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German Journal of Psychiatry

ISSN 1433-1055

Review of the Phenomenology, Etiology and Treatment of Pathological Gambling  


  Paula Moreyra¹, Angela Ibáñez², Jerónimo Saiz-Ruiz², Kore Nissenson¹, and Carlos Blanco¹  

¹Department of Psychiatry, Columbia University/ New York State Psychiatric Institute, New York

  ² Hospital Ramón y Cajal, Universidad de Alcalá de Henares, Spain   


Corresponding author: Carlos Blanco, M.D. Ph.D., Department of Psychiatry,

Columbia University/New York State Psychiatric Institute, Box 69, 1051 Riverside Drive,

New York NY 10032, USA

cb255@columbia.edu


Abstract  

Objective: Pathological gambling is an increasing public health problem. Many mental health professionals have limited information regarding the etiology, phenomenology and treatment of this patient population. Method: Computerized literature search using PsycLIT and MEDLINE for the years 1984 to 1999. Results and conclusion: There are several competing conceptualizations of pathological gambling: as an impulse control disorder, a mood disorder, an obsessive-compulsive spectrum disorder, or a non-pharmacological addiction. An alternative model of pathological gambling is as a heterogeneous disorder with different subtypes sharing certain characteristics. Both biological and psychological factors play a role in the etiology of pathological gambling. Treatment options include several medications, psychotherapies and attendance to Gamblers Anonymous, although none of them are established treatments. There is the need for further research in order to improve the understanding of this disorder and improve the quality of the treatments available (German J Psychiatry, 2000;3:37-52).

  Key words: pathological gambling, impulse control, mood disorder, obsessive-compulsive disorder, addiction


 

Introduction

Pathological gambling is a frequently underdiagnosed and disabling disorder the  prevalence of which appears to be increasing along with the increment of gambling opportunities (Volberg, 1994). Many decades have passed since excessive gambling was recognized as a form of psychopathology. But the attention paid to this disorder grew considerably when pathological gambling started to be considered a public health issue, as well as when the American Psychiatric Association (APA) included pathological gambling in the third edition of its Diagnostic and Statistical Manual of Mental Disorders (DSM-III) in 1980. Over the last decade, there has been a growing interest to refine the diagnostic criteria of pathological gambling, assess its prevalence, identify the possible causes of this disorder, and find effective treatments for it.

Pathological gambling is a chronic and progressive condition that disrupts the life of the individual and those close to him. Not only is pathological gambling associated with financial problems due to the large amounts of money spent on the activity or the loss of a job, but this disorder increases the likelihood of other emotional and psychiatric problems, and general health problems in the individual or his family (Lorenz and Yaffee, 1986, 1988). Suicide is a possible consequence of pathological gambling. Exceeded only by mood disorders, schizophrenia and some neurological conditions, the suicide rate due to pathological gambling has been found to be very high.

Phenomenology of pathological gambling

At present, there are several competing conceptualizations for pathological gambling.

(1) The World Health Organization (WHO), as well as the APA, classify pathological gambling as an impulse control disorder, because the individual becomes increasingly incapable of resisting his impulses to gamble. All the impulse control disorders share the following characteristics: difficulties to resist an impulse, desire or temptation to perform some behavior that is detrimental for the individual or others; a progressive emotional discomfort or tension before performing the act; pleasurable or gratifying feelings while performing the behavior, which means that the behavior is egosyntonic; in some cases, negative feelings of guilt, remorse or shame when the act is over. All of these characteristics are recognizable in the pathological gambler.

(2) Because of the high incidence of depression throughout the life of pathological gamblers, up to 75% reported in some studies, many authors consider that pathological gambling could be a form of affective disorder (McCormick et al., 1984; Linden et al., 1986; Roy et al., 1988a; Cusack et al., 1993; Sullivan et al., 1994). Supporting this hypothesis is the fact that there is high comorbidity between pathological gambling and alcoholism (also related to affective disorders), and a higher frequency of affective disorders in first degree relatives of pathological gamblers. Additional evidence in support of this hypothesis are the high incidence of suicidal attempts found in this population (Saiz-Ruiz & López-Ibor, 1983; McCormick et al., 1984; Sullivan et al., 1994) and the high scores found in scales that measure depression (Glen, 1979; McCormick et al., 1987; Blaszczynski & McConaghy, 1988; Saiz-Ruiz et al., 1992). Contrary to the idea that pathological gambling is a form of mood disorder is the idea that in many cases the affective disorders observed in pathological gamblers are not primary, but constitute a secondary reaction to the negative consequences of gambling (Saiz-Ruiz & López-Ibor, 1983; Taber et al., 1987a; Ramírez et al., 1988; Saiz-Ruiz et al., 1992; Sullivan et al., 1994; Thorson et al., 1994; Moreno et al., 1995). Additionally, some studies have not found significant differences in the frequency of affective disorders in first degree relatives of pathological gamblers and the general population (Thorson et al., 1994; Ibáñez, 1997).

