1. Residential Substance Abuse Treatment (RSAT)
Problem Gambling: The Hidden Addiction Victor Ortiz, MSW, LADC I, CADC II
Presentation for:
Residential Substance Abuse Treatment (RSAT)
December 17, 2014

2. Acknowledgement Harvard Medical School Division on Addiction
National Center for Responsible Gaming
Go around have everyone introduce self and what they would like to take away from the training.

3. Agenda Provide an Overview of Gambling Disorders
Gambling Disorders and Substance Abuse
Gambling Disorders and Mental Health
Gambling Disorders and Corrections
Discuss DSM IV and DSM-5 - Gambling Disorders
Review Resources
Go around have everyone introduce self and what they would like to take away from the training.

4. What is Gambling?`
“… risking something of value on the outcome of an event when the probability of winning is less than certain.”
Korn, D.A. & Shaffer, H.R. (1999). Journal of Gambling Studies, 15(4), p.292.
Looking at this definition – what is gambling to you?
First def. - most people will say casinos, lottery, scratch tixs;
The GA definition is more expansive – to include charitable games, raffles, Chucky cheese, day trading.
The GA definition looks at the BEHAVIOR of gambling v. just taking a chance.
There is a huge gap between how most people view gambling and how it is viewed by problem gamblers.
Its everywhere – stop n shop; McDonalds monopoly game – the idea of scratching something to win a prize to GA is gambling;
online surveys that are at the bottom of your CVS or Home Depot receipts; slot type ads – see ex. 4

5. Gambling in the U.S.
Approximately 85% of U.S. adults have gambled at least once in their lives; 60% in the past year.
2 million (1%) of U.S. adults are estimated to meet criteria for pathological gambling in a given year.
Another 4-6 million (2-3%) would be considered problem gamblers.
Source: National Council on Problem Gambling , Retrieved from

6. Stores with past Powerball winners lure crowds
Worcester T&G-2013

7. Gambling Risk Factors Emotional difficulties Stress
Distorted expectations about winning
Social pressure to gamble
Risky gambling behavior
Attention deficits
Impulsivity
Illusion of control over outcomes
Addiction history
Family history of gambling problems
Move from thinking about gambling in just casinos and the lottery to when it can be a trigger for PG
These risk factors are similar to other found in sub abuse but the distorted expectations about winning is different. It is more amplified – a need to rationalize/control gambling because PG’s will not say it’s a gambling problem but a money problem.
Reason why I believe this is the envirt factors – how we take meaning from the world. The envirt of many gamblers is diff from others – lights and glitter- emphasizes action –feeds ego –make you feel important, visible, someone. Sub abuse doesn’t usually do that. 7 7

8. Gambling Disorders
and
Substance Abuse

9. National Epidemiologic Survey on Alcohol and Related Conditions
The 2008 NESARC study reported that:
73.2 percent of pathological gamblers had an alcohol use disorder (73.2%),
38.1 percent had a drug use disorder,
60.4 percent had nicotine dependence,

10. Gambling and Alcohol
Problem gamblers with frequent alcohol use have greater gambling severity and more psychosocial problems resulting from gambling than those without alcohol use histories.
Adolescents who are moderate to high frequency drinkers are more likely to gamble frequently than those who are not. (Grant, Potenza, etal, 2010)
For individuals with alcoholism and gambling disorders, addressing both problems simultaneously leads to better outcomes. (Hodgins and el-Guebaly, 2002)

11. Gambling and Drugs
Research indicate that cocaine-addicted individuals are nearly two times more likely to have serious gambling problems than those who are not cocaine-dependent.
Cocaine may artificially inflate a gambler’s sense of certainty of winning and skill, contributing to increased risk behaviors.
Pathological gamblers may use cocaine to maintain energy levels and focus during gambling and sell drugs to obtain gambling money.
Research also suggests a positive correlation between methamphetamine abuse and pathological gambling.

12. Pathological Gambling & Drug and Alcohol Disorders
Common features between pathological gambling and drug and alcohol use disorders
Failure to resist an impulse, drive, or temptation that is harmful to the person or to others.
Onset in adolescence and young adulthood – more men than women.
Occurrence of an urge or craving state prior to initiating the behavior.

