A case of pathological gambling

Sir,

Pathological gambling is an entity recognized centuries ago and has remained a menace from the social and economic viewpoint. The recognition of medical nature of this vice is, however, a recent phenomenon, with current views placing it parallel in nosology to substance use disorders. Long-term effectiveness of available modalities of treatment still elude us, and the disorder remains an enigma for Psychiatrists and Behavioral Therapists alike. There are no systematic studies of this disorder in India. Our case is unique, as unlike most pathological gamblers, our patient actively sought treatment and showed good response in early follow-up period.

Our patient, a 23-year-old male, with family history of problem gambling in his grandfather, premorbid novelty-seeking traits, self-reported for psychiatric evaluation with depressive symptoms of 5 months’ duration, in the background of progressively increasing engagement in online gambling with consequent heavy financial loss over the past 1 year.

A year ago, when, while surfing the internet, he came across an advertisement about huge profit with little investment in online rummy, and tried with an initial bet of 15 rupees. Initially, he won and started increasing the bet gradually, both regarding money wagered per game and number of games per day, in an attempt to increase the profit. Thus, he reached a bet of 5000 rupees per game within the next 2 months, playing up to 1–2 h every day. Subsequently, he started betting an entire day's winnings in a single game, for the thrill he experienced on betting “all he had.” The patient started losing thousands of rupees in a day, purchased a credit card, took a personal loan and eventually borrowed money from friends, citing false financial crises, to fuel his habit and to chase his losses. Soon, his debt stood at 4.5 lakh rupees, paid off by his father, to whom he promised he would never gamble again.

He exercised restraint for the next 3–4 months, but again started gambling and by the end of next 6 months; he was in a debt of 15 lakh rupees. He once again fell back on his father, who curtailed his access to money, as a precondition to clear his debts. However, he would often remain preoccupied with guilt, started remaining low, reduced his social interaction out of shame, lost his confidence and self-esteem and often wished he was dead. After one failed attempt at committing suicide by hanging, he sought psychiatric treatment.

Evaluation on admission revealed a dejected looking individual with slow, monotonous speech, depressed mood and constricted affect, guilt and worthlessness, with deranged bio drives. Investigations revealed normal hematological and biochemical profile, euthyroid status, negative viral markers and drug screen and normal neuroimaging. Psychometry scores were Beck Depression Inventory: 13 (mild depression), modified Yale–Brown Obsessive Compulsive Scale (YBOCS): 34 (severe), NORC Diagnostic Screen for Gambling Disorders (NODS) loss of Control, Lying, and Preoccupation (CLiP): 9 (positive for pathological gambling (PG)), Beck's Suicide Intent Scale (BSIS): 2 (no suicidal intent).

He was managed with capsule fluvoxamine 150 mg and tablet Naltrexone 50 mg. He was given individual psychotherapy on the lines of motivation enhancement therapy, cognitive behavioral therapy (CBT) for depression and coping skills training. Contingency management was explained along with high-risk situations for relapse and relapse prevention strategies, aiming at complete abstinence. His family members and employer were included in treatment as “significant other” and were provided psychoeducation about nature of illness, prognosis, and measures for external control as part of relapse prevention. He responded well to treatment and was found to be maintaining remission at 3 months follow-up.

Global prevalence of PG is not known. A Romanian study calculated prevalence of 2.6%–4% among children and adolescents using south oaks gambling screen-revised adolescent (SOGS-RA) and 20 GA-RA.[1] A recent Indian study on the prevalence of PG among patients with substance use disorders found an occurrence rate of 6.1%–12.3%, using International Classification of Diseases (ICD)-10 and Diagnostic and Statistical Manual of Mental Disorders (DSM)-5 criteria and SOGS as screening instrument.[2]

A bio-psycho-social model of causation is proposed, with such biological factors as right-dominant lateralized correlations between brain-derived neurotrophic factor and beta and theta power reflecting right-dominant brain activation,[3] psychological risk factors such as negative emotions, motor impulsivity, gambler's fallacy, and gambling self-efficacy and the role of “variable ratio schedule of reinforcement” and social factors as availability of gambling platforms.

In the classificatory systems, DSM-5 has placed gambling disorder among the rubric of addiction, and ICD-11 is expected to do the same. Comorbidities are common in PG especially Depression.[4]

There are various instruments available for PG, of which the ones used in our case were NODS-CLiP and modified YBOCS. Treatment modalities include both pharmacological and nonpharmacological measures. A combined approach is considered better than individual methods of treatment, as was employed in our case.[5] Internet-based interventions such as “Deprexis” and Internet supported CBT may be a useful adjunct to standard treatment.[6]

In our patient, no comorbid substance use disorder, and active help-seeking were positive markers of prognosis. However, male gender, young age of onset, family history of gambling, novelty seeking, and impulsive personality traits were unfavorable. In addition, nature of this relapsing illness, comorbid depression and history of suicidalty does not indicate good prognosis.

Current availability of online platforms and ease of transaction combined with covert marketing through apps have made gambling widespread. Our society at large needs to recognize the problem and take corrective measures both at organizational and individual levels.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his clinical information to be reported in the journal. The patient understands that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.