(3) Some authors consider that pathological gambling is best understood as an obsessive-compulsive spectrum of disorder. In this context, the term obsessive-compulsive spectrum disorder is used to describe a group of disorders with pathophysiological similarities that also share genetic and biological mechanisms. Patients with spectrum-related disorders show an intense desire to perform a specific behavior preceded by unpleasant feelings and physiological activation, all of which are relieved when the behavior is performed (Hantouche & Merckaert, 1991; Hollander, Skodol & Oldham, 1996; Cartwright et al., 1998). In addition, it has been noted that patients with pathological gambling report a repetitive thought related to gambling that they cannot remove from their minds, which leads them to gamble against their will, especially in advanced phases of the disorder (Lesieur, 1979).

Authors who oppose this view argue that the idea of gambling and the gambling behavior in itself, although not its consequences, are egosyntonic for the patients in all phases of the disorder, in contrast to what happens in the obsessive-compulsive spectrum disorders, where the behavior is consistently egodystonic (Moreno, 1991; APA, 1994; Ibáñez, 1997). Furthermore, pathological gamblers do not show the excessive doubt characteristic of obsessive-compulsive patients (Rasmussen & Eisen, 1992). Moreover, compulsive behaviors include increased evasive behavior, risk aversion and anticipatory anxiety, all of which are not observed in the behavior of pathological gamblers.

(4) A fourth model views pathological gambling as a non-pharmacological addiction. The common elements to all kinds of addiction are an intense desire to satisfy a need, loss of control over the substance or behavior, symptoms of abstinence and tolerance, thoughts about the use of the substance and performance of the behavior despite its adverse consequences (OMS, 1993). All of these elements are present in pathological gambling. Gamblers' intense longing to bet is equivalent to the cravings experienced by substance abusers, even a study by Castellani and Rugle (1995) found that gamblers had more difficulties resisting the cravings than substance abusers. Moreover, evidence suggests that up to a third of pathological gamblers experience withdrawal symptoms such as irritability, psychomotor agitation, difficulties for concentration and other somatic complaints (Wray et al., 1981; Dickerson, 1989). Gamblers also experience the equivalent of tolerance when they need to increase the frequency of bets or the amount of money spent in order to obtain the desired excitation. Furthermore, pathological gamblers become progressively preoccupied and involved in gambling-related activities at the cost of abandoning other sources of pleasure and enjoyment (Lesieur, 1979), and despite the negative domestic, professional, financial and social consequences of their behavior (McCormick & Ramirez, 1988; Bland et al., 1993).

Other findings in favor of this hypothesis are the high comorbidity found between pathological gambling and other addictive disorders, especially alcoholism; the family history of addictions found in pathological gamblers; the tendency to relapse; and, the positive response of pathological gamblers to psychological treatment modalities used for other addictions (Ibáñez, 1997).

(5) Finally, it is also possible that pathological gambling may not be an homogeneous entity that fits only into one of the models mentioned above, but rather a mixed group with different subtypes that share certain characteristics. In order to confirm or reject the existence of such subgroups and define their particularities, future research should assess phenomenological aspects of gambling behaviors such as the choice of the gambling setting and activity, the motivations to gamble, and the mood present during gambling or triggered by it. Studies of the natural history of the disorder, possible differential treatment response, and underlying neurobiological differences can further help in the definition of these subtypes.  

Etiology of pathological gambling

Along with the existence of different conceptualizations of pathological gambling, a number of biological and psychological theories have been presented to explain the etiology of pathological gambling. The biological theories have focused on the intervention of neurotransmitters’ systems in pathological gambling. The psychological explanations arise from different psychological orientations, including psychoanalysis, behavioral psychology or cognitive psychology.

Biological hypotheses

Serotonergic function

Phenomenological similarities between pathological gambling and other impulse control disorders have led to a search of serotonergic abnormalities in pathological gamblers. Serotonin dysfunction has been frequently shown to be associated to other impulsive behaviors such as fire-setting, violent offenses and violent suicide. Impulsivity implies a deficit in cerebral inhibition, which is partly mediated by serotonergic pathways (Carlton & Manowitz, 1987; Linnoila, 1990; Jacobs, 1991).

