9 Signs of Problem Gambling and Gambling Disorder

This episode was pre recorded as part of a live continuing education webinar on demand. CEUs are still available for this presentation through all CEUs register@allceus.com counselortoolbox hi everybody, I'm Dr. Donnelly Snipes and today in this episode we're going to be talking about gambling problems. This is just an introduction. I'm going to be doing a follow on episode that goes a little bit more in detail about the who's, what's whens, where's and whys. In this episode we'll define pathological gambling, gambling disorder and problem gambling. We'll explore the prevalence of gambling issues and identify who has a gambling problem, will identify links between gambling problems and other behavioral health issues and we'll identify tools for screening, assessing or diagnosing gambling problems and then we're going to touch briefly on treatment issues and strategies that may come up when working with somebody who has a gambling problem. Gambling problems can co occur with other behavioral health conditions. We know that people who have gambling problems also tend to have a higher rate of co occurrence of a whole lot of other mental health and or personality disorder issues and potentially addictions. We're going to talk about those percentages later. What's important to recognize is that if you're a clinician treating someone in private practice or in a clinic, recognize that people who have other co occurring mental health and addictive issues are at higher risk of also having gambling problems. So we do need to screen for that. Only about 10% of people with a gambling problem seek treatment largely because of stigma, partly because insurance doesn't tend to like to pay for it and partly because they don't know where to go to get gambling treatment. It's not like you just find any old therapist on Psychology today and go there to get gambling treatment. A variety of other problems can be related to gambling, including victimization and criminalization. A lot of people who have problems with gambling tend to get involved in some sort of criminal activity and it could be writing bad checks. I'm not talking about knocking over a liquor store, but we do see an increase in criminal behavior when people start having problems with gambling. It can also include social problems, causes a lot of stress with family and friends. When you're borrowing money, you don't have money, you can't pay back debts, and when you've spent through your kids college fund and health issues. When you're under a lot of stress, you're going to have health issues, eating changes, sleeping changes, the development of ulcers, chronic Pain increases in symptoms of any chronic illnesses or autoimmune disorders. There's a lot of stuff that happens physically when we're under stress. And there's, interestingly, also a higher risk for contracting sexually transmitted diseases and HIV or aids. A lot of that, they speculate, is because some people will turn to prostitution in order to get money to continue to gamble. Now, that's not everybody. It's just we do see an increase in those behaviors in people who have what the DSM 5 now calls pathological gambling disorder. Gambling is defined as a risking of something of value, usually money, on the outcome of an event decided at least partially by chance. So when people are playing poker, there's an element of skill to it, but there's also an element of chance. What cards you actually get dealt with. That's what we're talking about here. Gambling can also involve activities that are exclusively chance, like slot machines. What we're really looking at is risking something of value. It can be money, it can be your car. Generally, it's something tangible. Action gamblers are typically men. Not always. Again, we can't ever say with human beings that anything is 100%, one gender or another. But action gamblers tend to be men, and they tend to gamble because it's stimulating, they enjoy it, it brings them pleasure and a lot of fun. Action gambling requires some type of skill or knowledge. These are the people who play poker or who bet on sports teams or go to the racetrack and bet on the dogs or the horses or whatever you bet on there. Relief gamblers, on the other hand, are often female and gamble for escape and often gamble using games of ch such as the lottery or slot machines, or even bingo. And just because somebody plays poker or plays bingo. I know my grandmother just loved bingo. She went there four nights a week. It doesn't mean that they have a problem with gambling, and that's really important. Same thing is true with people who drink alcohol. Not everybody who drinks alcohol is an alcoholic, even if they drink every night. We need to look for other characteristics. It is important to be aware, though, if you've got someone who enjoys gambling and then they encounter excessive stress for some reason or a traumatic event, gambling could become a way that they cope or escape from that unpleasant feeling. In the DSM 5, pathological gambling was renamed gambling gambling disorder. Gambling disorder is categorized under substance related and addictive disorders. This was huge for those of us who have long been saying there are a lot of behavioral or process addictions out there that really mirror substance addiction. It does cause Certain neurochemical changes in the brain when there is. When you win a whole bunch of money, there is a flood of dopamine. Just like when you take a drug, there can be a flood of dopamine. We'll talk about some of the similarities and differences as we go on. But this is huge that the DSM is finally starting to recognize that addictions don't just have to be