rc/wp-content/uploads/South-
Oaks-Gambling-Screen-and-Score-Sheet-Adolescent.pdf
 Spanish Version
 http://www.ipgap.indiana.edu/images/documents/SOGS_span
ishversion.pdf

8.  Brief clinical screening instrument
 5-10 minute survey or interview – self-report
 14 items (only 7 scored & weighted score)
 Classifies Adults & Adolescents into 3 categories:
◦ Non-problem
◦ In Transition
◦ Pathological Gamblers
 MAGS (published by Springer)
http://link.springer.com/article/10.1007%2FBF02104901#page-2
 MAGS copy:
http://www.ncrg.org/sites/default/files/uploads/docs/monographs/mags.p
df
 Pathological gambling among adolescents: MAGS (n = 856 suburban
Boston HS students) http://www.ncbi.nlm.nih.gov/pubmed/24234969
 Correctly classified 96% of adolescent problem gamblers

9.  Can be accessed online:
 http://www.gamblersanonymous.org/ga/content/20
-questions
 Score of ≥ 7 indicates problem gambling behavior
 Don’t know specificity or sensitivity

10.  2 Question Rule Out Tool:
http://www.ncpgambling.org/files/NPGAW/Lie_Bet
_Tool.PDF
 Self-report

11.  Screening instrument designed for use by general
practitioner setting
 Score ≥ 4 indicates possible problem gambling
 NIH article:
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC307
6109/
 PDF version of instrument:
http://www.bpac.org.nz/BPJ/2010/June/docs/addic
tion_eight_gambling_screen.pdf

12.  Change diagnostic category from Substance-
Related Disorders to Substance Use and
Addictive Disorders
 The addition of Addictive Disorders indicate
acceptance of process or behavioral
addictions as a concept by the APA
workgroup that worked on this category.

13. Acknowledges behavioral processes can activate the
reward system and produce behavioral symptoms
similar to SUDS.
Includes Gambling Use Disorder as a diagnosis in
Section II under the Substance-Related and Addictive
Disorders category.
Includes Internet Gaming Disorder (p. 795) in Section
III.
Other process addictions must be categorized under
other diagnostic categories such as Feeding and Eating
Disorders, Impulse Control Disorders, Obsessive
Compulsive Disorders, and Sexual Disorders or
Paraphilias.

14.  Pre-occupation
 Tolerance
 Denial
 Progression
 Withdrawal

15. ◦ Clinically significant impairment or distress
◦ 4 or more criteria in 12 month period
 More money to achieve desired excitement (tolerance)
 Restless or irritable when tries to cut down/stop (withdrawal)
 Can’t control behavior (compulsion)
 Preoccupied with gambling (obsession)
 Gambles when feeling distressed (emotion regulation)
 Lies to conceal extent of gambling
 Impaired functioning
 Relies on others to provide money to continue gambling
◦ Not better explained by a manic episode

16.  Episodic or Persistent
 Remission:
◦ Early: 3-12 months
◦ Sustained:Over 1 year
 Severity Level
◦ Mild: 4/5 Criteria (less in treatment)
◦ Moderate: 6/7 criteria
◦ Severe: 8/9 criteria

17.  Distorted Thinking:
◦ Denial
◦ Superstitions
◦ Sense of power & control over the outcome of chance
events
◦ Overconfidence
 “Some are impulsive, competitive, energetic,
restless, and easily bored” (p. 587).

18.  “May be overly concerned with the approval of
others and may be generous to the point of
extravagance when winning.”
 “Others may be depressed and lonely, and they
gamble when feeling helpless, guilty, or
depressed.”
 About 50% in treatment have suicidal
ideation & about 17% have attempted
suicide.

19.  Prevalence
◦ Last 12 months .2%-.3% of the general population
◦ Lifetime prevalence rate gender & ethnicity
Males: .6%
Females: .2%
African Am .9%
Whites .4%
Hispanics .3%
◦ More common among young & mid-life
◦ Risk & Prognostic Factors:
 Temperament
 Genetic
 Course Modifiers

20.  Earlier onset:
More common with males
Often begin with family & friends
Associated with impulsivity & substance abuse
HS & college students who have the disorder may grow out of it
Younger prefer sports betting
 Older: Machine/bingo gambling more likely
 Females: mid-late adult onset is typical
more rapid development in females
more likely than males to have depression, bipolar, &
anxiety
 Low rate of treatment seeking in general <10%, but more older onset females
present for treatment than other populations
 Frequency gambling can be more associated with the type of gambling than
the severity of gambling. (scratch ticket vs. casino)
 Amount of money isn’t necessarily an indicator of a gambling problem.

