What’s a Gambling Disorder (as defined by DSM 5)?
What’s a Gambling Disorder (as defined by DSM 5)?
According to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM 5), gambling disorder is a behavioral addiction. The DSM 5 is the official text used by mental health professionals to positively diagnose mental and emotional disorders.
This is the first time the DSM 5 diagnosed gambling disorder as a behavioral addiction; the DSM-IV called the issue "pathological gambling" and classified it as an impulse control disorder, not an addictive disorder.
For decades, the similarities between drug addiction and gambling addiction have been noted by professionals. However, whether or not substance addictions share characteristics with behavioral addictions remains controversial.
What Exactly is the DSM-5?
The DSM-5 is used as the standard diagnostic tool for evaluating mental disorders. The Diagnostic and Statistical Manual of Mental Disorders lists detailed descriptions, symptoms, and other indicators for diagnosing every mental disorder, including behavioral addictions such as gambling.
The first edition of the Diagnostic and Statistical Manual of Mental Disorders was released in 1952. The fifth and latest edition was released to the public in 2013.
For the fifth edition, the American Psychiatric Association called upon 160 mental health professionals worldwide to evaluate the newly revised disorders based on science.
This professional diagnostic tool is considered the "gold standard" for diagnosing mental and emotional health issues.
Gambling Disorder DSM 5
DSM-IV classified what is now designated as gambling disorder, as an impulse control disorder. However, what was formerly known as pathological gambling in DSM-IV is now classified as a behavioral addictive disorder.
For decades, the experts have noted the similarity between drug addiction and addiction to gambling. But, whether behavioral addictions were truly akin to substance addictions remained controversial. However now, experts have established undeniable links between substance addictions and gambling.
Researchers have confirmed that there is a high rate of similarity between substance addiction and compulsive gambling. For example, a study conducted at an outpatient addiction clinic showed that over 73% of patients diagnosed with a gambling disorder DSM 5 were also diagnosed with alcohol dependency. In fact, alcohol addiction is the most common co-occurring diagnosis with gambling disorder.
Also, within a general antisocial lifestyle, gambling and cocaine addiction co-occur. A person with a cocaine addiction can see gambling as a socially acceptable way to get money to buy drugs. Also, a cocaine habit can inflate the ego, causing the addict to believe that they can’t lose at gambling.
Also, alcoholics, drug addicts, and compulsive gamblers share several of the same genetic markers for reward-seeking and impulsivity.
Research has found that both pathological gambling and drug addiction involve underactive brain circuitry related to reward. Due to this, addicts often take bigger risks with both substance abuse and activities such as gambling. Similar to the same way that a drug addict needs more drugs to get the same high, pathological gamblers need to take more risks, betting more and more money.
Also, people diagnosed with both substance abuse and gambling disorders have higher rates of antisocial personality disorder, ADHD, obsessive-compulsive disorder, and engage in high-risk sexual behaviors.
Gambling Disorder DSM 5 Symptoms
To meet the definition of a gambling disorder according to DSM 5, a person needs to have four or more of the issues listed below, within the last year. These symptoms must also present alongside a "recurrent and persistent behavior of problem gambling:"
- The compulsion to gamble with more and more money to get the same feeling of exhilaration
- Feelings of restlessness and irritability when attempting to stop or reduce gambling
- Repeated, failed attempts to reduce or stop gambling
- Constantly thinking about gambling, both planning gambling trips and reliving previous gambling experiences.
- Gambling when feeling anxious, guilty or depressed.
- Gambling more to win back losses
- Lying to hide how much they are really gambling
- Losing not only money, but also gambling away their relationships, job, and career opportunities
- Dependency on others for money to deal with financial difficulties caused by gambling losses
Those suffering from a DSM 5 gambling disorder can experience times when gambling isn’t really a problem. Bur, unfortunately, the irresistible urge to gamble eventually always comes back.
Moreover, gambling disorder DSM 5, as well as other addictive behavior in general, runs in families. Addictive disorders often begin during adolescence, but sometimes don't manifest until later in life. Men are more often to show signs at a young age, while women are more likely to show signs of addiction later in life.
Also, environmental factors contribute heavily to a gambling disorder according to DSM 5. Friends, family, and environment play a role in shaping the triggers that compel someone to gamble. Managing a gambling disorder DSM 5 involves identifying both external and internal triggers. An internal trigger could be feelings of depression or anxiety. An external trigger could be a place where the addiction began, watching a game, or a certain person. Gambling triggers must be identified, and either avoided or modified through therapy.
How Does Gambling Disorder Coincide with Bipolar Disorder?
