A hierarchy of gambling disorders in the community

Abstract

Aims To help refine the definition and diagnosis of gambling disorders, we investigated the distribution among US gamblers of the 10 DSM-IV criteria for Pathological Gambling. Design We drew data from two stratified random surveys ( n = 2417, n = 530) of gambling behavior and consequences among community-based samples of US adults. A fully structured questionnaire, administered by trained lay interviewers, screened for the life-time prevalence of problem and Pathological Gambling. Per DSM-IV definitions, anyone meeting five or more of 10 itemized criteria was considered a pathological gambler. We analyzed these criteria among all gamblers who met one or more criteria ( n = 399). Findings Most gamblers who met only one or two criteria reported 'chasing their losses'. At subclinical levels (three to four criteria), gamblers also reported elevated rates of gambling-related fantasy: lying, gambling to escape and preoccupation. Pathological gamblers with five to seven criteria reported marked elevations of loss of control, withdrawal symptoms and tolerance (internalizing dimensions of dependence); risking their social relationships and needing to be bailed out financially (externalizing dimensions). Most of the highest-level pathological gamblers (eight to 10 criteria) reported committing illegal acts to support gambling. Conclusion Dependence in a biobehavioral sense appears to be a hallmark of Pathological Gambling, but it marks only one threshold in a qualitative hierarchy of disorders beginning with a common subclinical behavior, 'chasing'. Epidemiological assessments and future DSM revisions might consider explicit recognition of a problem gambling disorder, identifying people presenting some cognitive symptoms of Pathological Gambling but not clear signs of dependence. Pathological gamblers in turn appear to have two distinct levels of severity.

An Examination of a Proposed DSM-IV Pathological Gambling Hierarchy in a Treatment Seeking Population: Similarities with Substance Dependence and Evidence for Three Classification Systems

“…Counselors reported their clients had much higher percentages of criteria endorsement in the Low Pathological and High Pathological sub-groups (see Table 2), while a much smaller proportion was classified as At-Risk gamblers in the current study compared to Toce-Gerstein et al (2003). As a consequence, only the Problem Gambler subgroup proportions were nonsignificant at the 95% confidence level when the current study was compared with the ToceGerstein et al (2003) study.…”

“…The best fitting curve to two decimal places was then chosen as representative of the underlying functions within the data (as specified by Toce-Gerstein et al (2003); a decelerating curvilinear concave downwards curve indicated a 'low-threshold' relationship between the criterion and gambling severity, a linear curve indicated a directly dependent relationship, and an accelerating concave upwards curve indicated a 'high-threshold' relationship). Polynomial curves were fitted to the data using three or four free parameters, depending if the additional free parameter added to the fit of the squared correlations.…”

“…Such results may support a hierarchical structure in the valuing of criteria and question the appropriateness of using only 'case-ness' as the sole diagnostic approach. Toce-Gerstein et al (2003) attempted to refine the diagnosis of pathological gambling by examining the association of individual DSM-IV diagnostic criteria relative to the distribution of gamblers from a general population survey and an in-person survey of gambling facility patrons in the United States. The combined sample from these two studies comprised 399 participants who reported at least one loss of more than $100 in a single year and endorsed one or more DSM-IV symptoms of life time pathological gambling.…”

“…These scores were then categorized based on the National Opinion Research Centre Diagnostic Screen for Gambling Problems (NODS) taxonomy, and suggested four levels of problem gambling severity: a) At-Risk gamblers reporting predominantly Chasing gambling losses, gambling Preoccupation, and gambling for emotional Escape; b) Problem gamblers endorsing elevated rates of Chasing gambling losses, Preoccupation with gambling, gambling for emotional Escape, and Lying to others; c) Low Pathological gamblers endorsing elevated rates of Loss of Control, Withdrawal symptoms, Tolerance, Risked Relationships and needing to be Bailed out financially from gambling debts or paying for essential goods and services; and d) High Pathological gamblers endorsing elevated rates for almost all of the ten DSM-IV criteria and higher endorsement rates of Illegal Acts than any other gambling severity. Toce-Gerstein et al (2003) argued that although the severity of gambling problems can be represented along a continuum, their results suggested that groupings of symptoms may also be predictive of four separate patterns; an At-Risk non-clinical pattern marked by Chasing losses, a Problem subclinical pattern, a clearly separate diagnosis of Low Pathological gambling, and a more severe level of High Pathological gambling marked by elevated rates of Illegal Acts. They also suggested this hierarchy can make important clinical distinctions between sub-clinical problem gambling and pathological gambling based on the endorsement of Withdrawal and Loss of Control, as these criteria both describe the phenomenon of repeated and unsuccessful attempts to resist the urge to gamble; a phenomenon typically associated with problematic gambling (Kushner et al, 2007).…”

Chasing losses in online poker and casino games: Characteristics and game play of Internet gamblers at risk of disordered gambling

“…Theoretical models of disordered gambling posit that chasing losses is central to the initiation and continuance of gambling sessions, contributing to on-going unaffordable losses and subsequent negative consequences (Blaszczynski and Nower, 2002;Sharpe, 2002). Both irrational beliefs and chasing behaviours are commonly reported by disordered and problem gamblers, including Internet gamblers, and in particular, characterise the lowest levels of disordered gambling severity (Blaszczynski and Nower, 2002;Orford et al, 2003;Toce-Gerstein et al, 2003;Strong and Kahler, 2007;Mackay and Hodgins, 2012). Critically, chasing losses is one of the few signs and criteria for disordered gambling that is observable.…”