The Vulnerable Faces of Pathological Gambling

Abstract

Pathological gambling is an emerging psychiatric disorder that has medical, psychiatric, and social consequences. Recently, research has been focusing on identifying which portions of the population are most vulnerable to developing problems related to ongoing gambling. Specific populations of interest have included adolescents, elderly, minorities, those with comorbid psychiatric or substance use disorders, and gender differences. Each group possesses unique biological, psychological, and/or social characteristics that confer a vulnerability to develop pathological gambling behaviors. Being able to recognize those who are at risk to become pathological gamblers is the first step toward developing effective prevention and early intervention programs. This is Part Two of a three-part series on pathological gambling. Part One appeared in the March issue of Psychiatry 2005.

Introduction

Pathological gambling is a growing public health concern as evidenced by the increased availability of legalized gambling, the high costs to society, and an increasing demand for treatment services. From a societal perspective, the costs of pathological gambling have ranged from $5 billion to $35 billion per year, made up principally of lost time and productivity, legal costs, lost wages, and the expense of treating comorbid medical and psychiatric conditions.¹ Treatment for pathological gambling is available at the local and state level, but there are no national standard practice guidelines for treatment. Also, because funding for pathological gambling varies from state to state, the availability and accessibility of integrated treatments lags behind what is available for other psychiatric disorders. For instance, insurance companies do not typically reimburse for a diagnosis of pathological gambling, and there are only a handful of acute inpatient treatment centers and gambling-specific outpatient treatment programs. Lastly, awareness about the impact of pathological gambling is limited within the healthcare community. In turn, this de-emphasizes the priority for screening for pathological gambling even though it is a significant source of medical and psychiatric morbidity and mortality. As a direct result, pathological gamblers may go unrecognized in many healthcare settings, from primary clinics to mental health specialty treatment programs. Even in substance abuse programs, screening for pathological gambling is generally not part of the intake process, even though rates of comorbidity are significant.² Furthermore, even when presented with the symptoms or consequences of pathological gambling, some clinicians may not recognize the disorder and may not know how to treat it. In order to close this gap, clinicians must first become familiar with the portions of the population that are vulnerable to developing gambling problems. With this undertanding, clinicians will then be able to utilize appropriate screening instruments to be able detect gambling problems and may also develop prevention strategies that would minimize the harm of untreated pathological gambling.

Pathological gamblers have been portrayed in the mainstream media and popular culture as middle-aged Caucasian men who gamble incessantly at casinos and on sports. Recently, epidemiological work is beginning to show that this stereotype is far from the truth and that there are identifiable and discreet groups who are at risk to develop pathological gambling. This article will describe these vulnerable groups and will place particular emphasis are on how membership in these groups makes them vulnerable. In describing these vulnerable populations, this article will inform clinicians to whom they should consider screening for gambling problems. Groups to be discussed include adolescents, elderly, gender differences in vulnerability, ethnicity, and socioeconomic status. In addition, an examination of the types of gambling and the role access to gambling has in creating vulnerability will also be discussed. This is the second installment in a three-part series that reviews the impact of pathological gambling. The first focused on the biopsychosocial consequences of pathological gambling. This part addresses vulnerabilities to becoming a pathological gambler. The final part to follow will review psychotherapeutic strategies for pathological gamblers.

Vulnerabilities to Pathological Gambling

The etiology of pathological gambling is due to a combination of biological, psychological, and social risk factors. As with other behavioral disorders, this combination varies from individual to individual and the amount of expression needed from each risk factor in order to demonstrate disease is not a set one. Group vulnerabilities are a way of demonstrating an increased risk to developing a disease and are discovered through epidemiological research. In characterizing the risk factors to develop pathological gambling, they can be divided into biological, psychological, and social factors. Examples of biological risk factors include alterations in dopamine and serotonin functioning, genetic loading, and neurophysiologcal responses to gambling. Psychological risk factors include personality features, such as dysfunctional impulsivity, impaired reward processing, poor coping mechanisms to stress, and defense mechanisms like guilt and shame that drive ongoing addiction. Social risk factors include access to gambling, peer gambling influences, and age of onset of gambling. These risk factors work in concert to create vulnerabilities in certain demographic groups, thereby increasing that group's overall risk to become pathological gamblers.

