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Psychiatric Comorbidity Associated With Pathological Gambling

(PSYCHIATRIC TIMES) - Gambling has become a major recreational activity in the United States. Formerly confined to a few states such as Nevada and New Jersey, legal gambling opportunities have exploded across the nation in the past 2 decades. Some form of legalized gambling now exists in all but 2 states: 37 have lotteries, and 27 have casino gambling. Recent estimates indicate that 70% to 90% of North Americans have engaged in some form of gambling.1 Between 1974 and 1997, gambling expenditures more than doubled as a percentage of personal income.

Although disordered gambling has been recognized for centuries, criteria for pathological gambling (PG) were first specified in 1980 in DSM-III. Although categorized as an impulse control disorder (ICD), the current criteria are patterned after those used for substance dependencies and emphasize the features of tolerance and withdrawal, both of which have been described in persons with PG and in those with substance dependence.2 Ten specific maladaptive behaviors are enumerated, and 5 or more are required for the diagnosis.


Although most persons gamble responsibly, approximately 5.5% of those in the general population are problematic gamblers.3 PG—the most severe form of problematic gambling—affects 1% to 2% of the adult general population. These figures suggest that more than 2 million Americans suffer from PG; roughly twice that many have gambling-related difficulties but do not meet DSM-IV criteria.4,5 There is evidence that the prevalence of PG is increasing along with the ever-expanding availability of gambling venues.6-8

One-quarter to one-third of all persons with PG are women, but the gap is narrowing.9 (See the case vignette.) Women tend to begin gambling later in life, often in their early 30s, compared with men who start in their late teens or early 20s. Women tend to have a more rapid progression to PG.10,11

Special populations at risk for PG include adults with mental health or substance use disorders, persons who have been incarcerated, African Americans, and persons of lower socioeconomic status.12 However, the typical profile of a treatment-seeking gambler is one who is white, middle-aged, married, and employed, with a relatively low level of education.

Research has not empirically validated proposed subtypes, but the most widely discussed scheme is the distinction between “escape-seekers” and “sensation-seekers.”12,13 Escape-seekers are often older persons who gamble out of boredom or depression or to fill time, and they may choose passive forms of gambling, such as slot machines, lotteries, and scratch tickets. Sensation-seekers tend to be younger and prefer card games or table games, sports betting, or other gambling that involves some elements of skill and suspense.

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