Because platelet monoamine oxidase (MAO) activity is believed to be a good indicator of serotonergic systems, Blanco et al. (1996) compared platelet MAO activity in 27 male pathological gamblers and 27 controls matched for age, gender and tobacco consumption. Platelet MAO activity was significantly lower for the patients than for the comparison subjects, suggesting that pathological gamblers have a deficit in their serotonergic function.

In further support of the hypothesis of a serotonergic deficit in pathological gamblers, another study has found an allele variant of a polymorphism in the MAO-A gene in a group of 31 severe pathological gamblers (Ibáñez et al., 2000). In contrast, the same study found that the gene for MAO-B did not have a different allele distribution in patients and controls, suggesting that low levels of MAO-B activity in pathological gamblers are not determined by the gene for MAO-B, although they may be mediated through genes that modulate the expression of the MAO-B gene.

Moreno et al. (1991) administered IV clomipramine to 8 pathological gamblers and 8 healty volunteers matched for gender and age. Pathological gamblers had lower baseline prolactin levels and blunted prolactin levels at 60 minutes post-CMI infusion compared with controls, suggesting decreased serotonin transporter binding acitivity in pathological gamblers.

In a subsequent study, DeCaria et al. (1996) compared prolactin response to a single dose of m-CPP between pathological gamblers and matched controls. They found that pathological gamblers showed increased changes in prolactine in contrast with the controls, and a positive correlation between changes in prolactin and gambling severity. These findings suggest an hypersensitivity of 5-HT postsynaptic receptor in pathological gamblers.

Noradrenergic function

Central norepinephrine is involved in the physiological functions associated with arousal and impulse control. A study by Roy et al. (1988b, 1989) points to an implication of the NE system in the pathophysiology of pathological gambling related to arousal. They found an increase of CSF MHPG, plasma MHPG, urinary NE and vanillymandelic acid in pathological gamblers. Furthermore, they found a significant correlation between these indexes of noradrenergic functioning and the scores on the extraversion scale of the Eysenck Personality Questionnaire. This study suggests that pathological gamblers may have a functional disturbance of their noradrenergic system that could be reflected in their personality.

Using growth hormone (GH) response to clonidine, an alpha-2 adrenergic agonist, as a form of assessment of central noradrenergic function, DeCaria et al. (1997) compared a group of five pathological gamblers with eight healthy volunteers on GH response to clonidine. They found an increased response of pathological gamblers compared to controls. In addition, severity of gambling behavior correlated with the magnitude of clonidine-induced GH response, suggesting an involvement of the noradrenergic system in the etiology of pathological gambling.

Dopaminergic function

A growing body of literature relates the dopaminergic system to reward mechanisms and addictive behaviors (Wise, 1987). It has been hypothesized that some individuals may have deficits in dopaminergic transmission in the brain, which would lead them to experience generalized feelings of discomfort. These subjects would engage in activities or would use substances in an attempt to increase and normalize dopaminergic transmission (Sunderwirth & Milkman, 1991).

Based on the conceptualization of pathological gambling as a behavioral addiction, some authors have sought to investigate dopaminergic function in pathological gamblers. Roy et al. (1988b) failed to find significant differences in plasma, urinary and dopamine CSF between pathological gamblers and controls. However, more recently, in a study with ten pathological gamblers and seven controls matched for height and weight, Bergh et al. (1997) found that pathological gamblers had a decrease in dopamine in the CSF and an increase in dopamine metabolites compared to healthy volunteers. These findings suggest an increased release of dopamine in pathological gamblers. An explanation of the difference in the results obtained by these two studies is unclear and points to the need to perform more studies on the dopaminergic system of pathological gamblers.

Psychological hypotheses

Psychoanalytic theories

The first people to offer an explanation for pathological gambling was the psychoanalysts. Von Hattingberg conducted the first study of pathological gambling in 1914. He proposed that pathological gamblers had a fixation in the anal phase of development which explained the compulsive and masochistic traits in their personality. Pathological gamblers eroticize the tension and fear involved in gambling.

