7.1.1. PATHOLOGICAL GAMBLING
Gambling, a common activity around the world, involves risking something of value in the hope of obtaining something more valuable. (Fauth-Bühler et al., 2017). Adult gambles without problems. In the general population, the lifetime prevalence of pathological gambling is approximately 0.4-1.0% (DSM-V). Pathological gambling can be defined as a disorder that results in frequent and repeated gambling that dominates the patient’s life in a way that harms social, occupational, financial and family values and commitments (Fauth-Bühler et al., 2017). Excessive gambling was first recognized as a psychiatric disorder in the ninth edition of the International Classification of Diseases (WHO, 1977). Three years later, pathological gambling was added to the US diagnostic coding of the Diagnostic and Statistical Manual of Mental Disorders, third edition (DSM-III). The original diagnostic criteria included in the DSM-III were based on the clinical experience of several professors at the time; this emphasized damage and disruption to the individual’s family, personal or professional pursuits, and money-related matters. In this edition, gambling addiction is classified as an impulse control disorder (‘ICD’). In the next edition, the criteria for gambling addiction were revised to reflect its similarity to substance abuse, such as the addition of “repeated unsuccessful attempts to control, reduce, or stop gambling” (DSM-IV). In the DSM-IV, gambling addiction is classified under the heading “Impulse Control Disorders Not Elsewhere Classified”. While the growing scientific literature on gambling addiction is revealing common elements with substance use disorders, gambling addiction has been carried along with “Substance-Related and Addictive Disorders” in the fifth revision of the DSM (DSM-V). Also, gambling addiction has been renamed “gambling disorder” in the DSM-V. Today, gambling addiction is a non-substance related disorder or behavioral addiction.
220.127.116.11. PATHOLOGICAL GAMBLING VS FUN
It is known that someone who is too involved in gambling tends to gamble pathologically. But where should we draw the line? Fong et al. (Fong et al., 2012) summarized the differences between the recreational gambler and the pathological gambler. They described two cases of gamblers;
Gambler 1: Fun Gambler
• 67 year old retired doctor who plays poker at the casino 5 times a week and up to 5 hours per game.
• Gambling limits have not been increased in the last 20 years.
• Never stayed in the casino longer than the scheduled time.
• Allocates appropriate time for exercise and family.
• Financially comfortable with a retirement account.
• The family is aware of the gambling behavior.
Gambler 2: The Pathological Gambler
• Twenty-year-old college student who gambles whenever he has money.
• Skips classes and assignments to gamble instead.
• He engages in bank fraud and steals from his girlfriend to finance gambling.
• Has attempted to quit or cut down on gambling 10 times in the last 2 years.
• Hides gambling behavior from family and friends.
• Uses money from financial aid and scholarships to gamble.
• About to be expelled from university due to bad grades and financial situation.
Compared to the first gambler, the second gambler is unable to control his gambling and experiences significant negative consequences from his gambling behavior.
7.2. DIAGNOSIS OF GAMING ADDICTION
To be diagnosed with a gambling disorder according to the DSM-V, a person must meet at least 4 out of 9 diagnostic criteria within a 12-month period. See below for the DSM-V diagnostic criteria for gambling disorder:
1. The need to gamble with increasing amounts of money to obtain the desired excitement.
2. Is restless or irritable when trying to stop or quit gambling.
3. Made repeated unsuccessful efforts to control, reduce, or stop gambling.
4. Frequent preoccupation with gambling (for example, having persistent thoughts such as reliving past gambling experiences, preventing or planning the next attempt, thinking of ways to earn money for gambling).
