Introduction to Pathological Gambling

1. Introduction to Pathological Gambling Tom Litwicki, M.Ed., LISAC Emergent Recovery emergentrecovery.com 520.977.3201 emergentrecovery@gmail.com

2. Gambling is a socially acceptable form of entertainment practiced by most adults and a increasingly significant number of youth. Increased Opportunity = Increased Prevalence of Gambling Problems. Correlation between Gambling Problems and Substance Use/Behavioral Health Disorders = Need for Clinicians to Screen for the Disorder, Have an Awareness of Symptomology, and Available Treatment Options.

3. Definition of Gambling • Placing something of value on an event that has a possibility of resulting in a larger, more beneficial outcome (Petry).

4. Historical Context • Dice found in an Egyptian tomb (3000 B.C.E.) • Gaming board cut into a step of the Acropolis at Athens. • Hebrews divided the Promised Land through the drawing of lots. • Colony of Virginia financed through lotteries. • Early Universities (Harvard) funded through lotteries. • Prohibition by 1910 in U.S. – to include Nevada • 1968 – first lottery in New Hamshire. • Today – 38 state lotteries, 32 casino style gambling. • Legal in every state except Utah and Hawaii

5. Internet Gambling • Internet Gambling – 8 Billion (2006)

6. A Culture of Gambling

7. Prevalence Rates • North America • (1.6%) 2.2 Million Adults with pathological gambling • 3.9% at risk for developing

8. Continuum of Gambling Behaviors • Degree of Involvement and Problems • Level 0: No Lifetime Gambling • Level 1: Social or Recreational • Level 2: At Risk Gambling (Problem) • Level 3: DSM IV Pathological Gambling National Research Council, 1999

9. Progression • Initiation Phase • Often initial win • Obsessive Thoughts • Chasing After Wins • Compulsion to Continue Gambling • Impact Quality of Life • Losing Phase • Violation of Previous Norms/Rules in order to continue gambling

10. Pathological Gambling • Persistent and recurrent maladaptive gambling behavior as indicated by five (or more) of the following • (1) is preoccupied   • (2) needs to gamble with increasing amounts • (3) unsuccessful efforts to control, cut back, or stop • (4) restless or irritable when attempting to cut down • (5) gambles as a way of escaping from problems or of relieving a dysphoric mood •  (6) chasing losses • (7) lies to conceal the extent of gambling  • (8) committed illegal acts   • (9) jeopardized or lost a significant relationship, job, or educational or career opportunity • (10) 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

11. Arizona Prevalence Rates • U.S. Range of Lifetime Gambling by state is 81% to 89%. • Arizona is 89%. • 69% last year, • 23% monthly, • 10% weekly. • Problem Gambling - 2.3% Overall • Pathological .7%, Problem 1.6% 2003 Arizona Gambling Prevalence Study • Questionnaire 2,750 AZ Residents Age 18 and older.

12. Arizona Prevalence Rates • Between 14,600 and 38,000 Pathological Gamblers in AZ • Between 42,600 and 78,000 Problem Gamblers in AZ • Most likely male age 35 – 54. • Overrepresented Among Hispanic, Unemployed, and Disabled. • 70% Casino or Lottery. • 33% Horse, Dog, Sports, Private Games.

13. Gender Differences • Women • 32% of all pathological gamblers • Start later in life – 30 • Telescoping • Problem – Pathological in one year • Men = 4.5 years

14. Youth • 2008 Arizona Youth Survey: Overview and Results • The Arizona Criminal Justice Commission (ACJC) is mandated to measure the attitudes and prevalence of substance use, as well as the prevalence of gang activity among Arizona youth. The 2008 Arizona Youth Survey (AYS) administered to 8th, 10th and 12th grade students during the spring of 2008. • 54,734 Valid Results • 319 Schools • Representative State and County Samples

15. Youth Prevalence/Preference

16. Relationship to Crime • 21% of persons seeking treatment have been charged with a crime.

17. Older Adults • Primarily gambling behavior to relieve boredom, be active, engage in social activity. • Primarily slots, bingo, lottery. • Three times more likely to gamble daily. • Nursing Home Survey • 23% engage in games onsite more than once a week.