The work of von Hattingberg was further elaborated by Freud and Bergler who have largely influenced later psychoanalytic work on this topic. In his paper “Dostoyevski and Parricide”, Freud (1928) suggests that pathological gambling is a form of addiction related to the Oedipus complex. The individual gambles as a substitute for masturbation. Also gambling constitutes a way of punishment that secondarily becomes a pleasurable activity. Thus, Freud suggests masochistic component to pathological gambling. For Bergler (1957), pathological gambling is also masochistic and related to the Oedipus complex, but he emphasizes the relationship with authority figures as the origin of guilt.

More recently Rosenthal (1986) has suggested that pathological gambling may be more closely related to the preoedipal than to the oedipal phase of development. According to him, pathological gamblers tend to have narcissistic personality traits. Omnipotence and negation are then the defense mechanisms that explain the gambler’s belief in his capacities to win beyond any rational thought.

Behavioral theories

Behavioral theory views pathological gambling as a learned behavior acquired through a process of reinforcement. However, there is disagreement about the reinforcing element in pathological gambling.

Some authors consider that the occasional economic gains in a pathological gambler are a strong reinforcement, at least in the initial stages of the disorder (Morán, 1970). It has been shown that variability and unpredictability of reinforcements strengthens learned behavior (Skinner, 1953). Gambling is characterized by such an intermittent schedule of rewards, thus theoretically fostering the reinforcement of the gambling behavior. Supporting the hypothesis of economic gains as the most important reinforcement in this disorder is the fact that almost half of the gamblers report a significant monetary gain in the initial phase of their disorder that could act as a trigger for it. (Custer, 1982; Custer, 1984; Custer & Milt, 1985).

Other authors suggest that the true reinforcement in pathological gambling is not an external factor such as economic gains but an internal one. Brown (1986) has suggested that some form of arousal or excitement, either autonomic or cortical, plays a major role in the development and maintenance of gambling behavior. Each individual has an optimum level of arousal at which he feels best. Particularly when the environment is insufficiently stimulating for the individual, he seeks levels of stimulation that maintain his optimum level of arousal. Gambling has the power of changing this arousal level.

Blaszczynski et al.  (1986) and McConaghy et al. (1988) have postulated that what is essential in the etiology of pathological gambling is the "behavior completion mechanism". According to this theory, once a behavior becomes a habit, any stimulus associated to that behavior, either internal or external, creates a need in the subject to perform that behavior, so that if it is not completed the subject experiences an intense feeling of discomfort. The reinforcement would then be the avoidance of these negative physiological states, instead of the achievement of some pleasurable state.

In a similar line of thought, Hand (1998) suggests that pathological gamblers engage in this behavior in order to avoid or reduce unbearable mental states. However, in his model, these negative mental states arise, not as a result of the behavior completion mechanism, but as a consequence of environmental distress, coping deficits, psychiatric disorders or other daily-life problems in the individual. If the subject stops gambling, the negative mental state will arise again, and the subject is thus forced to engage in the behavior repeatedly.

Cognitive theories

Some authors emphasize the role of cognitive distortions in the development and maintenance of pathological gambling. Gambling creates the illusion of control in the subject and the perception that one is capable of controlling the results. At the same time, subjects develop a series of irrational thoughts related to gambling that lead them to make false inferences regarding their possibilities to obtain positive results, and to distort the meaning of the outcome of the gambling.

Regular gamblers have more irrational thoughts than occasional gamblers and therefore, they engage in more risky behaviors (Gaboury & Ladouceur, 1989). When the individual wins, his beliefs about his chances of winning again and about the role of good luck are reinforced. Losses are interpreted as a sign of an imminent gain because the bad luck has to end at some point. Supporting this idea, a study found that 60% of gamblers risk more money after having lost instead of after having won (Leopard, 1978).

Another distorted thought is related to the assessment of the results. Gamblers tend to remember and overestimate their gains, and they tend to forget, underestimate or rationalize their losses (Ladouceur et al., 1987). It is possible that these kinds of distortions explain the histories of initial gains, prior to the onset of the disorder, described by many patients.

Treatment for pathological gambling

The growth of the information available to professionals and the lay public about pathological gambling, and the increasing recognition of the negative consequences that this disorder brings for the lives of those who suffer from it, has made evident the urgency to find effective treatment options. Based on the different conceptualizations of pathological gambling, a number of treatment strategies have been tried in this population. Nevertheless, the treatment research in pathological gambling is still very scarce and there is no agreement about the relative efficacy of one form of treatment over others.

Pharmacological treatments

Pathological gambling as an obsessive-compulsive spectrum disorder

The selective serotonin reuptake inhibitors (SSRI) have been used in studies in which pathological gambling was thought to be a form of obsessive-compulsive disorder. Their use is based in the positive response of patients with diagnosis of obsessive-compulsive disorder to treatment with serotonin reuptake inhibitors.