5. Often gambles when feeling distressed (eg helpless, guilty, anxious, depressed).
6. After losing money in gambling, he often returns to another day to seek revenge (“chasing one’s losses”).
7. He lies to hide the extent of his relationship with gambling.
8. Endangered or lost a significant relationship, job, or educational or career opportunity due to gambling.
9. Relies on others to provide money to alleviate hopeless financial situations caused by gambling.
7.3. GAMBLING ADDICTION AND CHILDHOOD TRAUMA
Gambling addiction is classified as a behavioral disorder and has some phenotypic similarities with substance use disorders. Childhood distress and life stressors are associated with an increased risk of substance use in adulthood. (Felsher et al., 2010). Certain types of childhood trauma can have varying degrees of influence on the development of certain types of behavioral addictions, such as gambling addiction. Emotional neglect and physical neglect emerged as the most frequently confirmed type of childhood trauma in gambling addicted participants, regardless of trauma severity (Felsher et al. 2010). It has been shown that the relationship between childhood trauma and problematic gambling is affected by various other factors such as stress (Bergevin et al., 2006; Lane et al., 2016; Scherrer et al., 2007).
The article “Adverse Childhood Experiences and Gambling: Results of a National Study” by Sharma and Sacco is a new review of childhood trauma and gambling. Findings from this study suggest that adverse childhood events are associated with gambling problems, among other mental health problems. Prevention and treatment efforts for children and youth who experience adverse childhood events can reduce the risk of later developing gambling problems (Wiechelt & Straussner, 2015).
7.4. GAMING ADDICTION TREATMENT
Cognitive-behavioral therapy is currently recognized as the most effective treatment for gambling disorder. This type of therapy assumes the fact that irrational thoughts linked to a person’s ability to control the game and predict victory represent the main factors determining the development and maintenance of this pathology (Korn and Toneotta, 2004). The relevant literature includes more cognitive-behavioral therapy models for gambling addiction (Roylu N and Oei TP, 2010; Disney et al., 2011; Blaszcznski and Nower, 2002; Toneatto, 2002); (Apodaca and Miller, 2003; Hodgins et al., 2001; Petry et al., 2006); conducted a comparative study of 231 compulsive gamblers, which they divided into three groups: the first group was treated using the Gambler Anonymous method, the second group was treated using GA with the help of cognitive behavioral therapy guidance, the third group participated in the GA groups and eight individual CBT sessions. Improvements were found in 59% of the participants who benefited from CBT, 39.2% of those who completed the exercises in the CBT books, and 34% of those who participated in the GA groups only (Ladouceur et al. 2002). They proposed a therapy model for gambling addiction treatment that includes the following five steps:
• Information in terms of general aspects of the game;
• Changing the gambler’s irrational beliefs with how gambling activities are conducted;
• Development of new coping skills and problem solving;
• Acquiring social skills;
• Learning some relapse prevention techniques.
recommends a cognitive-behavioral therapy group therapy protocol lasting eight sessions at a weekly frequency. The assignment of the session, which includes the protocol (Petry, 2005):
• General information, presenting the reward system for game avoidance and identifying these factors, contributing factors to the urge to play;
• functional analysis of gambling behavior;
• Increased frequency of enjoyable activities;
• Automatic management plan;
• Coping with the urge to gamble;
• Training for assertiveness and the ability to refuse play;
• Changing irrational thoughts;
• Planning for emergencies and prevention of relapse.
7.5. CIS FOR GAMBLING ADDICTION
He proposed a model in which the main components refer to the restructuring of the gambler’s environment to be less conducive to pathological gambling; Patients are first taught to identify their irrational thoughts about gambling, to understand the connection between these thoughts and pathological gaming behaviors, and to identify new coping methods (Ledgerwood & Petry, 2005), and suggested a cognitive-behavioral therapy model that includes four steps (Roylu & Oei, 2010):
• Evaluating the client’s problems and needs, training, and motivations to change dysfunctional behaviors using motivational interviewing techniques;
• Introducing the gambler to the basic strategies of cognitive-behavioral therapy used to stabilize the gambler’s compulsive gambling behavior and to minimize the negative effects in case of relapse;
• Learning some coping methods in terms of maintaining positive changes in play behavior;
• Learning strategies for maintenance of therapeutic gains and prevention of relapse.
Introduced a self-help program for gamblers consisting of the following steps. (Blaszczynsky, 2010):
• Increasing motivation to stop the game;
• Monitoring of gambling behavior;
• Controlling the urge to gamble by following relaxation techniques;
• Identifying irrational thoughts and replacing them with other rationalities;
• Prevention of relapse;
• Learning about new ways to get family support.