Vulnerabilities by age. Adolescents. Adolescence is a time of increased vulnerability to other addictions, namely due to the maturing brain, underdeveloped mechanisms of self-control, and sensitivity to the effects of neurotoxic substances. There is little debate about the relationship between early exposure to substances of abuse increasing the likelihood of substance dependence.³ What is being examined now is whether or not this relationship is true for behavioral addictions. Targeting adolescents for early recognition and primary prevention of problem gambling is particularly important given the recent rise of televised poker. Numerous media reports are documenting the popularity of regular poker tournaments among high school students, some even sponsored by the school or by the community.

With the expansion of lottery and casino gambling over the last 20 years, the current generation of adolescents is being raised in a society that promotes gambling as entertainment. Gambling is a common activity among adolescents, with studies reporting that close to 80 percent of persons 12 to 17 years old have gambled in the last 12 months, and nearly 85 percent had gambled during their lifetime.⁴ The most popular types of gambling among adolescents are poker, dice, board games, and wagers on games of personal skill with sports betting and Internet gambling. This relfects gambling as an acceptable behavior for adolescents. Compared to alcohol or drug abuse, which are illegal, many forms of gambling among kids is not seen as illegal or breaking the law. In fact, high schools and parents have promoted casino nights as an alternative to post-prom parties.

Recent national epidemiological surveys report that the prevalence rate of adolescent problem and pathological gambling ranges from 4 percent to 8 percent.^1,5 Additional local and regional studies consistently demonstrate that adolescents have higher rates of problem gambling as compared to adults with prevalence rates varying between one percent and nine percent, with a median of six percent for adolescents and a one-percent rate for adults.^6,7

The first reason why adolescents may be more susceptible to becoming pathological gamblers is that negative consequences from gambling can arise quickly. Most adolescents do not support themselves and are usually dependent on someone else for full support. As a result, smaller amounts of debt will lead to lying, guilt, and deception in order to fund gambling. Adolescent pathological gamblers often do not have casino markers, credit cards, or checking accounts, and even accessing money may be a sign of pathological behavior (e.g., stealing a parent's credit cards).

A second explanation for the increased prevalence rate is that it may reflect the natural course of pathological gambling—peaking in adolescence and tapering off during adulthood. Evidence for this is supported by Slutske who reports that problem gambling tends to be more episodic and transitory.⁸ Most adolescent gamblers will spontaneously recover from problem gambling—similar to adolescents who use drugs and alcohol, otherwise the adult prevalence rate would be higher. Unfortunately, the predictors of which adolescents will develop gambling problems as adults have not been determined. Adolescent pathological gamblers who recover without treatment may do so because of improved control over impulses, adaptations in responses to gambling, and development of healthy defense mechanisms to deal with stress.

There are many reasons to pay close attention to the gambling done by adolescents. Research with adults has shown that individuals with severe gambling problems begin gambling much earlier in life than people without such problems.⁸ Another reason for concern is that children usually learn how to gamble from members of their immediate family or friends. A third reason is that gambling often co-occurs with other risky behaviors and mental health problems, such as drug use and unprotected sex, and if unaddressed may affect healthy adolescent development. Finally, underage gambling in casinos, playing lottery, and gambling on the Internet is often not reported or aggressively enforced like that of tobacco sales.⁹

Elderly. To date, several epidemiological surveys have not shown elevated rates of pathological gambling in older adults.^6,7 These studies, though, were done at a time before the rapid expansion of gambling and before industry marketing toward seniors through bus tours and day trips. Now, research is showing that older adults have higher participation rates than ever before, mainly because of the aging population and of rapid expansion and increased access to legalized gambling. The impact of gambling on the elderly is an area of ongoing debate where proponents tout socialization, structure, and entertainment while opponents describe stories of depression, enormous financial loss, and isolation. As a result, the elderly follow a unique pathway and have their own intervention and treatment needs.