substance related. Problem gambling is the term we use when the gambling doesn't meet the criteria for pathological gambling or gambling disorder. This is important. Just like any of your other nos sort of diagnoses. Problem gambling indicates that the person is having challenges and is experiencing some hence problems with it. However, they don't quite meet the criteria yet. Does that mean that we ignore it until they meet the criteria? Heck no. That means we need to start with early intervention to prevent it from becoming gambling disorder. What are those diagnostic criteria? And I'm going to parallel these between addiction so you can see how they are sort of similar in nature. Problematic gambling behavior leads to clinically significant impairment or distress as indicated by four or more of the following in the twelve month period. This is the same criteria we use for substance addictions. Gambles with increasing amounts of money to achieve the desired excitement. Well, this is similar to tolerance that we talk about with substances where a person has to use increasing amounts in order to get the desired effect. In gambling, the person is restless or irritable when attempting to cut down or stop. The same exact thing is true with substances. The person has made repeated unsuccessful efforts to cut back or stop gambling. Again, this is the very same thing that we look at in substance use. If the person has tried to cut back or stop using substances but been unsuccessful, then we're looking more towards an addictive behavior than something else. Is often preoccupied with gambling. People who gamble often think about what they're going to bet on next or they're busy looking at scores or whatever sheets. I don't know anything about sports gambling, but they're getting all their information together so they can make an educated bet. People who engage in relief gambling are often still preoccupied thinking about how they're going to get the money to go play or how they might be able to defeat that slot machine or which slot machine they're actually going to play on. But they're thinking about this gambling a lot. Not necessarily all the time, but a lot. The same is true with substances. People are often preoccupied with either getting, using or recovering from their substance. The person often gambles when feeling distressed, even if somebody is not a relief gambler, even if they are gambling because they enjoy it and it gives them a rush. Sometimes people do that when they're stressed because they want that rush, they want that adrenaline surge so they feel better. Both types of gamblers are often trying to deal with unpleasant feelings. One just happens to do it and gets sort of a euphoric feeling from it where the other one gets more numb and it allows them to escape. After losing money gambling, they often return another day to get even. Gamblers often see the next game as being their winning game. In substance abuse, we talk about chasing the high when somebody uses. Every time they use after that is often not as good as the first time they use. So they chase that high and keep coming back to try to get that feeling again. In gambling, the person lies to conceal the extent of involvement. Same thing's true with substance use. Most people who are in active addiction are going to conceal the problem. They're going to minimize, justify, and deny. From here until doomsday, gambling has jeopardized or lost a significant relationship, job, or career. Same thing is true for substance use. We look at what is the psychosocial impact of this behavior. Can somebody do it seven days a week and not be considered as having a gambling problem? Yes. If they're not meeting any of these criteria, if it's not causing them problems in their finances, if it's not jeopardizing their relationships or their careers, if it's not making them irritable, if they're able to control it. You see where I'm going with this? If they can stop whenever they want and it's not causing negative consequences in their life, then it's not a problem. We need to make that clear. And in gambling, the person relies on others to provide money to relieve financial problems. We do see that a little bit in addiction, where people are trying to do whatever they can to get their drug of choice. But this is sort of a unique characteristic to gambling addiction, where there's often a lot of borrowing of money from people. It is important to rule out that the gambling behavior is not better accounted for by a manic episode. When people who have bipolar disorder are in a manic episode, they often engage in high risk, potentially high reward behaviors. Because of that, when you control the manic episode, a lot of times the gambling behavior will subside. So is the gambling behavior universal, or is the gambling behavior only present in a manic episode that is a symptom of the manic episode? Warning signs. These are things that we want to tell significant others to look for, and these are things that we want to look for. Financial problems exist despite the person having an adequate income. Money has gone missing from a bank account or wallet, or valuables have disappeared. There's a lot of borrowing cash advances and living off credit cards. Now, some people have to do that because they just don't make enough money. We want to look at a change from a prior state of functioning, just like we do when we're diagnosing depression or anything else. Retirement insurance plans, et cetera, are cashed in or allowed to lapse. Again, this may indicate a problem. It may indicate the person's just not making enough money to make ends meet. The person avoids family functions or other social events. They neglect