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Gambling

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Elyse Mireille Charrois

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Objective: This self study module will explore the clinical aspects of gambling problems

Gambling addiction can have a profoundly negative impact on individuals, families, and
communities. Gambling is an activity that involves any betting or wagering, for self or others,
whether for money or not, no matter how slight or insignificant, where the outcome is
uncertain or depends on chance or skill (Gamblers Anonymous, 2000; McCormick & Cohen,
2007). The DSM 5 reclassified pathological gambling from an impulse control disorder to a
behavioural addiction (APA, 2012). The rationale for this change is that the research,
especially on the brain’s reward pathways, has revealed many similarities between
pathological gambling and substance-use disorders. Both involve cravings and highs; have
genetic factors; and the same forms of treatment (APA, 2012).

A person must have four of the nine behaviours listed below over a 12-month period to be
diagnosed with a gambling disorder in the DSM V (APA, 2012). A change from the DSM IV TR is
that illegal acts are no longer listed as a sign of pathological gambling because this criteria did little
to help form a diagnosis (APA, 2012). People who do not meet the criteria of four behaviours may
still have serious problems requiring early intervention.

• preoccupation with gambling

• gambling with larger amounts of money to increase excitement
• repeated efforts to reduce or stop gambling
• restlessness or irritability when attempting to control gambling behavior
• gambling to escape problems or to alleviate a negative mood
• trying to win back money after incurring losses while gambling
• lying about the extent of gambling behavior to significant other(s)
• lost relationships with significant other(s) or lost career advancement because of
gambling
• dependent on others to provide financial assistance to relieve a debt caused by
gambling
Over the last several years, there has been an increase in gambling research, and substantial
findings have emerged in understanding the clinical aspects of pathological gambling as well
as in the area of treatment (Johansson, Grant, Kim, Odlaug & Gotestam, 2009). Common
terms that have been used interchangeably in the literature include gambling, problem
gambling, compulsive gambling, and pathological gambling. While these terms have been
used interchangeably, it is important to note that there are behavioral conditions inherent in
each term that distinguishes one from the other (Emshoff, Perkins, Zimmerman, Moos &
Zorland).
The Social Dimension of Gambling
The behavioural addiction of gambling has been described as “a silent epidemic” (Suissa,
2007). An Alberta prevalence study by Smith and Wynne (2002) indicated that 67%of
respondents were non-problem gamblers, 9.8% were low risk gamblers, 3.9% were
moderately at-risk gamblers, and 1.3% were considered problem gamblers. The National

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Opinion Research Centre (NORC) identified two types of social cost resulting from problem
and pathological gambling:
1) ongoing, annual costs resulting from job loss, unemployment and welfare benefits, poor
physical and mental health, and gambling disorder treatments, and
2) one-time (or less frequently occurring) costs over the lifetime of a gambler resulting from
bankruptcy, arrests, imprisonment, legal fees for divorce, etc. (Community Research Partners,
2010).
Griffiths (2013) described how addictive gambling behaviour resulted from an interaction
between many factors that can be grouped into four categories: Biological/genetic disposition;
social and environmental influences; psychological constitution; and the gambling activity
itself. The social, environmental and situational factors of the gambling experience have often
been modified by government regulatory agencies and law enforcement but not always
effectively. The increase in pathological gambling may be partly related to regulatory and legal
changes.
The timeline below shows the dramatic shift that occurred in Alberta. Online gaming is difficult
to measure but there is accurate data about Video Lottery Terminals (VLTs) and slot
machines. This technology includes inducing and reinforcing features that promote addictive
tendencies (Smith & Wynne, 2004). They are known to be a highly addictive gambling
experience but were not available in Alberta until 1992. Today, Albertans are spending $23
Billion a year on those two forms of gambling and the Alberta government has become
dependent on the revenue of $1.5 Billion annually.

The Progression of Gambling in Alberta

1910- Horse betting becomes legal in Canada.