13. Pathological Gambling & Drug and Alcohol Disorders
Resulting “high” – need to increase the intensity of the behavior to achieve the same high.
Financial and marital problems.
Criminal behavior to fund addictive behavior or cope with consequences of it.
Source: Grant, J.E. J.D. Potenza, M. MD, Weinstein, A. PhD., Gorelick, D. MD, PhD. (2010) The American Journal of Drug and Alcohol Use, Early Online 1-9. DOI: /

14. Differences of Gambling Disorder and Substance Abuse Disorders
There is no substance
Bail out by family or friends
There is no obvious signs: slurred speech, blood shot eyes, or odor
Reward
Bail out – family feels if they pay off gamblers debts the problem will go away- thinking that money is the problem- so that is the answer. Do not realize the behavioral nature of gambling – its not the money it’s the action, The high one gets by actually gambling.
Also REWARD is big difference – a substance used abusively will not say the addict is a winner!!But gamblers are constantly being told just that – you are a winner!!! The internalization of the reward concept – that element of entitlement contributes to the distorted thinking. Casinos boost your self esteem. The reward so both in the environment and the game,
Different in the view of the recovery community too = if in recovery usually abstain from all drugs yet there are prob. gamblers who drink and smoke but don’t gamble..
They still share the stigma. 14

15. Neurological Similarities between Gambling & Drug and Alcohol Abuse
Multiple neurotransmitter systems are implicated in the pathophysiology of behavioral addictions and substance use disorders.
Serotonin and dopamine, in particular, may contribute to both sets of disorders.
Serotonin is involved with inhibition of behavior.
Dopamine is involved with learning, motivation, stimuli, and rewards.
Alterations in dopaminergic pathways in the brain are thought to underlie reward-seeking (gambling, drugs, alcohol) that triggers the release of dopamine and produces feelings of pleasure.
Source: Grant, J.E. J.D. Potenza, M. MD, Weinstein, A. PhD., Gorelick, D. MD, PhD. (2010) The American Journal of Drug and Alcohol Use, Early Online 1-9. DOI: /

16. Evidence supporting a broader conceptualization of addiction is emerging. For example, neurobiological research suggests that addictive disorders might not be independent: each outwardly unique addiction disorder might be a distinctive expression of the same underlying addiction syndrome. Howard J. Shaffer, PhD, CAS,, 2004 16

18. Clinical Practice
Addiction
Drugs
Gambling
Smoking
Alcohol 18

19. Gambling Disorders
and
Mental Health

20. National Epidemiologic Survey on Alcohol and Related Conditions
The 2008 NESARC study reported that:
49.6 percent had a mood disorder,
41.3 percent had an anxiety disorder,
60.8 percent had a personality disorder.

21. Gambling and Mood Disorders
Roughly one-third of pathological gamblers have a biological parent or sibling with a major mood disorder (Roy et al., 1988; Linden et al., 1986)
Close to 20% of formerly diagnosed pathological gamblers were still depressed in follow-up after stopping gambling and improving their other functions (Taber et al., 1987) 21

22. Gambling and Mood Disorders
Pathological gamblers in inpatient treatment setting have depression rates as high as 50%-75% (far above the population average of 10-25%) (McCormick et al., 1984; Linden et al., 1986).
Gamblers’ own reports show that they gamble to forget troubles, to avoid feelings of loneliness, depression, and stress — evidence that gambling serves as a way for gamblers to modify their internal state (Corless & Dickerson, 1989). 22

23. What comes First, PG or Other Disorder?
PG First
Other Disorder First
Onset at Same Time
Any Mood Disorder*
23%
65%
12%
Any Anxiety Disorder*
13%
82% 5%
Any Impulse Control Disorder
100%
Any SUD*
36%
57% 6%
* These disorders more common among PGs compared to rest of US population
© Source: Henry Lesieur (2014, March). Using best practices in treatment of dual diagnosis and pathological gambling. Workshoppresentation to 2014 Problem Gambling Conference: “Ohio’s Response to aChanging Landscape.” Columbus, Ohio.

24. Medical Problems Among Pathological Gamblers
Depression
Intestinal Disorders
Cardiovascular Problems
High Blood Pressure
Migraines
Stress-related Disorders
Allergies
Respiratory Problems
Oral-Dental Disease
Nerve-Sensory System Disorders

25. Gambling Disorders and Suicide
The DSM-5 states that up to half of individuals in treatment for a gambling disorder have suicidal ideation and about 17% have attempted suicide.
According to the World Health Organization, factors such as mood disorders, stressful life events or circumstances and a history of physical or sexual abuse in childhood put people at increased risk for harming themselves (World Health Organization, 2002). All of these factors are common among those experiencing problems related to gambling.
1 in 5 – higher than any other addictive disorder;
DSM 5 says up to half of individuals in treatment have had suicide ideation.
And about 17% have attempted suicide.
I work closely with suicide Prevention agencies to get this information out so they are aware of this high rate and can recognize and PG and refer them to our Helpline. 25