responsibilities or make excuses. They drop other leisure activities to focus on gambling. They arrive late for work or other commitments. They may disappear for large blocks of time. They appear deceptive and secretive about behavior, particularly as it relates to money. They may seem edgy, reactive, or defensive, especially if you're asking them, for example, where they've been, why they're late, where the money's gone, anything that may make them feel vulnerable to being outed, if you will. And you may see a change in sleep, eating, or sexual behaviors. Stress goes up, sleep goes down. Eating generally changes, and libido typically goes down in adolescence. Adolescence. Remember, your brain doesn't finish developing, especially those impulse control areas, until about 24 or 25 years old. So when adolescents engage in addictive behaviors, their brain is still in a very malleable state. So a lot of times what we found is, is the impact from these dopamine surges and the addictive behaviors is significantly more intense in the brains of adolescents. We do want to look for warning signs in adolescents. I remember my daddy went to military school when he was in high school, and evidently they had a whole gambling ring thing going on that he was the leader of. That he recounted in retrospect, was probably not the best idea. But. But my point is adolescents do gamble. They play cards. They bet on sports. They bet on video games. If they can get to online gaming, online betting, they may engage in that as well. So we do need to be aware that it's so much more present and it's so much easier for adolescents to access gambling venues now, since gambling is online, slot machines are online everywhere, that they are at greater risk for being tempted to engage in this behavior and eventually possibly developing addiction. Gambling problems. Things that we want to look for in adolescents, if they can't account for Missing money, if they skip school, if they borrow or steal money from friends or family, if they sometimes have a large amount of unexplained cash, if they have a fake id, a casino entry card, or gambling receipts among their belongings. You know, you're doing their laundry and you clean out their pockets and all of a sudden, lo and behold, what do you find? They're preoccupied with video arcades, Internet gambling sites, or even day trading. And they've left a trail of Internet visits or credit card charges to gambling sites. If you're concerned about an adolescent engaging in gambling behaviors, one of the first things to do is to look at their Internet history. Prevalence. Roughly 1.5 million Americans have experienced pathological gambling or gambling disorder. An estimated 6 million Americans on top of that. So we're talking about 7.5 million Americans struggle with problem gambling. Men are more likely than women to have gambling problems. And people diagnosed with gambling disorder have a lot of co occurring issues. 73% of them have an additional addictive disorder, 50% of them. So half of the people with a gambling disorder also have a mood disorder. And 61% of the people with gambling disorder also have personality disorders. That is a huge percentage. So more than 50% of people with a gambling disorder also have at least one, if not multiple co occurring issues. They all need to be addressed. If we don't address them, then the chances of the gambling relapsing is a lot higher. Because a lot of times gambling is a behavior that is engaged in in order to escape from negative feeling states or to provide a sense of euphoria when none exists. So we need to figure out why this person can't feel happy or doesn't feel happy without self medicating, if you will. People who have both a substance use disorder and gambling disorder have high rates of attention deficit disorder. That's important to screen for. If you're working with somebody, a lot of times they will present for substance use treatment. That's where they enter the system, if you will. You're treating them for the substance use disorder, you discover they have gambling disorder. Okay, so you start thinking about how do we treat this? Well, as soon as you discover they've got gambling disorder, if you haven't already done it, it's important to screen for ADHD because that will need to also be concurrently addressed in order to ensure this person has the greatest chance of sustained recovery. The level of gambling involvement may be seen on a continuum from no gambling at all to casual social gambling, serious social gambling, risky gambling, problem gambling, and Then pathological gambling. Obviously, pathological gambling or gambling disorder is where it's really starting to cause significant distress in biopsychosocial functioning. And along that continuum, you can see people engaging in more and more risky behaviors. A lot of times their wagers become bigger and bigger. Screening for gambling problems is important because few people seek treatment for these problems and instead seek help for other complaints like insomnia, stress, depression, anxiety, relationship problems, pretty much anything but gambling. When people come in, it's not hard to screen. There are very short screening instruments that you can use, and there are a lot of very available free instruments. So if you are in private practice, you're not having to spend a bunch of money to one of the companies that creates these tests. They're freely available. The South Oaks gambling screen has 16 items and differentiates between no gambling problems all the way to probable gambling disorder. And it's freely available the National Opinion Research Center's Diagnostic Screen for gambling problems and is a questionnaire based