A recent national survey found that elderly who gamble recreationally were more likely to have better overall health and improved quality of life scores compared to those who were not recreational gamblers.¹⁰ Moreover, gambling in older adults was not associated with negative measures of health and well-being. Gambling for some older adults is portrayed as a positive recreational activity, especially when promoted by churches and senior centers through bingo games and bus trips to casinos.

On the other side, there is evidence accumulating that the elderly are a vulnerable group to develop gambling problems. Older adults represent a growing proportion of callers to problem gambling helplines in the US.¹¹ In a recent study, Levens surveyed 842 older adults from primary care populations, and 10.9 percent were identified as having at-risk gambling behaviors (defined as having bet more than $100 at one time or betting more than they could afford to lose).¹² Most significantly, this study population was primary care patients and not mental health patients, where the risk for pathological gambling may be higher because of comorbid conditions.

Geriatric populations are at more risk to develop problems related to gambling because they are likely to be on fixed incomes and may not be able to recover financially as quickly as those who are working for full incomes. Furthermore, gambling has the potential to affect retirement funds that can take a lifetime to save but just a few moments to lose. Older adults, once they lose control over gambling, may have difficulty stopping or getting help. They may have little structure or social support in their lives, and gambling may provide excitement and stimuli. Gambling is also a form of entertainment that can be done even when there are severe physical limitations. Another unexplored reason why the elderly may be at risk for gambling problems is the influence of mild cognitive impairment and dementia. There are no known studies that examine this relationship, but it conceivable that control over gambling can be lost if the elderly are not able to understand basic rules or betting strategies. For instance, they may mistakenly play more credits than intended or may not be able to manage gambling budgets with the same discipline as before. Also, one of the clinical symptoms of dementia is perseveration, difficulties in attention, and impaired adaptation—all of which could lead to continued gambling without being able to stop. Many of today's electronic gaming machines are much more complex and automated; soon, they may also have the ability to directly take credit cards, which could further create a vulnerable situation for the cognitively impaired.

Vulnerabilities by genetics. Family history. Patients who present to treatment who have a family member with pathological gambling are at an increased risk to become pathological gamblers themselves. Family studies have indicated a higher risk than expected to develop pathological gambling, and twin studies have shown that many of the symptoms of pathological gambling are genetically transmitted.¹³ Lesieur reported that family members of pathological gamblers have an incidence of pathological gambling of close to 20 percent, a rate much higher than the rate in the general population.¹⁴ The family environment is a significant contributor because of both the potential for early exposure and modeling gambling behavior. Many pathological gamblers started gambling early and learned how to gamble from family members or friends.¹⁵ Family studies conducted with adolescents and college students have also shown that adolescent or young adult gamblers who are problem or pathological gamblers are more likely to have parents who are pathological gamblers.^16–20 Eisen reported that the clinical symptoms of gambling larger amounts than intended and having repeated efforts to stop gambling were about 50-percent genetically mediated.²¹ Familial vulnerabilities included chasing behaviors (attempting to win back losses), preoccupation with gambling, and tolerance. From a neurobiological perspective, the precise risk factor that is transmitted remains to be determined, but some have pointed to such varied possible factors as dopamine receptors/transmission or differences in how rewards are processed to varying levels of arousal.^22,23 Given the evidence of heritability, clinicians should screen for gambling problems in family members of pathological gamblers, regardless of the presenting issues.

Vulnerabilities by social demographics. Ethnicity and culture. Recent research is showing that disproportionate numbers of African-Americans, Hispanics, Asians, and American Indians are pathological gamblers as compared to the general population. Cunningham-Williams, et al., did a general population survey in St. Louis and found that, among African-Americans, problem gambling was more common than gambling without problems.^24,25 Two national studies and several local and regional surveys have shown that pathological gambling is more prevalent among minority groups, especially African-Americans and Hispanics, than among Caucasians.^26,27 Among Asians, there have been a few studies all signaling an increased prevalence of pathological gambling, with a range from 6 to 10 percent, depending on the populations being examined.^28,29 Specific reasons for why certain minority groups are more vulnerable may be related to higher group gambling participation rates, location of gambling establishments (they tend to be in urban settings), and relationships to lower socioeconomic status, which is a separate risk factor by itself.