26. Gambling Disorders
and
Corrections

27. Do people with Gambling Problems
Question?
Do people with Gambling Problems
commit crimes?

28. Gambling Disorders and Corrections
Contrary to conventional wisdom, most individuals with a gambling disorder do not engage in criminal behavior. However, a small number resort to theft, embezzlement, fraud or other criminal activity to support their gambling. Some of these cases make the headlines, which in turn shape the conventional wisdom. People with gambling disorders might end up in court because of domestic violence, child support and custody issues — all of which might relate to their gambling problem NCRG, 2013
1 in 5 – higher than any other addictive disorder;
DSM 5 says up to half of individuals in treatment have had suicide ideation.
And about 17% have attempted suicide.
I work closely with suicide Prevention agencies to get this information out so they are aware of this high rate and can recognize and PG and refer them to our Helpline. 28

29. Gambling Disorders and Corrections
A complex relationship exists between illegal behavior and pathological gambling, and this relationship has significant implications in both the legal and clinical domains. Despite the importance of this relationship, relatively little research has examined illegal behavior in pathological gambling, particularly within a current gambling climate that has seen dramatic expansion over recent years. Although the article by Ledgerwood and colleagues provides additional insight into the relationship between pathological gambling and illegal behavior, many questions remain unanswered and warrant further investigation.
J. Grant, M. Potenza, 2007
1 in 5 – higher than any other addictive disorder;
DSM 5 says up to half of individuals in treatment have had suicide ideation.
And about 17% have attempted suicide.
I work closely with suicide Prevention agencies to get this information out so they are aware of this high rate and can recognize and PG and refer them to our Helpline. 29

30. DSM-IV and DSM-5
&
Gambling Disorders

31. DSM IV
According to DSM-IV criteria, gambling is considered an impulse control disorder and the criteria include three areas often associated with addictive disorders:
compulsion or craving;
loss of control;
and continuing behavior, despite the presence of adverse consequences.

32. DSM IV Challenges- Pathological Gambling Mental Health or Addiction
Barriers within Recovery Community
Third Party Billing
Treatment Challenges
Data and Research

33. Gambling Disorders: DSM-5
In May the DSM 5 was issued.
It moved what was called Pathological or Compulsive gambling from Impulse control Disorders under Substance Related and Addictive disorders– Non-Substance Related Disorders and now refers to it as Gambling Disorders.
Officially changing the name to “Gambling Disorder” is a welcome revision for many researchers and clinicians who have expressed concern that the label “pathological” is a pejorative term that only reinforces the social stigma of being a problem gambler.
It is the sole behavioral addiction in the new DSM. The words pathological and compulsive can no longer be diagnostically used to describe problem gambling
This give providers a better chance to diagnose PG

34. DSM-5 Reclassification of Gambling
Home
DSM 
    
DSM-5 Reclassification of Gambling
Contains significant changes to “Substance-Related and Addictive Disorders”.
Places “Gambling Disorder” in “Substance-Related and Addictive Disorders”, under “Non-Substance-Related Disorders”
Change reflects research findings that indicate that GD is similar to substance-related disorders in clinical expression, brain origin, comorbidity, physiology, and treatment.

35. DSM-5 Reclassification of Gambling
Placement in “Substance-Related and Addictive Disorders” could open the door to coverage under MH/SUD-related provisions of health reform.
Improve diagnostic accuracy and screening efforts.
Support more appropriate treatment and services.
Facilitate integration/bundling of services and payment processes with MH/SUDs services and primary care (e.g., SBIRT).
Increase public health awareness, and raise visibility among health care providers, insurers, and policy makers.
Accelerate research and development of more robust, evidence-based practices.

36. Gambling Disorder and DSM-5
According to DSM-5 criteria, gambling is considered a persistent and recurrent problematic gambling behavior leading to clinically significant impairment or distress, as indicated by the individual exhibiting four (or more) of the following in a 12-month period:
The chapter also includes gambling disorder as the sole condition in a new category on behavioral
addictions. DSM-IV listed pathological gambling but in a different chapter. This new term and its location in the new manual reflect research findings that gambling disorder is similar to substance-related
disorders in clinical expression, brain origin, comorbidity, physiology, and treatment.
Recognition of these commonalities will help people with gambling disorder get the treatment and
services they need, and others may better understand the challenges that individuals face in overcoming this disorder.
While gambling disorder is the only addictive disorder included in DSM-5 as a diagnosable condition,