Clomipramine, a triclycic antidepressant with a predominantly serotonergic mechanism of action, has been effective in a placebo controlled double-blind single-case study (Hollander et al., 1992). The patient had a history of twelve years as a pathological gambler. Treatment started with a dose of 25 mg. of clomipramine a day, and the dose was increased gradually up to 125 mg. a day. The patient stopped gambling during the third week of treatment and, except for a short relapse in week 17, her gambling behavior continued in remission for an additional 28 weeks, with a daily dose of 175 mg. of clomipramine.

More recently, Hollander et al. (1998) assessed the efficacy of fluvoxamine in the treatment of pathological gambling. 16 patients with a diagnosis of pathological gambling entered an 8-week single-blind placebo lead-in phase. Six dropped out while receiving placebo, and ten patients, six men and four women, completed the 8 weeks of treatment with fluvoxamine. The average dose at the end of the study was 220 mg. a day of fluvoxamine. Seven of the ten patients  that finished the study were considered responders: they had greater than 25% decreases in their gambling behavior scores on the pathological gambling modification of the Yale-Brown Obsessive-Compulsive Scale, and their CGI scores were very much improved or much improved. The seven responders were found to be abstinent by the end of the trial according to patient report, clinician and patient ratings, and information from other informants. 

Pathological gambling as a mood disorder

Lithium, a presynaptic agonist, has been used in a variety of pathologies. Also, the presence of mood disorders’ symptoms coupled with excitability and impulsivity has been a common link found in patients whose treatment with lithium was most effective. It has been hypothesized that in the case of pathological gambling the excitement for winning is bigger than the prize in itself. Furthermore, a risky situation increases the excitement. This intense combination of feelings of confidence, enthusiasm, fear and guilt seems to lead the patient to repeat the gambling behavior.

Based on these observations, Moskowitz (1980) used lithium in three patients. One of them has a history of ten years as a pathological gambler. The patient had periods when he played for long hours and felt confident and optimistic, alternating with periods when he stopped gambling and felt guilty and depressed. Treatment started with 600 mg. of lithium three times a day. After two weeks of treatment the patient reported a calming effect and for many months he was less willing to risk his money. At the same time, he improved his economic situation. At the follow-up, the patient continued to be stable. Another patient showed a similar pattern of gambling: phases of optimism and increased gambling were followed by phases of low mood and less gambling activity. Treatment in this case started also with a dose of 600 mg. of lithium three times daily. After one year the gambling periods decreased, the patient was able to maintain a job and his economic situation improved substantially. During the next one year and a half period of treatment improvement was moderate (Moskowitz, 1980).

Lithium seems to be effective in the treatment of pathological gambling, especially when there is comorbidity with a bipolar disorder. Nevertheless, it is necessary to do more research with lithium because the data obtained to date comes from small samples, and also because it is difficult to distinguish whether the improvement is specific for pathological gambling or is due to a successful treatment of a comorbid mood disorder.

Carbamazepine has also been tried as a treatment for pathological gambling due to its effectiveness as a mood stabilizer. Haller and Hinterhuber (1994) studied the efficacy of carbamazepine in a patient with a history of 16 years of pathological gambling. They used a double-blind, placebo-controlled design. Prior to this study the patient had been on behavioral therapy, psychoanalysis and Gamblers Anonymous but did not obtain positive results. On week 12 of the placebo phase of treatment there were no improvements according to the information obtained from the patient and measures of psychopathology and social functioning. The treatment phase with carbamazepine then began. The initial dose was 200 mg. daily, and it was gradually increased to a dose of 600 mg. daily. The patient stopped gambling in the second week of this phase of the treatment and the disorder stayed in complete remission for 30 more months with the same dose of carbamazepine.

Pathological gambling as a non-pharmacological addiction

Some preliminary reports suggest that pathological gambling may have a favorable response to naltrexone, an opioid antagonist. Although naltrexone was initially used for the treatment of opioid dependence, recently some studies show its usefulness in the treatment of other addictive behaviors (O'Malley et al., 1992; Volpicelli et al., 1992).

Naltrexone inhibits the transmission of dopamine in the nucleus acumbens, and modulates the dopaminergic paths that seem to be implicated in the etiology of addictions. Based on the purported alteration of dopanergic transmission in pathological gambling, Turón et al. (1990) used naltrexone in a study with 30 pathological gamblers. They found that 56% remained in abstinence after ten months of treatment with this substance.