In addition to environmental reasons, there are specific cultural factors that may relate and contribute to the development of pathological gambling. In a recent review, Raylu and Oei point to evidence that different cultural groups have preferences for different types of gambling and review studies indicating that certain ethnic groups (e.g., Arabic, Chinese, Korean, and Vietnamese) are unlikely to present for problem gambling services in spite of reporting higher levels of negative consequences related to gambling.³⁰ Although shame is a major factor contributing to low rates of seeking help across all of these groups, there are cultural differences in the basis for this shame. Among Arabic and Turkish individuals, shame is related to religious principles prohibiting gambling. In Asian cultures, shame is related to losing the respect of family and peers and they are more likely to believe that responsibility to regain control of gambling is their own. Asians also promote themes of good fortune, are superstitious, and feel that fate is predetermined by the ancestors, i.e., a person who is “lucky” in gambling is considered to be blessed from the gods.

Another cultural factor that contributes to pathological gambling is the immigration process. Gambling offers a unique appeal to immigrants as an enticing and rapid way to make money. Also, gambling does not require the ability to speak English or UScitizenship. Finally, since many immigrants may be gambling together, there is the added benefit of socialization and peer support. The process of acculturation is stressful in itself, further reinforcing the lure of gambling as a way to deal with adjusting to a new culture and with a way to avoid having to deal with the stressors of this process. To examine this, Petry screened 96 Southeast Asian refugees from Laos, Cambodia, and Vietnam from a community center and reported an astonishing pathological gambling prevalence rate of 59 percent in this population.³¹ Even more intriguing is that 42 percent had gambled more than $500 in the previous two months, an amount that undoubtedly represents a large percentage of the household income of refugees.

Socioeconomic status. Those in lower socioeconomic classes would appear to be more vulnerable to develop gambling problems simply because it doesn't take as much money to lose in order for negative consequences to arise. A $500 loss will create far more damage in a household making $30,000 per year as compared to a household earning more than $100,000.

Lower socioeconomic status has been linked to a higher risk for mental illness, drug addiction and poorer overall health. This is thought to be due to a lack of access to care, limited resources, and less opportunities for prevention. Various studies have attempted to link lower socioeconomic status as a risk factor for pathological gambling.³² The strongest evidence comes from the work of Welte, who performed a random-digit telephone survey of American households and determined that membership in a low socioeconomic group was a significant risk factor to become a pathological gambler.³³ Explanations for this include the possibility that lower socioeconomic groups may view gambling as a way to end poverty and thus continue to participate in it despite ongoing negative consequences. Alternatively, they may be more likely to suffer negative consequences because of their more limited options and resources. Data from the British Gambling Prevalence Survey also reports that those in the lowest income brackets were nearly three times as likely to meet criteria for pathological gambling.³⁴ What is unclear is the role of pathological gambling in creating or transitioning groups into a lower socioeconomic class. The lack of longitudinal research means that most studies are only able to demonstrate an association and not a causal relationship.

Gender differences in vulnerability. In the United States, problem and pathological gambling are about two times higher among men than among women.^7,26,35 The gender gap appears to be closing, especially given the rise in popularity and acceptance of women gambling. In terms of pathological gamblers, current research suggests that women represent between 32 percent^7,36 and 43 percent of all problem gamblers.²⁷ In recent years, the number of women seeking treatment for pathological gambling has increased. A decade ago, men made up about 90 percent of treatment-seeking gamblers.³⁷ Today, most gambling treatment programs in the US and internationally report that the gender gap has narrowed to about 60 percent men and 40 percent women.³⁸ With this shift in the demographic profile of treatment-seeking gamblers, new research is emerging to evaluate gender differences among treatment-seeking pathological gamblers.

