What’s a Gambling Disorder (as defined by DSM 5)?

Perhaps you've walked through a casino, astonished at the people mesmerized by the slot machines. Or, perhaps someone close to you seems compelled to gamble online. Gambling disorder, DSM 5 defined, is a real thing. Moreover, it can destroy lives.

A report issued by the UK Gambling Commission estimates more than 2 million people already have a gambling problem, or at risk of developing a gambling addiction. The report also estimated that the number of problem gamblers over the age of 16 has grown by a third in just three years. Finally, the report suggests that around 430,000 people suffer from a DSM5 gambling disorder.

According to a survey conducted last March, the biggest percentage of problem gamblers in the UK fall between the ages of 25 to 34. Individuals in that age group have a gambling addiction rate of 1.3%. The second-largest at-risk group is between the ages of 16 to 24 years, at 1%. By comparison, only 0.2% percent of those 65 years and older were problem gamblers.

What is the DSM-5?

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition is used as the authoritative tool for diagnosing mental disorders. The DSM is filled with symptoms, descriptions, and other parameters for diagnosing every type of mental disorder, including gambling and other addictions.

The Diagnostic and Statistical Manual of Mental Disorders was first published in 1952, and the most recent edition was released in 2013.

For this latest edition, the APA enlisted more than 160 top clinicians and researchers from all over the world to evaluate the evidence-based on science, to review the revisions to DSM–IV.

The Diagnostic and Statistical Manual of Mental Disorders is considered to be the "gold standard" when diagnosing mental health issues.

Gambling Disorder DSM 5

DSM-IV called what is now known as gambling disorder, pathological gambling and classified it as an impulse control disorder. However now, it's known as Gambling Disorder in the DSM 5 and is classified as a behavioral addictive disorder.

Experts have been pointing out the similarities between addiction to gambling and drug addiction for decades. However, whether or not behavioral addictions are similar to drug and alcohol addictions was controversial for years. But now, clear links between gambling and other addictions have been established.

Research suggests that a high rate of cross-over exists between gambling and substance addiction. A study conducted in the United States discovered that more than 73% of those diagnosed with a gambling disorder DSM 5 also suffered from alcohol addiction. In fact, alcoholism is the most common co-occurring condition.

Cocaine and gambling also cross-over in terms of an overall antisocial lifestyle. A cocaine addict may see gambling as an acceptable way to acquire drug money. Their cocaine habit may also increase their energy as well as inflate their opinion of their gambling skill, believing that they can’t lose.

Problem gamblers, alcoholics, and drug addicts also share some of the same genetics for impulsivity and reward-seeking.

Research indicates that people prone to both drug addiction and compulsive gambling and drug addiction have underactive brain circuits dealing with reward. Because of this, they tend to take bigger risks when it comes to both gambling and substance use. In the same way that drug addicts must take more drugs to achieve the same high, gambling addicts must take more risks and bet more money.

People with substance abuse and gambling disorders also have higher rates of ADHD, antisocial personality disorder, and risky sexual behaviors.

Gambling Disorder DSM 5 Symptoms

To meet the parameters for gambling disorder in the DSM 5, someone must have at least four of these symptoms within the last year. 

• The need to gamble with more money to get the same thrill
• Feeling irritable or restless during attempts to reduce or stop gambling
• Continued unsuccessful attempts to reduce or stop gambling
• Both recalling and reveling in past gambling experiences
• Constantly planning to gamble
• Gambling to relieve feelings of guilt, depression, or anxiety
• Attempting to win back gambling losses with more gambling
• Lying to conceal how much they are really gambling
• Gambles away not only money, but also their job, relationships, and career opportunities
• Is dependent on other people's money to deal with gambling-caused financial problems

Someone with a DSM 5 gambling disorder can have periods where gambling doesn’t seem to be a problem. However, the uncontrollable urge to gamble always eventually comes back.

Also, compulsive gambling and other addictive behaviors run in families, and the disorder can begin as early as the teenage years. However, sometimes it can kick in late into adulthood. Men are more likely to be afflicted at an early age, while women are more likely to be afflicted later in life.

Environmental factors also contribute to a gambling disorder according to DSM 5, such as triggers. To effectively manage a gambling disorder according to DSM 5 is to identify both internal and external triggers. An internal trigger could be a feeling of anxiety or depression. On the other hand, an external trigger could be walking by a betting shop. Triggers need to be identified, and modified through cognitive behavioral therapy.