on the DSM 4 criteria. You know, we've gone to DSM 5 and there were a couple of changes, but it's available to be used. Other tools are also available. Let me see if I can show them to you real quick. Other tools are also available. You have screening tools, Gammonon, the nods Clip, the nods, the South Oaks like I told you already, and Gambler's Anonymous 20 questions. You can download any of those that you want and take a look at them. So there are three major routes to gambling problems. They theorize. There's what they call the normal route. And these are people who are healthy, functioning adults who fall victim to easy access. Maybe a casino opens up in their area and they decide, hey, this is something that I really enjoy doing a lot. Poor judgment and a misunderstanding of odds. They think if they read the right books, they'll be able to count cards or they'll be able to beat the house. The odds are just stacked in favor of the house. It's important for people to understand the reality of things. Mood disorders are often the result of gambling, not the cause of gambling, in the person who progresses along the, quote, normal route. In the emotionally vulnerable route, it is the mood disorder that triggers the desire to gamble in order to escape. So sort of chicken egg sort of thing here. With normal, the mood disorder comes second. With emotionally vulnerable, the mood disorder comes first. And the third route is biologically based impulsivity. These people tend to be action gamblers. They want the rush. They tend to be the people you're going to think of as adrenaline junkies. As many as 20% of those with gambling problems have ADHD. We're looking for people in this route, if you will, who have impulse control disorders. ADHD is one of them. Intermittent explosive disorders. Another. Being aware of the fact that gambling disorder is out there, Most of our clients that we work with probably have at least one factor associated with them that makes them at higher risk for the development of a gambling problem. So we really probably should screen as a matter of course. People with biologically based impulsivity are likely to have a number of concurrent problems, such as addiction to other things, emotional lability, chronic boredom, and inadequate social skills. Risk factors for the development of gambling disorder A big early win. If you hit that jackpot really early, it's really tempting to go back, or especially if you hit less than the jackpot. You know how some of the lottery games, you can win $100,000 when the big pot was 3 million, or, I don't know, if you have a big win, something that's big to you, then that can produce that rush of dopamine, and you can have hope that if you play again, you'll win again. So when there's a big early win, that can reinforce the notion that this, this is a cool thing. It makes me feel better, and it actually may help with certain other problems. I've got a person who is susceptible to boredom is going to also be at a higher risk factor. And this is for any of them. This is not just for action gamblers. Obviously, action gamblers are going to be thinking about the odds in the horses or the basketball game or whatever. So they're engaged in a lot of stuff. They're having to keep up. There's mounds of information to know. But you also have people who go to bingo five, six, seven nights a week because they are susceptible to boredom. They're trying to avoid feeling bored. A poor understanding of randomness, and this is a poor understanding of the fact that, yeah, you're gonna win once in a while. That's just the way the world works. But the odds are stacked against you. Another risk factor is a tendency to use escape as a way of coping. So when the going gets tough, they just want to stick their head in the sand and pretend it doesn't exist. A stressful life with a lack of support and direction around the time that gambling began. So if you're gambling and, you know, enjoying it, it's normal gambling, not having any problems, that social gambling stuff that we were talking about. And then all of a sudden, Your spouse files for divorce, you may engage in more gambling for the social support, for the camaraderie, for the relief, for the escape, for something else to focus on. And that's when we see that people tend to really start having problems separating from the gambling. And people with a history of a mood, substance or mood disorder. Substance disorder or process addiction can also be at higher risk. If you already have some sort of addictive behavior than gambling addiction. You know, a lot of people have multiple addictions. That's not surprising at all. And people who have mood disorders often use gambling again to try to self medicate or make themselves feel better in some way. So if people have a history of that, then they are at greater risk for developing a gambling problem. Protective factors, financial security. If you're one of those people like, you know, Bezos or something who has more money than they know what to do with, and they couldn't possibly gamble it all away, then that's going to be a protective factor. Most of us aren't that lucky. If you have supportive friends, that's another protective factor. Because supportive friends are there to help buffer against stress, anxiety, help you deal with life on life's terms. Supportive friends are also a buffer against addiction and depression and a whole lot of other things. If you have hopes and dreams for the future, this is a protective factor because it runs counter to boredom. When you're bored, you don't have anything that you're interested in, you don't have anything you want to do. When you have hopes and dreams for the future, you may