In terms of gender differences of pathological gamblers, male pathological gamblers as compared to female pathological gamblers tend to be younger, have higher incomes, start gambling at a younger age, be more likely to have alcohol or drug-related problems, and prefer “action” oriented strategy gambling.^39–41 Female pathological gamblers describe loneliness and relationship problems as precipitants of their gambling. They are also more likely to be diagnosed with depression. Women also report starting to gamble later in life than men and are motivated more for social reasons than for financial gain. More research is needed though to understand the relationships between gambling patterns, gambling preferences and the development of gambling problems.

Another gender specific finding is that women progress more rapidly to problem gambling as compared to men.^40,42 Various explanations have been offered for this phenomenon, including the greater stigma attached to women's gambling problems, the limited financial resources available to women compared with men, experiences of loss and the stresses of caring for children and aging parents, and the greater difficulty of hiding gambling excursions and debts from family and friends. From a biological perspective, much has been written on the biological differences between men and women in terms of responses to drugs and alcohol. For instance, women are more likely to develop problems with alcoholism over a faster period of time due to differences in metabolism.^43,44 Research on understanding the neurobiological responses to gambling is ongoing and will look to answer questions about gender differences.

In summary, there are considerable differences between male and female pathological gamblers in terms of types of gambling, reasons for gambling, psychiatric comorbidities, and participation in treatment. As a result, specific vulnerabilities for each gender need to be taken into account in order to effectively screen or treat pathological gamblers.

Vulnerabilities by comorbid disorders. Substance use disorders. Persons who present to substance abuse treatment settings have higher rates of pathological gambling, suggesting that this is an important clinical population to screen. Close to 25 to 63 percent of persons entering substance abuse treatment also meet criteria for pathological gambling.^45–48 Welte conducted a national adult survey and showed that those who met criteria for alcohol dependency increased the risk of being a pathological gambler by a factor of 23.⁴⁹

Patients with substance use disorders are at an increased risk to developing pathological gambling for a variety of reasons. Drinking and gambling are common co-occurring behaviors, often promoted by the casino environment or by social interactions. Clinically, alcohol's disinhibiting effects may lead gamblers to become more impulsive, thereby influencing the probability of initiating gambling and persisting in gambling behaviors.⁶ In turn, this creates a cycle of ongoing substance use, gambling, and using more substances to deal with the consequences of gambling.

A second vulnerability conferred by substance use disorders may be a shared pathway to addictions. Recent neuroimaging work in pathological gamblers has implicated the same neural networks as in substance abuse, suggesting shared vulnerabilities between both disorders.^50,51 If the underlying process responsible for substance abuse is the same as for pathological gambling, this could mean that a substance-dependent individual will be at higher risk to develop gambling problems.

Psychiatric disorders. Pathological gamblers have high rates of comorbid psychiatric disorders, including major depression, anxiety disorders, and attention/deficit hyperactivity disorder (ADHD).^52,53 Additionally, rates of suicide attempts of gamblers seeking help (Gamblers Anonymous [GA] or psychiatric treatment) ranged from 20 to 30 percent.⁵⁴ Personality disorders in pathological gamblers have also have been found to be highly prevalent among pathological gamblers, particularly Cluster B (narcissistic, antisocial, borderline, and histrionic) disorders.⁵⁵

Examining the issue from the other perspective, most general psychiatric patients who present to treatment usually are not screened for gambling problems. It remains to be seen whether the comorbid conditions confer with the risk of developing gambling problems or how gambling affects the course of psychiatric disorders. Theoretically, major depressive disorder may create a vulnerability to gamble through the need to escape and to seek avoidance from pain. ADHD's core symptoms of impulsivity, inattention and attraction to highly novel stimuli create a vulnerability to fall into frequent and heavy gambling. The manic phase of bipolar disorder, by definition, may create an association and attraction to gamble - mainly triggered by the disinhibition and inability to control impulses. Even dementia may create vulnerabilities to pathological gambling in that impaired cognitive reasoning will result in an increased likelihood of losing and possibly in persisting with gambling behavior without realizing the consequences of doing so.