It's undeniable that gambling can become a problem, leading to huge financial, relationship, and emotional problems. Also, it's treatable with similar methods as substance addictions. This has been demonstrated repeatedly, and as a result, gambling disorder in the DSM 5 is now recognized as a true addiction.
Some people diagnosed with bipolar disorder gamble obsessively during manic episodes. In fact, researchers have discovered that gambling disorder DSM 5 and bipolar disorder often co-occur. One study showed that 50% of all compulsive gamblers in the US also suffer from a mood disorder.
A Canadian study demonstrated that gambling disorder DSM 5 was diagnosed at more than twice the rate for people with bipolar than for the general population. Another study found that in 80% of women and 58% of men, a mood disorder was diagnosed before a gambling disorder.
Extreme mood swings and energy levels are the hallmarks of bipolar disorder; during a manic episode, a bipolar person can feel elated, and full of purpose. That inflated sense of optimism, along with a feeling of invincibility, can lead to compulsive gambling. Likewise, reduced impulse control is part of a manic phase, leading a bipolar person to go on gambling binges. During a manic phase, a bipolar person can easily believe that they can't lose.
However, they eventually come down, sinking into a deep depression. At that point, they become acutely aware of the destruction their gambling has done to their lives. Unfortunately, bipolar individuals sometimes remember the thrill gambling gave them and go back to lift themselves out of the depression.
The treatment of bipolar disorder with medication often resolves gambling self-medicating behavior. This further demonstrates the link between gambling disorder DSM 5 and other mental disorders.
How is Gambling Disorder DSM 5 Different From Bipolar Disorder?
While it's undeniable that compulsive gambling can arise from emotional issues, it's also treatable like a substance addiction. Like drug abuse or alcoholism, 12-step programs and cognitive-behavioral therapy are successful treatments for gambling disorder DSM 5.
On the other hand, those with bipolar disorder use gambling as a way to self-medicate. Despite the behavior and consequences being the same, it's not the same as a gambling disorder. According to the DSM 5, gambling disorder is a pattern of addiction. On the other hand, gambling during a bipolar phase is a means to self-medicate.
However, a study by the British Journal of Psychiatry found that among bipolar individuals, moderate to extreme gambling is four times higher than in the general population. So, it's undeniable that there is a connection between bipolar and gambling disorder in the DSM 5. But, the core issues need to be determined before making an accurate diagnosis.
Magical and Disordered Thinking in DSM 5 Gambling Disorder
One of the unique and fascinating features associated with gambling disorder is magical thinking. Like any other addiction, denial is part of the problem. Unlike other addictions, however, people with a gambling disorder are susceptible to magical thinking. Gamblers are often superstitious, and those superstitions serve to reinforce the addiction. These people have a magical belief that they are destined to win; this magical thinking verges on a type of sympathetic magic.
Compulsive gamblers can have a deep-seated belief in the attainment of "lucky" energy. For example, if they see someone win at a slot machine, they can believe that particular machine is “lucky”. Likewise, if they win at a particular slot machine, they'll continue playing that machine, believing it is magical and lucky.
Furthermore, people with a gambling disorder believe in personal luck, and that some people are just born lucky. They also believe in lucky charms, such as a lucky hat or a rabbit's foot. However, luck is usually just out of reach, and compulsive gamblers have personal rituals to bolster their luck. Rituals could be things like saying a prayer.
Slot game designers use this magical thinking to their advantage, imbuing the games with magical, fantasy subjects. While ordinary people see slot game characters for what they are, fictional characters, a person with gambler disorder sees it very differently; they are often drawn into a fantasy world, really believing in the magical wizard, princess or pirates. They actually believe that a cartoon character is leading them to a hidden treasure. All they have to do is follow the clues, and stay the course.
Another pattern of disordered thinking manifests as "chasing losses”. Someone with a gambling disorder actually believes that they will win their losses back. Not only that, if they just keep at it, they'll hit that life-changing jackpot.
To compound the problem, “near-miss beliefs” are common. After losing, problem gamblers often ease their disappointment by telling themselves they “almost” won. Casino gaming developers also exploit this psychological characteristic. To the gambler, near misses justify more gambling, since in their mind, they came so close to winning. In fact, near misses are often even more emotionally and mentally stimulating, than actually winning.
DSM 5 Gambling Disorder and Brain Studies
Among the major factors that caused gambling disorder in DSM 5 to be classified as a behavioral addiction were brain imaging and neurochemical testing. That research supported classifying pathological gambling as an addiction.
In the way both gambling and drugs react with the brain, the studies showed they both shared much in common. The studies indicated that gambling triggered the brain's reward system in the same way that drugs and alcohol do. Deep with the brain is the ventral striatum, which has been shown to be involved in both rewards and addiction.