1925- Gambling at agricultural fairs and exhibitions is allowed
1967- Alberta's first charitable casino opened at Edmonton's annual fair, then called Klondike Days
1969- The federal law was changed to allow provinces to legally operate lotteries and casinos. Calgary
Stampede opened the Frontier Casino (which became a permanent facility under the name of
Stampede Casino in 1988).
1985- Canada's Criminal Code is amended to allow provinces to operate mechanical gaming devices
1992- Video Lottery Terminals (VLTs) were introduced in Alberta after test runs at summer fairs in
Edmonton and Calgary.
1995- First online gaming website opens
1996- Alberta gets slot machines and satellite bingo
1998- Nine Alberta communities vote to remove their VLTs
2001- There are 38,652 VLTs across Canada. Alberta introduces a new First Nations Gaming Policy
2006- River Cree Resort and Casino on the Enoch Reserve near Edmonton becomes the first casino to
open under the First Nations Gaming Policy
2009- 85% of gambling revenue in Alberta is from 18,000 VLTs and slot machines. The Government of
Alberta now earns more revenue from gambling than from the oilsands.
2012- Albertans spent $2.1 billion on alcohol and $23.8 billion on gambling during that year. The
provincial government received revenues of $687 million from alcohol sales and $1.5 billion from
gambling. Albertans spent $15.6 billion on slot machines, $7.4 billion on VLTs and $744 million on
lottery tickets.

Excerpted from: You bet your life, CBC News: The Fifth Estate. http://www.cbc.ca/fifth/main_youbetyourlife.html Retrieved, April
2013; Alberta Liquor and Gaming Commission's 2011- 2012 Annual Report and BC Partnership for Responsible Gambling.
(2007) Internet gambling

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With the rapid global expansion of the internet since the mid-1990s, gambling online also
became a common form of betting (McCormick & Cohen, 2007). The first online gambling
website appeared in 1995 (BC Partnership for Responsible Gambling, 2007). Online wagering
and online gaming are the two most common forms of gambling online. Online wagering
involves placing bets on an event including horse races, sports games and poker, for
example. Online gaming involves playing games generated by software that determines
results randomly (McMillan, 2000). Online gambling, as compared with traditional casinos,
have become more popular with young adults, rising from 1.4 percent in 2001, to 5.5 percent
in 2005 (Responsible Gambling Council, 2007). In Canada, online gambling is regulated, to
the extent that anything on the internet can be regulated, according to provincial legislation
and under the federal criminal code (BC Partnership for Responsible Gambling, 2007).

Gambling Screening Tools

If a problem with gambling is present in an individual’s profile, it is important for health care
professionals to explore how often (frequency), how long (duration), and how much (amount)
they gamble relative to what they can afford to lose (Fong & Reid, 2012). The severity of the
gambling addiction might also be conceptualized by the extent of self-control and the
disregard for negative associated consequences (Fong & Reid).

Screening tools may be helpful in determining the presence of a gambling issue. The
following is an overview of the screening tools available (Centre for Addiction and Mental
Health, 2012).

South Oaks Gambling Screen (SOGS): The SOGS, which was developed in the US,
is a 20-item questionnaire used to screen for pathological gambling in clinical settings.
This instrument was developed many years ago based on an inpatient population of
males in a Virginia hospital and limitations in the instrument have been identified.

South Oaks Gambling Screen – Revised Version (SOGS – RA): The SOGS-RA is a
revised version of the SOGS that was developed in order to measure pathological
gambling among adolescents.

CAMH Gambling Screen: This tool, developed at the Centre for Addiction and Mental
Health (CAMH), is intended as a short screen to quickly identify people who might
have a problem, but who are currently not seeking treatment for problem
gambling. The screen could be used by anyone who wants to investigate gambling as
a possible issue without completing a longer questionnaire. Clients can use the CAMH
Gambling Screen as a self-assessment tool, or can use it as part of a screening
process.

Problem Gambling Severity Index (PGSI): The PGSI is an abbreviated version of

the original tool called the Canadian Problem Gambling Index, consisting of 9 items
rather than 31. Clients can use it as a self-assessment tool, or health care
professionals can use it as part of their screening process.

The original 31-item tool, which measures gambling involvement, problem gambling
behavior and adverse consequences, was developed to measure the prevalence of
gambling and problem gambling in the general population. Research is currently being
done to test its use with a treatment population.

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 Check Your Gambling: This five page questionnaire is intended to be an anonymous
tool to help gamblers, their loved ones, and health care professionals answer
questions about gambling.

GA 20 Questions: This questionnaire, which was developed by Gamblers

Anonymous, is intended as a self-assessment for “compulsive gambling”. It has not
been scientifically tested and validated, so caution should be exercised in its use.