Vulnerabilities by type of gambling. There is ongoing debate about which types of gambling carry the most risk to cause problems related to gambling. Theoretically, forms of gambling that have a rapid turnover of betting and a variable payout (intermediate reinforcement) could be more likely to maintain gambling behavior. Today's gambling machines offer much faster play, more bets per minute, and instantaneous results. Together, these factors may make it easier to lose money faster, and as a result, electronic gambling machines (EGMs), such as slot machines and video poker, have been called the “crack cocaine of gambling.”⁵⁶

Evidence for the addictive potential of EGMs comes from New Zealand, where 90 percent of helpline clients report that their problems were due to playing the EGMs.⁵⁷ In Ontario, Rush et al.⁵⁸ reported that EGMs accounted for almost 40 percent of the treatment population, making slot machines the number-one reason for seeking help.⁵⁸ EGMs are the most profitable form of gambling and they account for 80 percent of casino profit.⁵⁹ EGMs cost less to gamble (as little as one penny per bet), offer relative privacy and anonymity, and essentially have no learning curve. For these reasons, they may appeal to women, the elderly, adolescents, the newly immigrated, and others who would not otherwise be gambling.

Most recently, Welte conducted a national telephone survey to understand risk factors for pathological gambling and found that gamblers who engaged in multiple forms of gambling were the most likely to be pathological gamblers.⁶⁰ Interestingly, the forms of gambling that carried the highest degree of risk were pulltabs (instant games), casino gambling, bingo, card playing, lottery, and sports betting.

Vulnerabilities by special populations. Military populations. Although few systematic studies of active and retired military personnel have been done, there are a few reports of increased rates of pathological gambling in the military. Daghestani reported that 33 percent of substance-abusing veterans met criteria for pathological gambling, a figure much higher than general population estimates.⁶¹ This may be related to characteristics of volunteers to the military (i.e., risk-taking, sensation-seeking) or it may be related to a way of dealing with stress. Coincidentally, gambling is an activity that is frequent among military personnel; especially given the large amounts of time people spend with one another in close quarters. Furthermore, there have been reports of military bases installing slot machines and EGMs as a way of recreation for the troops. In response to these concerns, there are two dedicated gambling treatment programs for the military—one is an inpatient program in Brecksville, Ohio, while the others are outpatient programs in Las Vegas and San Diego.⁶² In one of the few systematic studies of pathological gambling veterans, Kausch⁶³ reviewed 114 cases and reported that close to 40 percent of pathological gambling veterans had attempted suicide in their lives; furthermore, close to 65 percent of these suicide attempts were related to gambling.

Legal populations. For those who are incarcerated, the risk of being a pathological gambler is elevated as compared to the general population. To date though, studies have not proven whether this risk is secondary to comorbidities often seen in incarceration such as substance abuse disorder or personality disorders. As in the military, gambling is a frequent activity among prisoners and very little is known about the impact of gambling on prison life. Blaszczynski⁶⁴ found that past pathological gamblers have a higher risk of committing criminal offenses and meeting criteria for antisocial personality disorders.

Casino workers. Selection bias may play a role as to why casino workers are more likely to develop pathological gambling. It is unclear about what the rate of pathological gambling is in casino workers prior to employment or whether this rate increases after employment. It is possible that cognitive distortion may arise as casino workers look for flaws in the games, but it would also seem likely witnessing the numerous losses would teach them not to gamble. Shaffer found that the rate of pathological gambling among casino workers was much higher than the general population.⁶⁵

Conclusion

Vulnerability to pathological gambling has been the subject of several recent studies, and to date, several specific populations have been shown to be at a higher risk. Clinicians need to be aware of these population groups and, particularly, need to be aware of combinations of group vulnerabilities. For instance, Asian casino workers with a family history of pathological gambling may carry an increased vulnerability due to the presence of multiple risk factors. In the future, more work is needed to determine the precise strength and impact that each vulnerability carries. By recognizing these vulnerability factors and by screening for gambling problems, clinicians may be able to identify problems related to gambling as they are emerging, thereby providing early intervention that may stem the harm of pathological gambling.