While their brains were being scanned, test subjects with gambling disorder engaged in gambling, and the changes in specific brain regions were documented. These scans highlighted the areas of the brain which were most active. In one study, pathological gamblers had less activity in the ventral striatum compared to control subjects. Also, while gambling and anticipating a win, pathological gamblers had less ventral striatum activity compared to normal people.
While the findings appear to be counterintuitive, researchers don't think so. They theorize that individuals with a gambling disorder have a sluggish brain reward system. Due to this, they're attracted to gambling as a means to stimulate the underactive reward circuitry in their brains.
The prefrontal cortex is another brain region involved in gambling disorder. The prefrontal cortex is involved in cognitive control, impulse control, and decision making. Researchers have discovered that pathological gamblers have less activity in the prefrontal cortex in response to gambling. Also, studies have shown that problem gamblers are more impulsive than the general population. This could also be due to reduced activity in the prefrontal cortex.
Right now, it remains unclear whether brain anomalies lead to gambling disorder, or if problem gambling changes the brain.
Gambling Disorder, DSM 5 and Dopamine
Dopamine is released in the brain during enjoyable activities like eating, sex, doing drugs and for some people, gambling. However, the neurotransmitter is also released when the reward for a certain action is unknown. Also, the anticipation for a potential reward also increases dopamine release. Reward anticipation could explain why dopamine release is involved in the gambling “high”. Also, dopamine likely is involved in the risk-taking behavior of pathological gamblers.
While it appears counterintuitive, losing can trigger dopamine release in someone with a gambling disorder, to almost the same levels as winning. Because of this, losing can trigger the urge to chase losses.
Research also indicates that dopamine dysfunction can lead to magnified reward anticipation. Moreover, dopamine dysfunction increases a person's sensitivity to doubt. These factors appear to contribute to gambling disorder DSM 5. Also, dopamine dysfunction has been linked to increased impulsivity; impulsivity is a known risk factor for gambling disorder.
Gambling disorder ranges between .4% and 3.4% in the general population, but strangely, it's more common in people with Parkinson's disease. This could be due to dopamine agonist drugs, which are often used to treat Parkinson's disease. Dopamine agonist drugs stimulate the dopamine receptors in the brain, to mimic dopamine levels.
Among Parkinson's patients taking dopamine agonists, had a 50% increased risk of developing a gambling disorder. Dopamine influences the reaction to reward, probably playing a role in gambling disorder.
Also, gambling disorder in some Parkinson's patients taking low doses of dopamine agonist medications indicates a potential genetic predisposition. Some researchers have discovered specific genetic variations in Parkinson's patients who developed gambling disorders.
Due to gambling triggering dopamine in the same way as drug addicts, gambling addicts suffer the same type of withdrawal symptoms.
Suicide and Gambling Disorder
Among the reasons why gambling disorder has come to the attention of the public are the dramatic consequences for both the gamblers and others. Many individuals with a gambling disorder gamble away everything, sometimes resulting in bankruptcy. Also, pathological gamblers are much more likely to become suicidal, compared to the general public. Around half of the compulsive gamblers in treatment have thought about suicide. Also, in one study, 23% of pathological gamblers attempted suicide.
However, it's not clear if gambling alone increases suicidal ideation. Debt, financial problems, job loss, and loss of personal relationships may make suicide seem like the only option. Also, the combination of a mood disorder, impulsivity, and social factors likely explain suicidal behavior in problem gamblers.
The good news is most compulsive gamblers who have contemplated suicide have recovered and moved on to lead healthy lives. Psychological treatment and support groups can help someone with a gambling disorder learn to cope, ending suicidal ideation.
Warnings that someone you know could be at risk for committing suicide:
- Talking about wanting to die or of committing suicide
- Looking for ways to commit suicide online
- Saying they have no reason to live or of feeling hopeless
- Feeling like they're trapped
- Saying they feel unendurable emotional pain
- Feeling like they're a burden to others
- Increased drug or alcohol use
- Agitated behavior or extreme anxiety
- Reckless behavior
- A dramatic change in sleeping patterns
- Isolating and withdrawal from friends and family
- Rageful behavior or seeking revenge
- Extreme mood swings
If you or someone you know shows signs of suicidal ideation, call the National Suicide Prevention Lifeline: 1-800-273-TALK right away.
Gambling Disorder DSM 5 Comorbidities
With gambling disorder, psychological comorbidities are the norm, not the exception. Most people suffering from a gambling disorder also suffer from drug, alcohol, or other addictions, anxiety, depression, impulse control disorders, bipolar disorder, or personality disorders.
Clearly, pathological gamblers have a problem with substance abuse. One survey revealed that those with gambling disorder had seven times more alcoholism and drug addiction compared to recreational or non-gamblers. Other surveys showed that the rate of alcoholism is at least 4 times higher among pathological gamblers compared to the general population.