Utilizing gambling screening tools will provide information to guide decisions about whether
the individual is, in the most severe case, a pathological gambler or if the individual is, in the
least severe instance, a recreational gambler. The following table illustrates an example of the
difference between an individual who struggles with a pathological gambling addiction
(pathological gambler) and an individual who does not (recreational gambler).

Table 1: Two cases of gamblers: Recreational vs. pathological

Recreational Gambler Pathological Gambler

• 73 year old retired air traffic • 25 year old college student who
controller who plays poker at the gambles whenever he has money
local casino 4-5 times per week • Skips courses and assignments to
and up to 6 hours per session gamble
• Not increased gambling limits for • His girlfriend left him because he
the past 15 years stole money from her bank account
• Never stayed at the casino for more • Has attempted to quit or reduce
than time planned gambling 8 times in the last 1.5
• Allocates appropriate time for years
exercise and family • Conceals gambling behavior from
• Financially comfortable with family and friends
retirement account • Used money from financial aid and
• Family is aware of gambling scholarships to gamble
behavior • About to get kicked out of college
for poor grades and financial status

Adapted from Fong, T. W., Reid, R. C. & Parhami, I. (2012). Behavioral addictions: Where to draw the lines? Psychiatric Clinics of
North America, 35, 279-96.

Levels of Gambling

Shaffer, Hall, and Vander Bilt (1997, 1999) describe gambling-related behavior as existing on
a continuum from abstinence, to severe problems, to pathological gambling (cited in Alberta
Health Services, 2009). As a result, three levels of gambling were proposed on this
continuum, including level one, level two, and level three. The first level describes no
gambling at all or recreational gambling, as discussed above. People in the first level on the
gambling continuum, gamble for social and recreational purposes, do not typically exceed
self-imposed monetary limits, and experience little or no financial, psychological or
interpersonal damage (Alberta Health Services).

The second level describes problem gambling and requires some indicators of a gambling
problem or sub-clinical levels that can cause issues but do not meet the full diagnostic criteria
for pathological gambling (Alberta Health Services). Problem gambling is defined as an

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involvement in risky gambling behaviors that adversely affect the individual’s well-being
potentially with issues related to relationships, family, financial standings, social matters and
vocational pursuits (Arizona Council on Compulsive Gambling Inc., 1999). Individuals may
move from either end of the continuum or simply maintain a moderate level of problem
gambling (Alberta Health Services).

The third level describes a significant behavioural addiction to gambling and occupies the end
of the continuum. Compulsive gambling is characterized by a continuous or periodic loss of
control over gambling activity; a preoccupation with gambling and with obtaining money with
which to gamble; irrational thinking; and a continuation of the behavior despite negative
consequences (Arizona Council on Compulsive Gambling).

Types of Pathological Gamblers

Pathological gamblers can present in many ways but there are some common prototypes. The
‘action gamblers’ and the ‘escape gamblers’ have different motivations for gambling, different
preferred gambling activities, and different rates of recovery from gambling (Arizona Council
on Compulsive Gambling, 1999). The following table illustrates the differences between action
and escape gamblers (Arizona Council on Compulsive Gambling).

Table 2: Characteristics of action gamblers versus escape gamblers

Action Gamblers Escape Gamblers

-likely to have domineering personalities -likely to be nurturing individuals
-likely to have above average IQ’s -likely to be very responsible
-usually exude energetic and assertive -prefer games of luck (bingo & slot
behavior machines)
-generally suffer from low self-esteem -begin gambling later in life
-tend to start early in life (adolescence) -use gambling for escape or empowerment
-prefer games of skill (poker & dice) -more prevalent among women
-more prevalent among men -more likely to seek professional help

Adapted from Emshoff, J., Perkins, A., Zimmerman, L., Moos, A., Zorland, J. (2007). Pathological gambling
nd
treatment literature review (2 ed.). Georgia State University.

Pathophysiology of Gambling
Abnormalities in serotonin, norepinephrine, dopamine, glutamate, and endorphins have been
found in individuals with pathological gambling issues (Pallanti, Rossi, & Hollander, 2006;
Ibanez, Blanco, Perez de Castro et al., 2003; Fong & Reid, 2012). Research shows evidence
of decreased activity or availability of serotonin which contributes to decreased feelings of
well-being and happiness within the pathological gambler. Cerebrospinal fluid (CSF) levels of
norepinephrine were determined to be higher in pathological gamblers (Roy, Adinoff,
Roehrich, et al., 1988). Norepinephrine function is associated with arousal and sensation
seeking (Gould & Sanders, 2008). As a stress hormone, norepinephrine affects the amygdale
in the brain which is responsible for responses of heightened attention. Norepinephrine, in
tandem with epinephrine, modulates the fight or flight response which when activated,
increases heart rate, releases glucose as available energy from storage, increases oxygen-
rich blood available to skeletal muscle and the brain, and can also suppress
neuroinflammation within the body.