18. Nixon, Petry Prison Problem Gambling Prevalence

19. Age and Tx HistoryFreedom Group

20. Co-Occurring Disorders • 76% Major Depression • Antisocial Personality Disorder 15 – 40% • (general population 3% males, 1% females)

21. Substance Abuse • 7 times more likely to have substance abuse concerns • Lifetime Level 2 – 15.01% • Lifetime Level 3 – 14.23% Shafer, Hall, Vander Bilt (1999)

22. Arizona and State Prison Group

23. Problem Activity

24. Screening and Assessment • South Oaks Gambling Screen • NORC

25. Treatment and Recovery

26. Why do people gamble too much? • Behavioral Theories • Positive Reinforcement – variable reward schedule. • Negative Reinforcement • Initiating but not completing a habitual behavior leads to uncomfortable states of arousal. Chasing until you win. • Vicarious Learning • Imitate behaviors that are followed by reinforcers.

27. Why do people gamble too much? • Cognitive Theories • Thinking Errors • Superstition – Luck • Interpretive Bias Win = skill Loss = fluke • Temporal Telescoping • Expecting wins sooner for self than others • Selective Memory – ignore losses • Illusory Correlations • I won because of X • Sunk-cost Effect: Willingness to engage in behavior because of money or time already in behavior.

28. Why do people gamble too much? • Dispositional Theories • Personality Factors increase risk • Extroversion • Neuroses • Impulsivity • Low ego strength • Over or under arousal

29. Why do people gamble too much? • Neurobiological Systems • Differing reinforcement sensitivity • Serotonin • Possible impact on impulse control • 2 out of 3 studies found low levels • Dopamine Imbalance • Rewarding and reinforcing behaviors

30. Treatment Engagement • 8% of Level 3 gamblers get treatment (NRC, 1999) • Why don’t they come into treatment? • 80% wished to handle problem on their own. • 50% embarrassment • Other • Gambling not perceived as a problem • Unaware treatment is available • Unable to share problems with others • Concern over stigma • Only a minority of patients identified cost of treatment as a barrier.

31. Natural Recovery • Lifetime v. Last Year • 40% of persons with pathological gambling in lifetime, do not meet criteria for pathological gambling in the last year (Higins, 1999). • 36% to 46% Level 3 gamblers considered in recovery (NRC, 1999). • Why did they Stop? • Financial loss and emotional pain.

32. Evidence Based Practice • Motivational Interviewing/MET • Motivational interviewing is a goal directed, client-centered counseling style for eliciting behavior change by helping clients to explore and resolve ambivalence. • Miller, Rollnik (1991) • 3 Randomized Clinical Trials

33. Promising MAT Approaches • Managing Cravings • Naltrexone – Opioid receptor antagonist • Inhibits dopamine release and blocks the effect of endogenous endorphines (not as rewarding) • Better than placebo in short term pathological gambling treatment. • Increased outcome for those with unusually strong urges. • Antidepressents • Inhibits serotonin reuptake • Fluvoxamine • Mood Stabilizers

34. Promising Behavioral Approaches • 12 Step • Loss of Control • Solution - spiritual and character renewal • Cognitive Behavioral • Thinking = Emotions = Behaviors • Solution – modify thinking • CRA • Skill Building – refusal skills • Reward Positive Behavior – Social Events • Contingency Management • Variable Reward Schedules

35. Peer Mutual Aid Groups • Gamblers Anonymous • Stuart and Brown (1988) followed 232 GA attendees • 7.5% received 1 year pin • 25% only attended 1 meeting • 75% attended 10 or fewer • SMART Recovery • Christian Recovery Groups • Bi-polar and Depression Peer Support Groups • ?

36. Accessing Services • Arizona Office of Problem Gambling • Treatment Administrator • Education and Prevention • 1-800-Next Step • Treatment Assistance Program

37. Questions