He proposed a different model while using an alternative to cognitive-behavioral therapy (Wulfert et al., 2003) for the treatment of gambling addiction, which includes motivational interviewing techniques, cognitive-behavioral therapy, and relapse prevention techniques. Increasing motivation when the key concepts are: it is essential to increase the motivation of the gambler to observe the product of change; motivation is a dynamic feature; and motivation is influenced by external factors, including the counselor’s behavior and attitude. (Miller & Rollnick, 2004) The advantages of cognitive-behavioral therapy are that it is a well-structured type of therapy, performed in a limited time frame, requires less cost than other types of therapy, and provides long-term results. In studies conducted so far, the success rates of this type of treatment for gambling addiction range from 36% (Sylvain et al., 1997) to 42% (Ladouceur et al., 1998); up to 72% (Tolchard et al., 2000) up to 77% (Ladouceur et al., 2003); to 49% (Petry, 2005); and 74% (Rizeanu, 2014).
Treatment of gambling disorder presents many problems, first of all, because pathological gambling has only recently been recognized as a disorder in its own right, insufficient research has been done, and there is a lack of trained professionals. It is important to provide psychological and psychiatric services in this area. In Romania, the cognitive-behavioral therapy model for gambling addiction was introduced, mainly based on cognitive restructuring techniques and with the following key objectives:
• Reducing the consequences of gambling disorders that interfere with the daily functioning of gamblers;
• prevent or reduce the risk of developing gambling addiction behavior;
• Managing the negative emotionality associated with this disorder (depression, anxiety, stress);
• Meeting the need for entertainment and developing new and pleasant recreational and social activities that do not risk having a devastating impact on the lives of the subjects.
The model includes several stages such as assessment and formulation, introduction to psychoeducation and ABCDE model, cognitive restructuring, problem solving training, assertiveness skills training, and relapse prevention. In the clinical evaluation phase, the individual’s participation in the therapeutic process is examined by increasing the motivation to change the gambling behavior and the following points are clarified (Rizeanu, 2013):
• The source of the individual’s pathological gambling problems;
• Etiological and maintenance factors;
• The extent to which subjects have access to psychological support and the effectiveness of the support they receive;
• Whether they sought treatment on their own initiative or at the request of their friends;
• How they are aware of our specialist psychological services;
• The reasons for this if they have not reached psychological support. Active listening, reflection, nonverbal communication (maintaining visual contact, clear body posture, non-evaluative facial expression, tonal consistency, etc.) and verbal communication (eg the meaning of what is said).
Dryden and Matweychuk believe that maintaining benefits from treatment requires the development of coping skills in relation to risk situations and future temptations as long as addictive behavior relapses; the authors offer the following recommendations (Dryden, 2000).
• Develop a few healthy beliefs, such as letting go of the habit of pleasing others and putting yourself first and others second;
• Create (or develop) several social interests: understand that the people around you have their own desires and goals in life and cannot always provide you with unconditional support, you should also consider how you can support and stand by them;
• Learn how to take control of your life; don’t let your addictive behaviors control your life;
• Develop a high tolerance for disappointment so that you can achieve the goals you have set for yourself;
• Be flexible to deal with the next challenges in your life;
• Learn to accept uncertainty, because we live in a world of possibilities where nothing is absolutely certain;
• Develop your creativity so you can find new ways to spend your time;
• Think logically, set short and long-term goals and consider the possible consequences of your actions;
• Learn to accept yourself unconditionally without making global judgments about who you are as a person;
• Take only limited risks to increase your chances of achieving the goals you have set for yourself;
• Adopt the philosophy of long-term hedonism, balancing between immediate gratification and long-term gratification;
• Take responsibility for your own negative emotions without attributing them to external causes;
• Adopt a healthy lifestyle with a healthy ratio of work, rest, sports and leisure activities;
• Develop a sense of humor to maintain a good temper even in the face of difficulties.