A case report by Kim (1998), also suggests that naltrexone may be useful in the treatment of pathological gambling. The patient was a 55 year-old male pathological gambler. Treatment started with 50 mg. of naltrexone daily during two weeks, after which the patient reported no changes in his symptoms. The dose was changed to 100 mg. daily and after a few days the patient’s interest towards gambling and his gambling behavior completely disappeared. The patient continued in abstinence during the nine months of treatment.

Psychological treatments

Psychoanalysis and psychoanalytic psychotherapy

Bergler (1957) was one of the first authors to report a successful treatment of pathological gambling through psychoanalytic psychotherapy. From a total number of 60 patients, he reported that 14 had improved with psychoanalysis. However, little information is available about the other 46 patients, suggesting that psychoanalysis may be of benefit to only a minority of pathological gamblers. Other authors have observed positive results with the use of psychoanalysis or psychoanalytic psychotherapy in some case studies. However, it is difficult to assess the degree of efficacy of these types of treatment due to methodological problems, such as lack of randomization and comparison groups, the indequate use of assessment tools, and the lack of long-term follow-up studies (Allcock, 1986).

Behavioral psychotherapy

The types of treatment used initially for pathological gambling, based on behavioral theories, were aversive conditioning through the use of electric shocks (Barker & Miller, 1968; Koller, 1972), response prevention (Symes & Nicki, 1997) and imaginary desensitization (McConaghy et al., 1983). These studies showed a significant decrease in the impulse to gamble and the corresponding behavior in the patients, achieving complete abstinence in some cases. However, these studies used small sample sizes and lacked valid and reliable tools to assess the outcomes.

Cognitive-behavioral psychotherapy

At present, from a psychological perspective, theories that combine behavioral and cognitive findings are the dominant models as an explanation of the etiology of pathological gambling (Sharpe & Tarrier, 1993). Bujold et al. (1994) reported the successful application of cognitive-behavioral therapies using cognitive restructuring strategies, problem-solving, social skills training and relapse-prevention in three pathological gamblers. Patients became abstinent after four weeks of treatment and the results were maintained during the nine-month follow-up. In another study, these researchers (Sylvain et al., 1997) assigned 29 pathological gamblers randomly to manual-guided treatment or a waiting list control group. From the 14 patients that completed the study, twelve were considered responders, while only one out of 15 in the control group responded to the treatment. After a twelve-month follow-up, eight patients from the active treatment group were still improved.

Gamblers Anonymous

Gamblers Anonymous, a self-help group modeled after Alcoholics Anonymous, is the most widely used treatment option for pathological gambling. It emphasizes confession to a group of peers in order to attain total abstinence, and it offers financial, legal and vocational assistance. Nevertheless, its efficacy when it is used exclusively has not been established. The information available suggests that only 10-30% of patients that attend a meeting ever return. Moreover, from those who continue the treatment, only 8% remain abstinent after one year and 7% do so for longer than two years (Stewart & Brown, 1988).

There is some evidence suggesting that the combination of Gamblers Anonymous with some type of professional treatment leads to better results. Lesieur and Blume (1991) studied the response of patients to treatment in an inpatient program that combined multimodal individual and group psychotherapy. Attendance to Gamblers Anonymous was strongly encouraged. From the 124 participants, 72 were contacted between 6 and 14 months after being discharged, and 64% of them continued to be abstinent.

Other studies also encourage the notion of combining treatments in order to obtain better outcomes. Russo et al. (1984) studied the outcome of patients who received individual and group psychotherapy, and attended Gamblers Anonymous at the same time in an inpatient program. 55% of the patients were abstinent. Another study by Taber et al. (1987b) similarly found that 56% of a total of 57 hospitalized patients were abstinent.

Discussion

Pathological gambling is a growing public health problem with psychological, familial, financial, and legal consequences. The available literature suggests that both biological and psychological factors play a role in the etiology of pathological gambling, and that further research on its competing conceptualizations is needed to clarify its place in the psychiatric nosology.

There are currently no standard treatments for pathological gambling. However, both cognitive-behavioral approaches and medications have obtained promising results. In addition, referral to GA and Gam-Anon may assist some gamblers and their families, although GA participation alone may not be sufficient for most patients. As public awareness and interest of policy-makers about the severity and consequences of pathological gambling continues to grow, psychiatrists will benefit from an increased understanding of the phenomenology and treatment of pathological gambling.

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