21.  Poor general health & utilize medical services at a high rates
◦ Tachycardia & angina more common in GD population even when other
substance use disorders are controlled for.
 Jeopardize or loss of important relationships
 Repeated lying to cover up the extent of gambling
 May request money used for gambling or to pay off gambling
debts
 Employment/educational activities may be adversely impacted
◦ Absenteeism
◦ Poor work/school performance

22.  Differential Diagnosis:
◦ Non-disordered gambling
◦ Manic Episode
◦ Personality Disorders
◦ Other Medical Conditions (e.g. Parkinson’s meds)
 Comorbidity
◦ Substance use disorders
◦ Depressive disorders
◦ Anxiety disorders
◦ Personality disorders

23.  Genetics: research “suggests that the possession of the
dopamine D2A1 allele receptor gene may result in
deficits in the dopamine reward pathways” (Ashley &
Boehlke, p. 56).
 Trauma History: Kausch et al. found 64.4%
 Cognitive Distortions (next slide)
 Accessibility: Gerstein et al. double risk if within 50 miles
of a casino - controversial
 Co-morbid SUDs, mood, ADHD
 Criminal behavior, Bankruptcy
 Suicidal Thinking

24. Cogitive Distortion Example
Gambler’s Fallacy Belief that completely random events (coin toss) are
influenced by recent events
Illusions of Control Superstitious behaviors where gamble believes s/he
has a reliable means of manipulating the event
outcome in his/her favor
Magnification of
Gambling Skills
Exaggerated self-confidence
Recall Bias Tendency to remember and overestimate wins while
forgetting about, underestimating, or rationalizing
losses.

25. Level Refers to:
0 Never gambled
1 “Social” or “Recreational” gambling
Gambling does not result in significant problems
2 Wagering resulting in some gambling-related problems
At-Risk Gambling
In-Transition Gambling
Problem Gambling
3 Gambling associated with significant problems
Meet diagnostic criteria for Gambling Use Disorder

26. Phase Description
Winning •Betting is fun, exciting, social, and a way to escape
•Occasionally win large sums generally leading to betting larger
amounts and spending more time gambling.
Losing •Preoccupied with gambling
•Needs to place larger bets more frequently
•Losses increase but rationalized as a “loosing streak”
•Begin to “chase” losses, lie about extent, and experience gambling-related
difficulties.
•Begin to make and break promises to self and others to quit gambling.
Desperation •May experience health problems & relationships may deteriorate
•Feelings of desperation & hopelessness ensue
•Losses continue to mount
•Fantasizes about winning
•May steal, write bad checks, or commit other crimes to finance
gambling
Hopeless •No longer believes there is hope or help
•Gives up
•Suicidal ideation or attempts
•Jail or prison becomes a possibility

27. Gamblers seek different emotional
experiences through their gambling
activity:
◦ Escape Gamblers: Gambling
becomes a trance-like escape
◦ Action Gamblers: Gambling becomes
a powerful stimulant

28.  Predisposing Factors:
 Physical, emotional, or sexual abuse
 Poor relationships
 Losses
 Values:
 Denial of gambling as a problem
 Maintain family trust is important
 Gambling Habits:
 Onset later in life
 Faster progression of compulsive behavior
 Seeking to escape from loneliness or boredom
 Begins as a social activity and entertainment
 Participates mainly in games of chance
 Fewer big-win experiences

29.  Emotional Consequences:
 Becomes emotionally dependent on gambling
 Preoccupied with gambling
 Depression
 Secretive about excess gambling
 Guilt about both financial losses and failure to meet standards of behavior
 Guild over lost time with family
 Shame related to dishonesty
 Fears of being revealed and disgraced
 Financial Consequences:
 Loss of household money
 Credit card problems
 Use of money from family savings or accounts
 Sale of valued family possessions
 Recovery Issues:
 Denial that gambling is a problem
 Frequently doesn’t want to stop gambling
 Partner may not intervene
 Family less supportive in getting help
 Child care
 Male dominated treatment and recovery services

30.  Predisposing factors:
 Family of origin
 Personality characteristics
 Introduction to Gambling:
 Introduced by friends or family
 Begins betting at an early age
 Occasional gambling
 Experimenting with new types of gambling
 Developing a relationship with gambling
 Deviant behavior
 Precipitating or traumatic event
 Experiences a big win

31.  Winning Phase:
◦ Frequent winning
◦ Fantasizing about winning
◦ Increases amount of money bet & time spent
gambling
◦ Lies about gambling
◦ Brags about winning

32.  Losing Phase:
 Chases losses
 Loses time from work or school
 Cannot stop gambling
 Begins to accumulate debts
 Relationship with family & friends impacted
 Frequently borrows money
 Drops non-gambling activities
 Becomes irritable, restless, depressed

33.  Desperation Phase:
 Unable to pay debts
 Sells possessions or family valuables
 Increases drug/alcohol use
 Thoughts of committing crimes to finance gambling
 Loss of job or drops out of school
 Withdraws from family & friends
 Blames others
 Shame, guilt, despair
 Thoughts of or attempts at suicide
 Emotional, physical, financial breakdown.

34.  Often begins when a recreational gambler wins big.
 Predominantly male, view gambling as a skill to be learned
& as a desirable way to make a living without the drudgery
of employment
 Experience an unequaled rush of sensation; feel powerful
& special, adrenaline rush; enjoy recognition & status
 Tend to play games requiring skill like black jack, craps, or
poker; or a handicapping sporting event (like racing).