Gambling Disorder the DSM 5 and Bipolar Disorder

Those diagnosed with bipolar disorder often engage in compulsive and addictive behavior, including gambling. Some of the people you see glued to video poker machines could be bipolar. They also spend too much money on lottery tickets and haunt casinos.

Researchers have discovered that, like substance addiction, gambling disorder DSM 5 and bipolar disorder often go together. For example, 50% of all problem gamblers in the US also have a mood disorder. Likewise, a Canadian study found that the incidence of gambling disorder DSM 5 was more than double for bipolar individuals than for people in the general population. One study found that the diagnosis of a mood disorder preceded the diagnosis of a gambling disorder in 58% of men and 80% of women.

Extreme mood swings are a key component of bipolar disorder; these mood swings can cause fluctuating energy levels. During a manic episode, a bipolar individual can feel excited and joyful, and filled with a sense of purpose. But they can also suddenly sink into depression, feeling joyless, sad, and tired.

Bipolar individuals could use the thrill of gambling to help lift themselves out of a depressive phase. Likewise, during a manic phase, impulse control is reduced, and a bipolar person could go on a gambling binge. Also, during a manic phase, the person could easily believe that they can't lose.

If someone with bipolar disorder is self-medicating by gambling, they are using it to make themselves feel better. Thus, the treatment of an underlying bipolar disorder could also treat the self-medicating behavior of gambling.

How Gambling Disorder DSM 5 Differs From Bipolar Disorder

While there is no question that gambling disorder can stem from emotional problems, it's treatable in the same way as substance addictions. Cognitive-behavioral therapy and 12-step programs are often successfully used to treat a gambling disorder DSM 5.

On the other hand, people who have bipolar disorder engage in gambling as a way to self-medicate their bipolar symptoms. This is not the same as a gambling disorder, despite the behavior as well as the consequences being the same. This is not to say that gambling during manic or depressive episodes are not serious. It's just to point out that a gambling disorder according to the DSM 5 is a pattern of addiction, not something that occurs during a bipolar phase.

However, a study conducted by the British Journal of Psychiatry found that moderate to extreme gambling issues were four times higher in bipolar individuals compared to the general population. So the connection can not be denied. However, the core issue, either bipolar disorder, or gambling disorder DSM 5, needs to be determined for proper treatment.

Magical Thinking and Gambling Disorder DSM 5

One of the fascinating and unique things associated with gambling disorder DSM 5 is magical thinking. Like other addictions, denial of the problem is quite common. However, unlike other addictions, people with a gambling disorder engage in magical thinking. They are unusually superstitious, and those very superstitions reinforce their addiction. They have a near-magical belief in winning, to the point of engaging in a sort of sympathetic magic.

Problem gamblers can have an unconscious belief in the transfer of "lucky" energy. For example, if a problem gambler sees someone win at a particular slot machine, they may believe it is “lucky”. Also, if they've won at a particular machine, they may continue to play that machine, believing it has magical luck.

Moreover, those with a gambling disorder can believe that luck is personal, and that some people are imbued with “luck”. They can also believe in lucky objects, such as a rabbit's foot or a lucky charm. Luck is constantly just out of reach, and they may have personal rituals to strengthen their luck.

The designers of video slot games play upon this magical thinking, crafting their games around magical, fantasy themes. While an ordinary person will see the characters in a slot game for what they are, cartoon characters, a compulsive gambler sees it differently; they can be drawn into the fantasy world, actually believing in the cartoon princess, pirate, or wizard. They begin to believe that a cartoon character is actually leading them to hidden riches. They just have to stay the course.

Another pattern of distorted, magical thinking involves "chasing losses”. A problem gambler really believes that they will win their losses back, and then some.

Furthermore, magical thinking includes “near-miss beliefs”. Gambling addicts often ease their minds after losing by telling themselves they “almost” won. This is another psychological feature video game developers can exploit. In the gambler's mind, these near misses justifying even more gambling. In fact, near misses can be even more stimulating, than actually winning.

Brain Studies and Gambling Disorder DSM 5

One of the major factors that changed gambling disorder to be classified as an addiction in DSM-5 involved neurochemical tests and brain imaging. Much of that research supports classifying compulsive gambling with other addictions.

These studies revealed that gambling and drug addiction share much in common, in the way they react with the brain. Research indicates that gambling triggers the brain's reward system similarly to drugs or alcohol. Specifically, deep with the brain is the reward center, the ventral striatum. This brain  has been shown to be involved in both addiction and rewards.

When test subjects with gambling disorder played gambling games while their brains were being scanned, changes in blood flow to specific brain regions were noted. These changes indicated which areas of the brain were more active. In one study, gamblers showed reduced activity in the ventral striatum compared to healthy test subjects. Furthermore, problem gamblers had less ventral striatum activity while gambling and during the anticipation of winning, compared to normal people.