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Dopamine function is associated with the reward pathways in the brain (Gould & Sanders).
Research shows that every type of reward experienced by the pathological gambler increases
the level of dopamine transmission in the brain. Dopamine is known to function in behavior,
cognition, voluntary movement, motivation, punishment and reward, inhibition of prolactin
production (involved in lactation and sexual gratification), sleep, dreaming, mood, attention,
working memory and learning (Duke Medicine News and Communications, 2006). The
presence of dopamine stimulates the secretion of the neurotransmitter glutamate, which is
known to stimulate the prefrontal cortex. The prefrontal cortex is the part of the brain that
remembers the events that contributed to pleasurable experiences as a result of the abundant
presence of the glutamate (Lang, 2012). Glutamate is the chemical that secures the
pleasurable experience in the memory of the pathological gambler. Endorphins are released
during the course of gambling behaviors which produces a feeling of euphoria that
pathological gamblers so affectionately describe.

Pathological gamblers display deficits in a variety of tasks designed to illustrate executive

function (Gould & Sanders, 2008). Researchers tested pathological gamblers using the delay
discounting task tests to determine if the individual would indicate a preference for a smaller
immediate reward or a larger delayed reward (Goudriaan, Oosterlaan, de Beurs, et al., 2004).
It was found that pathological gamblers were more likely to select the immediate reward
(Gould & Sanders, 2008). In the Iowa Gambling Tasks, pathological gamblers were more
likely to continue to prefer the high-reward, high-loss decks with long-term net loss (Gould &
Sanders). Results as shown within these research studies illustrate how pathological
gamblers display challenges with executive function in persistently making decisions that lead
to negative consequences. The phenomenon of poor decision-making is also found in
individuals who have damage to the ventromedial prefrontal cortex. Studies of damage to the
ventromedial prefrontal cortex has led to identifying a somatic hypothesis of decision-making.
This hypothesis has been proposed for impaired decision-making in pathological gambling
(Gould & Sanders).

Suicide Risk with Pathological Gamblers

Suicide risk is a very serious consequence for individuals who are challenged by a
pathological gambling addiction. Battersby, Tolchard, Scurrah et al. (2006) found that 81% of
pathological gamblers in treatment displayed some suicidal ideation, and 30% stated that they
had one or more suicide attempts in the preceeding 12 months. Several studies have found
that the risk for suicide attempts or ideations is notably higher in those who suffer from
gambling addiction compared with those of other disorders (Blaszczynski, & Farrell, 1998;
Zangeneh, 2005; Ledgerwood & Petry, 2004; Petry & Kiluk, 2002). Thus, it is important for
health care professionals to be vigilant in assessing for suicidal thoughts, especially during
admission to the program and during individual relapse by conducting a suicide risk
assessment.

Treatment Approaches to Pathological Gambling

Non-pharmacologic treatment approaches for pathological gamblers include self-help

opportunities, brief interventions, short-term therapy, psychodynamic therapy, motivational
interviewing, cognitive behavioral therapy, exposure and response prevention, cognitive
restructuring, developing healthy coping skills (assertiveness, problem solving, relaxation),
and support groups (Gamblers Anonymous) (Fong & Reid, 2012; Gould & Sanders, 2008).
Self-help opportunities and internet guided interventions are an economical and expedient

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therapy for some individuals with gambling problems, especially people avoiding treatment
due to shame and privacy issues (Gainsbury & Blaszczynski, 2011). King, et al. (2012)
summarized the current non-pharmacological best practices as follows:

1) An activity-monitoring schedule may be useful for a clinician and client to develop clarity
about the addictive activity.
2) Treatment goals should be realistic and abstinence may not always be possible.
Controlled or regulated behaviour may be the goal initially.
3) Behaviour based strategies may be useful to reduced prolonged gambling activity in the
initial stages.
4) CBT and especially cognitive restructuring is useful to modify the core beliefs about
gambling
5) Psychoeducation is a useful adjunct to CBT.
6) Motivational Interviewing is a useful adjunct to CBT.