Likewise, among those with a gambling disorder, drug addiction is 4 times higher than that of nongamblers. In another survey, 38% of those with gambling disorders also suffered from drug addiction. Conversely, only 9% to 16% of drug abusers were pathological gamblers.
Furthermore, nearly half of those with a gambling disorder also have a mood disorder. Mania is the most common in relation to gambling disorder.
Also, anxiety disorders are very much associated with a gambling disorder. One study revealed that more than 60% of problem gamblers had some sort of anxiety disorder.
To make things worse, more than half of pathological gamblers have phobias, 22% suffer from a panic disorder, and close to 15% have posttraumatic stress disorder.
Researchers also found that 16% of those with a gambling disorder also had a borderline personality disorder. Following closely behind borderline personality, at around 8% each, are paranoid, antisocial, and narcissistic personality disorders. For someone with a gambling disorder, the odds of having a personality disorder are over eight times greater.
Antisocial personality disorder rates are nearly 6.5 times greater among those with a gambling disorder DSM 5; 15% of compulsive gamblers also had an antisocial personality disorder, in contrast to only 2% of the general population.
Do You Meet the Definition for Gambling Disorder, DSM 5?
If you see any of the signs and symptoms of a gambling disorder in yourself, consider having a psychiatric evaluation with your physician, or with a mental health professional.
To assess you for a gambling disorder, your health care professional will ask the following:
- Questions focused on your gambling habits. In addition to asking you detailed questions about your gambling, you may also be asked for permission to question your friends and family about your gambling. However, confidentiality laws prevent your health care provider from releasing information about you without your written consent.
- Review your medical history. Some medications, such as dopamine agonists, have the rare side effect of causing compulsive gambling. A physical examination can also identify health problems that are sometimes associated with pathological gambling.
- Conduct a psychiatric evaluation. This involves asking questions about your thoughts, feelings, and behavior related to your gambling. You may also be evaluated for mood, personality, or other mental health disorders.
- Use the Diagnostic and Statistical Manual of Mental Disorders. Finally, your health care provider will compare your symptoms with the definition of gambling disorder DSM-5.
Once a diagnosis is made, you'll work with your health care professional to outline a treatment plan.
A treatment plan for gambling disorder can include:
- Therapy. Behavioral therapy and cognitive-behavioral therapy can be useful. Behavior therapy exposes a person to their gambling triggers and then teaches techniques to resist the compulsion to gamble. Cognitive-behavioral therapy identifies the unhealthy, irrational, and negative beliefs around gambling. It then replaces those with positive, healthy beliefs.
- Medication. Antidepressants and mood stabilizers can help, especially when other mental health problems accompany a gambling disorder. Medications used to treat substance addiction could also be helpful.
- Self-help groups. Sharing your thoughts, feelings, and experiences with others who also have a gambling disorder can be helpful. Groups like Gamblers Anonymous are a network for peer-to-peer support, and to also make new friends.
Treatment for a gambling disorder can include outpatient or inpatient treatment, or even a residential treatment program.
Is Anyone You Know a Problem Gambler?
People with a gambling problem negatively affect the lives of everyone around them. From family, friends, and coworkers, everyone can suffer from the destructive fallout from a problem gambler. The fact is, dealing with a pathological gambler can be overwhelming.
For friends and family, it's wise to save your energy and work on changing your own situation. Trying to change the gambler can be impossible if they don't want to change.
It's important to:
- Understand you're not to blame for their behavior.
- Don't try to make the gambler admit they have a problem.
- Not try forcing the gambler to stop gambling.
- Understand that only the gambler can stop gambling.
- The individual is not the problem, the gambling is.
To ease strained relationships caused by a gambling disorder:
- Let the gambler know how their behavior negatively impacts you. Be open, but be careful communicating your feelings.
- Don't try to take control of the gambler’s life. It won’t work and you will be wretched.
- If the gambler feels ashamed, embarrassed, or out of control, let them know you're there to help.
- Treat them like an adult. Don't talk down to them and don't try to protect them.
- You can support them, but don't carry their burden. They need to do the work to make changes in their life.
- Expect them to take responsibility and deal with the fallout of their behavior. For example, do not lie for them. They need to deal with bill collectors.
Also, never lend a problem gambler money, and don't pay their bills. Finally, take your name off of any joint bank accounts. You need to keep your credit record clean. Also, don't sign anything you haven't read.
You can love and support someone with a gambling disorder while protecting yourself.
While dealing with a gambling disorder is hard, remain positive, it can be overcome. First, admit there is a problem. Second, seek help. Stick with it, change won't happen overnight. But, there will be a memorable day, when gambling will no longer control your life.
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