While those findings seem counterintuitive, researchers think otherwise. They postulate that people with a gambling disorder suffer from an underactive brain reward system. Because of this, they are drawn to gambling as a way to stimulate those reward pathways in their brains.

Another brain region implicated in gambling disorder is the prefrontal cortex. This region of the brain is involved in impulse control, cognitive control, and making decisions. Studies have shown that problem gamblers demonstrate less prefrontal cortex activity in response to gambling. Studies have also shown that compulsive gamblers are more impulsive than most people. That could be due to reduced prefrontal cortex activity.

Presently, it's unclear whether brain differences lead to gambling disorder, or if compulsive gambling causes changes in the brain.

Dopamine and Gambling Disorder, DSM 5

The neurotransmitter dopamine is released in the brain during fun activities like sex, eating, and doing drugs. However, it's also released during situations in which the reward for an action is uncertain. Moreover, potential, anticipated reward increases the release of dopamine. The anticipation of a reward could explain why the release of dopamine is tied to the gambling “high”. Dopamine also probably reinforces the risk-taking behavior of problem gamblers. 

It seems counterintuitive, but losing can trigger the release of dopamine in a gambling addict to nearly the same level as winning. As a result, losing triggers the urge to keep playing, or, chasing losses. 

Research suggests that dopamine dysfunction in the brain can lead to exaggerated reward anticipation as well as an increased attunement to uncertainty. These two factors could play into addictive gambling. Moreover, increased impulsivity has been linked to dopamine dysfunction; impulsivity is a well-known risk factor for compulsive gambling. 

Curiously, gambling disorder DSM 5 ranges between .4% and 3.4% in adults, however, it seems to be more common in those suffering from Parkinson's disease. This could be because Parkinson's disease is often treated with dopamine agonist drugs. These medications stimulate the dopamine receptors in the brain, mimicking increased dopamine levels.

Parkinson's patients taking some dopamine agonist drugs, saw an increased risk of developing a gambling disorder of 50%. The neurotransmitter dopamine influences the action of reward and reinforcement, likely playing a role in gambling disorder.

The development of gambling disorder in Parkinson's patients receiving low doses of dopamine agonist drugs indicates a possible genetic predisposition. In fact, some research has uncovered genetic variations linked to Parkinson's patients who develop a gambling addiction.

Gambling addicts suffer the same dopamine withdrawal symptoms as drug addicts, due to gambling triggering dopamine release in a similar way.

Gambling Disorder and Suicide 

One of the main reasons why gambling disorder has come to the forefront is the extreme consequences for both the gamblers and their families. People with a gambling disorder often gamble away everything they own, resulting in bankruptcy. Not only that, they are much more likely to become suicidal compared to most people. Around half of those in treatment have suicidal ideation, and in one study, 23% of problem gamblers attempted suicide.

However, it remains unclear whether gambling itself increases the risk of suicide. Likely, financial losses, debt, job loss, and damage to personal relationships make suicide seem like the best option. The conclusion to be drawn is that a combination of impulsivity, mood disorders, and social factors explains suicidal behavior.

Fortunately, most problem gamblers who have had suicidal ideation have recovered, and gone on to lead healthier lives. Treatment and support groups can help those with a gambling disorder learn coping skills, and end thoughts of suicide.

Warning signs that someone you know may be at risk for suicide:

• Talking about suicide or wanting to die
• Looking up ways to kill oneself on the internet
• Talking about not having reason to live or feeling hopeless
• Saying they feel trapped
• Talking about experiencing unbearable emotional pain
• Saying they are a burden to others
• Increased drinking or using drugs
• Acting agitated or extremely anxious
• Reckless behavior
• Sleeping too much or too little
• Withdrawing and isolated from friend and family
• Acting rageful or wanting to seek revenge
• Extreme mood swings

If you or someone you know is at risk for suicide, immediately call the National Suicide Prevention Lifeline: 1-800-273-TALK.

Comorbidities Related to Gambling Disorder

Psychological comorbidities are the rule, not the exception, for those with a gambling disorder. The majority of problem gamblers can also suffer from alcohol dependence, drug or other addictions, depression, anxiety, bipolar disorder, impulse control disorders, or a personality disorder.

Problem gamblers clearly have a relationship with substance abuse. One survey found that compulsive gamblers had seven times the rate of alcohol or drug abuse than recreational gamblers or non-gamblers. Surveys also show that the rate of alcohol dependence is at least 4 times higher among those with a gambling disorder than the general population.