Pathological gamblers have been successful with recovery utilizing a combination of

psychopharmacological and psychotherapeutic interventions as part of their treatment
pathway (Gould & Sanders, 2008). In the last decade, several research studies have been
exploring the impact of pharmacologic treatment options on pathological gambling, including
antidepressants, mood stabilizers and antipsychotic agents. From these studies, it was
determined that the pharmacologic agents that display the most promising profile in treating
pathological gambling include opioid receptor antagonists (eg. Naltrexone) and amino acid
and glutamate modulators (N-acetyl cysteine) (Hodgins, Stea, & Grant, 2011; Achab &
Khazaal, 2011). Naltrexone moderates activity of the mesolimbic dopamine pathway, which is
thought to mediate reward and reinforcement, thus reducing urges and thoughts of gambling
and gambling behavior (Gould & Sanders). The use of the tricyclic antidepressant
clomipramine, and Selective Serotonin Reuptake Inhibitors (SSRI’s) have shown to reduce or
eliminate gambling behaviors in a short term context (Gould & Sanders). As well, mood
stabilizers (lithium, valproate, and carbamazepine) have assisted in reducing the symptoms of
pathological gambling, especially with individuals who may experience co-morbidity with
bipolar disorder (Gould & Sanders).

Conclusion

Like all addictions, gambling is rooted in neurobiological brain structures that are especially
susceptible to adverse events in early development. Personal strengths and resilience can
counter balance these vulnerabilities. The mid-1990s were the beginning of a remarkable
expansion of gambling availability in Alberta and may have added had a negative weight to
this scale for many people. On the other side of the balance, effective treatment for behavioral
addictions are emerging and treatment outcomes for these conditions appear to be similar to
those with other addictive disorders (Fong & Reid, 2012). Recovery based services offer hope
of living a meaningful and satisfactory life, building on strengths, and developing resilience.

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 Appendix A: Gambling Information Resources

Alberta Gamblers Anonymous: A non-profit, self-sufficient fellowship of recovering pathological

gamblers who convene regularly to assist others with recovery from the disease of compulsive
gambling. http://www.albertaga.net/index.php

Set a Limit Alberta: A resource to facilitate learning with understanding gambling and its process
that facilitates educated decision-making in relation to gambling behavior on an individual level.
http://www.setalimitalberta.ca

Alberta Liquor and Gaming Commission: A Government of Alberta agency responsible for
administering the Gaming and Liquor Act regulation, ensuring the gaming and liquor activities in
Alberta are conducted honestly, openly and with integrity, and maximizing the economic benefits of
gaming and liquor activities in Alberta http://www.aglc.gov.ab.ca/

Responsible Gambling Council: A non-profit organization dedicated to pathological gambling

prevention. http://www.responsiblegambling.org/rg-news-research/links-and-resources/links-and-
resources-list/-in-Category/Categories/locations/alberta

Multicultural Gamblers Help Program: A source of culturally sensitive gambling resources

http://www.ceh.org.au/ourprograms/our_programs_mghp/problem_gambling_resources/multilingual
_brochures_gamblers

ProblemGambling.ca: This is an online community supported by the Centre for Addiction and
Mental Health (CAMH) that provides information about pathological gambling to sufferers, others
and health care professionals. http://www.problemgambling.ca/Pages/Home.aspx

Centre for Addiction and Mental Health Journal of Gambling Issues: This is an online forum
that illustrates developments in research, policy and treatment related to gambling and its
associated behaviors through peer-reviewed journal articles. http://jgi.camh.net/loi/jgi

International Centre for Youth Gambling and High-Risk Behaviors: Members of the Centre
conduct research projects that contribute to the advancement of knowledge in the area of youth
gambling and concurrent disorders. In addition, the Centre is involved in training, treatment,
prevention, and policy development related to youth gambling. http://www.youthgambling.com/

The Alberta Gambling Research Institute: Is a consortium of the University of Alberta, the
University of Calgary, and the University of Lethbridge (Alberta Gambling Research Institute, 2013)
that is funded by the Government of Alberta. Its primary purpose is to support and promote
research into gambling in the province (Alberta Gambling Research Institute).
http://www.abgamblinginstitute.ualberta.ca/

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Information and Evaluation Services, Edmonton Zone mireille.lecharrois@albertahealthservices.ca April, 2013 11

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