37. Gambling Disorder DSM-5 Criteria
Needs to gamble with increasing amounts of money in order to achieve the desired excitement
Is restless or irritable when attempting to cut down or stop gambling
Is often preoccupied with gambling (e.g., having persistent thoughts of reliving past gambling experiences, handicapping or planning next venture, thinking of ways to get money with which to gamble).
Often gambles when feeling distress (e.g., helpless, guilty, anxious, depressed).
Internet gaming disorder will be included in Section III of the manual. Disorders listed there require
further research before their consideration as formal disorders. This condition is included to reflect the
scientific literature on persistent and recurrent use of Internet games, and a preoccupation with them,
can result in clinically significant impairment or distress. Much of this literature comes from studies in
Asian countries. The condition criteria do not include general use of the Internet, gambling, or social
media at this time.

38. Gambling Disorder DSM-5 Criteria Cont.
After losing money gambling, often returns another day to get even (“chasing” one’s losses).
Lies to conceal the extent of involvement with gambling.
Has jeopardized or lost a significant relationship, job, or educational career opportunity because of gambling.
Relies on others to provide money to relieve desperate financial situations caused by gambling.

39. Differences in DSM-4TR and DSM-5
DSM-IV
DSM-5
“Is preoccupied with gambling” 
Gambles as a way to escape from problems”
“Is often preoccupied with gambling”
Gambles when feeling distressed”

40. Differences in DSM-4TR and DSM-5 Cont.
The omitted criterion reads, “Has committed illegal acts such as forgery, fraud theft or embezzlement to finance gambling.”
The DSM-5 Work Group felt that any illegal acts would fall under “Lies to conceal the extent of involvement with gambling
One major change in the DSM-5’s clinical description of gambling disorders is the elimination of the criterion “has committed illegal acts such as forgery, fraud theft or embezzlement to finance gambling.”
The rationale for this change is the low prevalence of this behavior among individuals with gambling disorder. In other words, no studies have found that assessing criminal behavior helps distinguish between people with a gambling disorder and those without one.
Studies suggest that its elimination will have little or no effect on prevalence rates and little effect on diagnosis. However, although committing illegal acts will no longer be a stand-alone criterion for diagnosis, the diagnostic features part of the text will state that illegal acts are associated with the disorder.
In particular, the criterion related to lying to others to cover up the extent of gambling will be described to include specific mention of illegal activities as one potential form of lying.

41. Resources 41

42. National Council on Problem Gambling www.ncpg.org
Massachusetts Council on Compulsive Gambling
Harvard School Division on Addiction
National Center for Responsible Gaming 42

43. Massachusetts Council on Compulsive Gambling
Victor Ortiz, MSW, LADC I, CADC II
Sr. Director of Programs and Services 43

44. Work Cited
Petry, NM, et al. (2005) Comorbidity of DSM-IV pathological gambling and other psychiatric disorders: Results from the national epidemiologic survey on alcohol and related conditions. Journal of clinical Psychiatry. 66:
Grant, J.E. J.D. Potenza, M. MD, Weinstein, A. PhD., Gorelick, D. MD, PhD. (2010) The American Journal of Drug and Alcohol Use, Early Online 1-9. DOI: /
Petry, NM, et al. (2013). An Overview of and Rationale for Changes Proposed for Pathological Gambling in DSM-5. J Gambl Studies.
Howard J. Shaffer, PhD, CAS, Debi A. LaPlante, PhD, Richard A. LaBrie, EdD, Rachel C. Kidman, BA, Anthony N. Donato, MPP, and Michael V. Stanton, BA; Toward a Syndrome Model of Addiction: Multiple Expressions, Common Etiology, Harv Rev Psychiatry 2004;12:367–
Shaffer HJ, Martin R. Disordered gambling: etiology, trajectory, and clinical considerations. Annu Rev Clin Psychol. 2011; 7:
 Shaffer HJ. On the nature and meaning of addiction. Natl Forum 1999;79(4):10–4.67

45. Work Cited
Shaffer HJ. The most important unresolved issue in the addictions: conceptual chaos. Subst Use Misuse 1997;32:1573–80.
Shaffer HJ. Rethinking addiction: how gambling and other behavioral addictions are changing the concept and treatment of alcohol and substance use disorders. Acad News 2003(2):1,3,7.
American Psychiatric Association. DSM-IV: Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington, DC: American Psychiatric Association; 1994
American Psychiatric Association. Diagnostic and Statistical Manual
of Mental Disorders. 5th ed. Arlington, VA: American Psychiatric Publishing; 2013
Grant JE, Potenza MN. Commentary: illegal behavior and pathological gambling. J Am Acad Psychiatry Law. 2007;35(3):302–305. .