May 16, 2011
USA - Out-of-control gambling -- a particular problem among regular slot machine players -- will be reclassified from a behavioral disorder to an addiction, as of 2013.For more than 30 years, doctors have considered pathological gambling a behavioral disorder, not an addiction. But that's about to change.
In 2013, the psychiatric community will officially classify uncontrolled gamblers as addicts -- the first-ever "behavioral addiction." Pathological gambling will no longer be an impulse-control problem, like fire-starting and obsessive hair-plucking.
Instead it will be grouped with "classic" addictions such as alcoholism, smoking and drug abuse in the next edition of the American Psychiatric Association's Diagnostic and Statistical Manual, the sourcebook that guides diagnosis and treatment.
The change signifies that getting hooked doesn't necessarily require ingesting a mind-altering substance, like chugging whiskey or injecting heroin. It also can result from spinning a slot machine's reels.
The re-branding of pathological gambling as an addiction is based on research -- much of it in the last decade -- that shows striking similarities between the conditions. The brain-functioning and behaviors of all addicts have a lot in common, scientists say, whether the person is drinking, smoking, shooting up or gambling. That suggests, but doesn't prove, they share the same biological underpinnings.
Pathological gambling's reboot is controversial. Some critics believe it's political and further "medicalizes" a behavioral weakness that shouldn't be labeled a disease.
Still, it could alter how pathological gamblers are treated, how their care is paid for, and how society views them.
Pathological gambling a young research field
Non-gamblers and those who gamble without problems often have trouble understanding why anyone can't just walk away from a slot machine, or avoid a casino altogether.
"I think we probably are still fairly judgmental" about pathological gambling, said psychologist Loreen Rugle, the director of Connecticut's problem gambling services program. "Most people rank gambling as a moral offense that should literally be treated with a good swift kick in the pants. Public awareness is years behind other mental health and addictive disorders."
Loreen Rugle, psychologist and Connecticut's director of problem gambling services, talks about differing attitudes toward problem gambling and harm-reduction.
Part of the reason is lack of knowledge. Scientists, and therefore the public, have a much better understanding of substance-based addictions than of pathological gambling. They've been the subject of decades of study, much of it federally funded, with national institutes dedicated to alcoholism and drug abuse established in the early 1970s.
Pathological gambling research, by contrast, is a young field that often scrambles for money.
The popular view of excessive gambling as a moral weakness also stems from widespread skepticism that a misbehavior could be beyond a person's control, especially if a mind-altering substance isn't involved.
In short, people may find it hard to believe that preoccupation with gambling is a disease.
But if the definition of a disease is a physiological, biochemical or genetic abnormality that causes harm, then pathological gambling fits the bill.
More to the point, gambling addicts and substance addicts share enough of those abnormalities, as well as symptoms, to convince researchers the disorders are closely related.
Dr. Heather Chapman, director of the Brecksville VA Medical Center's gambling addiction treatment program, discusses gambling addiction.
"There are a host of reasons why [pathological gambling] should be with substance-use disorders," said psychologist and addiction researcher Nancy Petry, a member of the American Psychiatric Association committee that recommended the change.
For example, brain scans show that uncontrolled gamblers and drug abusers both have lowered activity in a neural circuit that's involved in judging risk, University of Colorado researchers reported in 2007.
There's also evidence that vulnerability to gambling addiction and substance addiction is inherited, suggesting the conditions have gene defects in common. "We're seeing people who are prone to pathological gambling who have addictions in their family in general," said psychologist Heather Chapman, who runs the gambling treatment program at the Brecksville VA Medical Center.
And the symptoms, treatment and outcomes for both types of addicts have a lot of overlap. Gamblers and substance abusers tend to get hooked as teens or young adults, and they're the same personality types: impulsive, bad-decision-making risk-takers.
They both feel cravings, both need more and more gambling or drugs as time passes to experience the same high (a condition called tolerance), and both undergo uncomfortable withdrawal when they stop. That hints the addicts' brain wiring has undergone similar changes -- or neuroadaptation -- whether by thumbing a slot machine a thousand times an hour or smoking crack every morning.
Their addictions each wax and wane. They may recover without treatment, but both respond to motivational and 12-step programs.
The drug naltrexone, which blunts drug and alcohol cravings, also seems to help gambling addicts resist the urge to bet, further suggesting -- though not proving -- that behavioral and substance addictions are two sides of the same coin. In fact, more than 70 percent of gambling addicts also have alcohol problems and more than 30 percent are drug abusers.
"It's very rare that I get a 'pure' gambler," Chapman said. "Most of them have another addiction in the past."
Reclassifying could affect funding
Switching pathological gambling to the category of addictions could help attract more research money, and more researchers, said Christine Reilly, executive director of the Institute for Research on Gambling Disorders.
Under its current incarnation as an impulse disorder, "I don't think a lot of people in the field have taken it seriously as an addiction," said Reilly, whose organization manages pathological gambling research paid for by the casino industry. The more than $22 million donated by the industry since 1996 has filled a huge void in government funding.
"If you're a young investigator and you see hardly any gambling research getting funded at the national level, why would you pick that as your career?" Reilly said. Reclassifying gambling as an addiction "could make a huge difference."
The change also could affect the willingness of insurers to pay for pathological gambling treatment.
"They pay for [substance] addiction now, whereas a lot of companies won't pay for impulse disorders," said Jenny Campbell-Roux, who directs the Problem Gambling Network of Ohio.
Adding gambling addiction to the list of covered disorders probably won't happen without a fight, warned Keith Whyte, executive director of the National Council on Problem Gambling. "If [insurers] have been refusing to address this disorder for decades, it's unlikely they're going to change their policies without regulation or legislation."
The biggest impact of gambling's reclassification as an addiction may be on pathological gamblers themselves, who often have difficulty comprehending why they can't quit betting.
"You have addicts in recovery who don't understand -- 'If it's a [behavioral] action, why can't I stop it? I'm not putting something into my brain.'" said Campbell-Roux. "They don't get it."