“Gambling is a wonderful distraction from one’s problems. It partly does this by creating new problems,” says psychiatrist Richard J. Rosenthal, MD. “It also offers a simplified view of things: One wins or loses…the rules are clear-cut, all without the messiness of life.”
Experts have grappled with a label for the behavior of those who find themselves unable to stop, and the DSM-5 landed on a term: gambling disorder. In many ways, Rosenthal says, gambling disorder resembles other addiction disorders—with one big exception. When you’re caught up in it, you believe it can solve all of your problems. You might hold the irrational belief that you can undo your guilt—that you can start over—by winning back what you have lost. As Rosenthal puts it: “It is as if by getting even, one had never gambled.”
To understand the disorder, we spoke with Rosenthal, who is a codirector of the UCLA Gambling Studies Program and a coauthor of the DSM-IV. He walks us through the characteristics of the disorder, how it resembles—and may co-occur with—other addictions, and how to find help.
A Q&A with Richard J. Rosenthal, MD
Q: What is gambling addiction? What does it look like?
A: Gambling disorder is the name for what was, until recently, known as compulsive gambling, pathological gambling, problem gambling, and disordered gambling. Although it was not difficult to diagnose, the number of names and labels for it reflected disagreement about what it was and how best to conceptualize it. There is general agreement now that it is an addiction, in fact the first and only officially recognized behavioral (nonsubstance) addiction.
I recently defined addiction as a pattern of behavior in which the relationship with a substance or activity is harmful, progressive, and unstable.
The progressive elements are: 1) the time and importance attached to the behavior, 2) the individual’s inability to regulate or control their involvement (they have difficulty setting or sticking to predetermined limits and difficulty stopping or not starting), 3) the harm it causes both to others and to themselves, and 4) their worsening feelings of shame, guilt, anxiety, depression, and/or helplessness.
Additional characteristics of addiction include:
1. The continuation of the behavior despite awareness of its harmful consequences, and the increasing loss of control. In fact, there may be a vicious cycle in which the substance or behavior causes harmful or negative consequences, the solution for which is thought to be more of the substance or activity, which will then cause more negative consequences, ad infinitum.
2. Tolerance, in that the individual needs to take more of the substance or engage in more of the activity in order to experience the same desired level of excitement. In the case of gambling, this is accomplished by wagering more money, making more bets, playing faster, and/or taking greater risks.
3. The absence of fullness or satisfaction. There is no end point; one can never win enough, there is never “enough.” Spectacular success, no matter how great, will need to be repeated. And even if relief can be achieved, it is only temporary.
Q: What are the signs that gambling has become an addiction?
A: Like other behaviors, gambling can be done to excess, and it can even become a bad habit without becoming an addiction. What makes it excessive isn’t cultural condemnation or someone’s value judgment, but rather objective harm. In the case of gambling, this objective harm is usually financial in the beginning.
Feelings of distress at losing more money than one can afford to lose include shame, guilt, anxiety, even panic. Losing is no longer part of the game—it becomes intolerable. A typical response is to start chasing: The individual will abandon their gambling strategy and try to win back their losses all at once. Most people will soon realize the folly in this and quit.
Others will continue chasing, even though they can see that their problems are getting worse. This is when it has crossed over into addiction. Feeling shame and desperation, they become more isolated and secretive and start lying about their debts and the extent of their gambling. As this progresses, they may become irritable and angry and grow more depressed. Some will turn to alcohol, drugs, food, or whatever they think might distract or numb them; mostly it will be more gambling.
The earlier an individual can recognize signs of a problem, the better. At UCLA, we have used the Brief Biosocial Gambling Screen, which consists of just three questions:
1. Have you become restless, irritable, or anxious when trying to cut down on or stop gambling?
2. Have you tried to keep your family or friends from knowing how much you’ve gambled?
3. Have you had such financial troubles associated with gambling that you had to get help from family, friends, or welfare with living expenses?
Anyone who answers yes to one or more of these questions should be evaluated further as they are at risk for developing a gambling addiction.
Another easy way to test whether gambling has become “too important” is to stop gambling for thirty days and see what life is like without it. You can see whether you’ve been gambling as a way to avoid or escape problems or perhaps to numb certain painful and uncomfortable feelings. How restless and uncomfortable were you when you stopped gambling? Did you have urges and cravings that were difficult to ignore? Were you bored?
Q: How common is it?
A: About 1 percent of the adult population will qualify for a diagnosis of gambling disorder at some point in their lives. For as long as we’ve done prevalence studies and collected data on this, the disorder has been twice as common in men as in women. Until now. Recent percentages may be going in the opposite direction.