Also, drug addiction among those with a gambling disorder is around 4 times higher than that of nongamblers. In one survey, the prevalence of drug addiction was 38% among those with gambling disorders. Conversely, just 9% to 16% of drug addicts were possible problem gamblers.

More than 49% of people with a gambling disorder also have a mood disorder, with mania being the most related to gambling disorder.

Anxiety disorders are also strongly associated with gambling disorders. One study found that over 60% of problem gamblers' samples had some type of anxiety disorder. More than half suffer from phobias, 22% have panic disorder, and nearly 15% have posttraumatic stress disorder.

Investigators found that the rate of borderline personality disorder stood around 16% among those with a gambling disorder. Following behind borderline personality disorder were antisocial, paranoid, and narcissistic personality disorders, at around 8% each. The odds of having a personality disorder are more than eight times greater for someone with a gambling disorder.

Rates of antisocial personality disorder are nearly 6.5 times more among those with a gambling disorder DSM 5; 15% of sampled pathological gamblers also had an antisocial personality disorder, compared to just 2% of those without a gambling disorder.

Do You Meet the Criteria for Gambling Disorder, DSM 5?

If you recognize some of the signs and symptoms of a gambling disorder within yourself, discuss having an evaluation with your doctor, or mental health professional.

To evaluate you for a gambling disorder, you'll likely be asked the following:

• Detailed questions about your gambling habits. Your therapist may also ask for your permission to speak with the people close to you about your gambling habits. But remember, confidentiality regulations prohibit your doctor or therapist from revealing any information about you without your consent.

• Go over your medical history. Certain medications have a rare side effect triggering compulsive gambling. A physical examination can also pinpoint health problems that are occasionally associated with a gambling disorder.

• Perform a psychiatric evaluation. The evaluation is comprised of questions about your feelings, thoughts, and behavior related to gambling. Depending on the results, you may also be evaluated for other mental health disorders related to compulsive gambling.

• Use the Diagnostic and Statistical Manual of Mental Disorders. Your doctor or therapist will compare your symptoms with the criteria for gambling disorder DSM-5, for a diagnosis.

Once a diagnosis is made, you can work with your doctor or mental health professional to come up with a treatment plan. Treatment could include:

• Therapy. Cognitive-behavioral therapy or behavioral therapy can help. Cognitive-behavioral therapy helps you to identify irrational, unhealthy, and negative beliefs and replace them with positive, healthy beliefs. Behavior therapy systematically exposes you to gambling triggers, and teaches you ways to resist the urge to gamble.

• Medication. Mood stabilizers and antidepressants can help other mental health problems that often accompany a gambling disorder. Medications used to treat substance abuse problems may also be helpful.
• Self-help groups. Getting together with others who also have a gambling disorder to share and talk can be useful. Self-help groups, such as Gamblers Anonymous provide a network for peer support.

Treatment for a gambling disorder can also include outpatient treatment, inpatient treatment, or even a residential treatment program.

Does Someone You Know Have a Gambling Problem?

Someone with a gambling problem affects the lives of everyone close to them, from family, friends, and coworkers. Dealing with someone who has a gambling disorder can be draining. It's better to use your energy to change your own situation rather than try to change them.

It is important to keep in mind:

• You're not to blame for their behavior.
• You can't force the gambler to admit they have a gambling problem.
• Trying to force them to stop gambling is pointless.
• Ultimately, only the gambler can choose to stop gambling.
• Gambling is the problem, not the individual.

Suggestions to ease the strain on relationships caused by a gambling disorder include:

• Tell the gambler how their behavior is negatively impacting you. Be open about your feelings, but communicate them carefully.
• Do not attempt to take control of the gambler’s life. You'll just be miserable, and it won’t work.
• The gambler could feel embarrassed, out of control and ashamed. Let them know you are willing to help them.
• Don't talk down to them. Also, don't try to protect them. Treat them like an adult.
• You can support them in their battle, but do not carry their burden. They need to do the work to change.
• Expect them to take responsibility for their behavior. For example, they need to deal with their employer and bill collectors. Do not help them lie.

Finally, never lend a gambler money, and do not pay their debts. Also, remove your name from any joint accounts, to help keep your credit record clean. Don't sign anything you haven't read or understand. 

You can love and support a gambler, while also protecting yourself.

There is Hope

While dealing with a gambling disorder is overwhelming, it can be overcome. The first step is to admit there is a problem. The second step is to seek help. Change won't happen overnight, so stick with it. One day, gambling will no longer rule your life.