35.  Often describe a system they have
 Generally much more competitive personalities
 Like to be perceived as a high-roller, respected &
admired, viewed as talented and skilled
 Stimulated by overcoming the odds – even purposely
take irrational risks to provide more stimulation that
comes from digging out of a hole

36.  Compulsive Activity
 Loss of Control
 Continued Use Despite Adverse Consequences

37.  Stein, Hollander, & Liebowitz (1993) define compulsive
gambling as “a conflict between a gambler’s stated
intention, such as to not gamble, or to not gamble more
than X amount, and the actual behavior, which violates
the intention.”
 May experience ‘fugue-like’ states where they “find
themselves engaging in unplanned, spontaneous
gambling activity” (Chamberlain, 2004, p. 135).
 Triggers: internal & external

38.  The Chase (1984) – the more they lose the more they gamble –
chasing losses
 Double Down: double each bet they make following a loss with the
intention of winning the bet that will eliminate the loss.
 Downward spiral of loss of more than intended and continuing to
gamble to try to win back the losses.
 Gambling binges frequently end in exhaustion, disoriented, & an
overwhelming sense of despair and depression that is
unavoidable.
 Reports of being overpowered by the impulse to gamble
 Increasing pervasiveness of gambling in a person’s life to the point
that all activities center around gambling.

39.  Mental health consequences include anxiety,
depression, substance abuse, loss of a sense of self,
loss of hope, feelings of shame & embarrassment, fear
of consequences, suicidal ideation & attempts.
 Financial consequences, job loss
 Relationship issues: abandonment of family members;
wives of compulsive gamblers are 4 times more likely to
commit suicide than the general population (Lesieur,
1993); miss family commitments; irritability,
defensiveness, verbal and physical violence.

40.  “The risk for self-destructive behavior is higher [in
gambling] than with any other addiction”
(Chamberlain, 2004).
 The longer they are able to hide the gambling, the
more problematic it becomes. There are no obvious
signs of intoxication, like substance dependence.
 Gambling is non-linear in it’s consequences (may
have a win as they are going through a downward
spiral, where substance addiction consequences
generally progressively get worse.)

41.  CBT
◦ Abstinence or
◦ Harm reduction
 MI
 12 Step

42.  4 Strategies:
◦ Cognitive Restructuring
◦ Developing Problem-Solving Skills (alternative responses to stress)
◦ Social Skills Training
◦ Relapse Prevention (identify, avoid, and/or cope with High Risk
Factors (HRFs)
 CBT Research Studies:
◦ * Many studies compare CBT intervention with wait list or Gamblers
Anonymous, which are both non-treatment. So it’s difficult to discern
whether these studies are only indicating that treatment is better than
no treatment.
◦ Tend to be short-term follow up
◦ Placebo effect is high

43.  Approach:
◦ Both directive & client-centered styles used
◦ Designed to enhance client’s motivation to initiate process of change
◦ Identify and mobilize the client’s intrinsic values and goals to stimulate
behavioral change
 MI Research:
◦ MI was developed out of research on what worked for SUDs clients
◦ Raylu & Casey (2010) n=102 randomized
CBT workbook plus MI better outcomes 6 months than CBT alone or
waitlist
◦ Hodgins et al. (2001) n= 102 compared CBT workbook and workbook
plus MI and wait list
6 month follow up: frequency and amount lost were lower in MI group
2 year follow-up: 77% MI group improved

44.  Self-exclusion:
Some casinos offer a program that allows
gamblers to ban themselves from the
establishment, thereby limiting HRFs
 Funds-Management
Limit access to funds. Canceling CCs, removing
ATM cards and/or credit cards from wallets, direct
deposit paychecks

45.  GAM-ANON – established as a program for the
families and friends of problem gamblers
 Community Reinforcement and Family Therapy
(CRAFT) model adapted for gambling
◦ Use behavioral principles to reinforce non-gambling
behaviors (negative reinforcement)

46.  Opiod Antagonist
◦ Most studied and efficacious class of meds for this
population
◦ Naltrexone – block mu opiod receptors and modulate
dopaminergic transmission in mesocorticolimbic pathway
 Glutamatergic Agents
◦ N-acetylcystein (NAC), a glutamate-modulating agent
demonstrates potential as an intervention
 Lithium and Anti-epileptics: no significant
differences
 Atypical Antipsychotics: negative outcomes
 Antidepressants : Mixed results

47.  Journal of Addiction and Offender Counseling
 Journal of Gambling Studies (Springer publishes)
 Gamblers Anonymous
http://www.gamblersanonymous.org/ga/
 24 hour confidential National Gambling Helpline:
1-800-522-4700

48.  American Psychiatric Association . (2013). Diagnostic and statistical manual of mental disorders (5th ed.).
Washington, D.C.: APA.
 Grant, J. E., & Odlaug, B. L. (2014). Diagnosis and treatment of gambling disorder. In Behavioral addictions:
Criteria, Evidence, and Treatment. K. P. Rosenberg & L. C. Feder (Eds.). Boston, MA: Elesvier.