It’s hard to say definitively why this might be. There has been an increase in binge drinking among college women, and it may be that the increased interest among young women in poker and other competitive, action-seeking types of games previously thought of as appealing more to men reflects a similar shift. Additionally, smartphones and devices that can be operated from home have made slot machine gambling far more accessible, as has the recent trend toward gambling on social media, which is also favored by women.
Q: What is the relationship between gambling addiction and alcohol addiction?
A: Gambling disorder and alcohol use disorder frequently co-occur. The relationship between them is simple: Each makes the other worse. Someone newly in recovery from an alcohol problem may start gambling as a way to deal with boredom, restlessness, or other uncomfortable feelings. Initially gambling is exciting, but when they find that they are losing, they turn back to alcohol and drugs to cope with their disappointment, anxiety, and depression. People may find themselves tempted by free alcohol in the casinos and use alcohol prior to or while gambling to reduce their anxiety while gambling. They may also use drinking as a way to cope with their feelings after they have lost. Instead of one addiction, they find themselves with two.
Q: Can gambling addiction be related to depression or other mental health diagnoses?
A: There is also a reciprocal relationship between gambling and depression. Many people gamble to ease feelings of depression, only to find that the consequences of their gambling cause a secondary depression. Generally, this is true because gambling is thought of as a way to self-medicate various problems, including affective and anxiety states and other mental disorders. The issue is that the problems then caused by gambling exacerbate those disorders. Panic attacks and suicidal thinking are not uncommon.
An acute gambling binge can mimic many other disorders, especially the mania of bipolar disorder, and therefore many gamblers have been misdiagnosed as bipolar. A careful assessment of a patient’s history is necessary, and it may also be necessary to follow the individual to make sure that their mood swings are independent of their gambling.
There is one other disorder that frequently co-occurs with gambling disorder, and that is attention deficit hyperactivity disorder. At least 25 percent of individuals with GD have a co-occurring ADHD. There are multiple reasons for that, including self-esteem issues, a need for stimulation and excitement, early validation through competitive sports, and habitual secrecy. Just as stimulant medications and activities provide a paradoxical calming or slowing down, the excitement of gambling may have initially provided a normalizing effect that the individual continues to seek. Clearly, when GD and ADHD co-occur, both need to be treated.
Q: What fuels gambling addiction?
A: Gambling is a wonderful distraction from one’s problems. It partly does this by creating new problems. It also offers a simplified view of things: One wins or loses, and one usually learns immediately where one stands; the rules are clear-cut, and without the messiness of life.
There are several features unique to gambling that contribute to the progressive nature of the disorder. Winning and losing are personalized. To win is to be a winner, with all that entails. Gambling, it is believed, can solve all one’s problems, and not just with the short-term fix common to all addictions, but in some fundamental way. Chasing, which is also unique to gambling, is the irrational belief that by winning back what one has lost, one can undo feelings of guilt. It is as if by getting even, one had never gambled. Various aspects of the gambling experience hold out this possibility of starting over. A second chance, a do-over, a mulligan.
Furthermore, since gambling is so unpredictable, the consequences are not immediate or certain. Gamblers, therefore, believe they can get away with not being held accountable. Characteristics of gambling and the accompanying fantasies fuel the belief that persistence at gambling will be rewarded. And that the solution to one’s problems—including those recently created by gambling—is available if one keeps gambling.
Q: What are the available resources and treatment options?
A: Gambling is a very treatable disorder, and there are a variety of resources for those looking to get help. The website of the National Council on Problem Gambling offers a directory of certified gambling counselors listed by state. NCPG also sponsors a national helpline, 800.522.4700, which will make direct referrals. There is another helpline number, 800.GAMBLER, which is available in California, New Jersey, Pennsylvania, and West Virginia.
California’s Office of Problem Gambling has partnered with the UCLA Gambling Studies Program to provide trained therapists for gamblers and their affected family members. Because the program is funded by the state, treatment is offered without charge.
Gamblers Anonymous has been offering help since 1957. It is compatible with and complements professional treatment, and the best outcomes are achieved by those who do both.
Richard J. Rosenthal, MD, is a clinical professor of psychiatry at the David Geffen School of Medicine at UCLA and the codirector of the UCLA Gambling Studies Program. He coauthored the diagnostic criteria for gambling disorder and has written about its phenomenology, course, complications, and treatment. In 2018 the National Council presented him with its lifetime achievement award for research. His recent publications include “Why Dostoevsky Quit Gambling” and “The Etymology and Early History of Addiction.”
This article is for informational purposes only, even if and regardless of whether it features the advice of physicians and medical practitioners. This article is not, nor is it intended to be, a substitute for professional medical advice, diagnosis, or treatment and should never be relied upon for specific medical advice. The views expressed in this article are the views of the expert and do not necessarily represent the views of goop.
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