be engaged in learning or working hard at your job. You may have a focus that is grabbing your attention. People who are doing well at work or school tend to be less likely to develop a gambling disorder. People who use support or other coping skills rather than escape to deal with stress tend to have less of a chance of developing gambling disorder. If they have a knowledge of randomness, that mathematical stuff we were talking about. If they're able and willing to set limits on betting. When my daddy and his wife used to go to gamble, that was what they did every year for their vacation. That's what they enjoyed doing. They went to Atlantic City and they would set an amount. They had X number of dollars that they were allowed to gamble. If they lost it in the first day, then so be it. If they didn't, then that was good too. But they set very hard limits on what they were willing to bet based on what they were willing and able to lose. That's in the realm of social gambling. People who have gambling problems can't set those limits or they set them and they can't adhere to them, which starts causing problems. And that's where you have borrowing against credit cards and draining bank accounts. So services what do we do for people with gambling issues? First, provide information and resources to assist clients with financial difficulties. Debtors Anonymous can help people learn how to budget their money and rein in their spending. When a person presents for treatment and this gambling issue comes out, a lot of times they're feeling very desperate about their financial situation. So. So if you can help them, start getting a handle on that and seeing some sort of way to get out of this hole that they've dug themselves into, it provides hope, it provides incentive. They're probably dealing with marital and family issues. Gambling contributes to chaos and dysfunction within the family and can contribute to separation and divorce and is associated with much higher rates of child and spousal abuse than in the non gambling disordered population. Disclosing the gambling secret can be devastating to relationships, leading to resentment and a loss of trust. A lot of times when somebody discloses the gambling secret, it's after the finances have all but been wiped out. A lot of times college funds have been drained and bank accounts have been drained and the spouse was completely oblivious and they feel very violated. We want to refer the client, if they're willing to go to a 12 step program, to gamblers Anonymous and family members, to Gammonon. The third type of issue that many people with gambling disorder may present with are legal issues. Like I said earlier, the legal issues are very rarely severe criminal infractions. A lot of times they are misdemeanors, could even be felonies depending on the size of the check. But a lot of times it's something like passing bad checks or other nonviolent crimes. Treatment Strategies Motivational Interviewing Just like with most any other type of client that you see, we need to help people get motivated to stop gambling. Gambling has served a purpose. It had a function. There were benefits for the person. Now they also had a lot of consequences, but there were benefits. So we want to help them highlight the benefits of not gambling and highlight the consequences of gambling so they are more motivated to want to change. Go to SAMHSA's Treatment Improvement Protocol 35 on motivational interviewing if you want to learn more about helping people increase their motivation. Brief solution focused counseling is often very helpful, as is cognitive behavioral therapy. Cognitive behavioral therapy is used to treat gambling disorder by helping people identify and changing cognitive distortions about gambling, particularly the one that says, I can win, I can beat the system. We want to reinforce non gambling behaviors and help people continue to recognize positive and negative consequences of their gambling as well as their recovery. Help them see the positive consequences of their recovery and the negative consequences of gambling. We also want to ask, what function did the gambling serve for that person? Because we need to help them meet that need somehow. If they were using it to numb pain or to escape, then we need to help them figure out how to deal with those really awful, painful feelings. We can't just take the gambling away and go, good luck. That's crucial to relapse prevention and finally, relapse prevention. We want to help people identify and avoid risky situations that can trigger or cue feelings or thoughts that can lead to relapse. For gambling or anything else, but especially for gambling, risky situations can be a lot of things. But what is it that triggers your gambling? Is it when you feel stressed? Is it when you feel depressed? Well, then we have to figure out what triggers your stress and what triggers your depression. We also want to look at environmental triggers and people triggers, people, places and things. And in relapse prevention, we need to help people learn to prevent vulnerabilities. Remember that vulnerabilities are those things that make you more likely to react strongly and negatively when things happen. So instead of reacting to something, on a scale of 1 to 10, instead of reacting with a 2 because somebody left the cap off the toothpaste, you react with an 8 and just an extreme reaction. So we want to look at these vulnerabilities. For a lot of people, if they are overtired, if they are exhausted, it is more difficult to deal with life on life's terms. So they tend to be more irritable if they're sick, if they're in pain, if they're depressed, each person is going to have their own vulnerabilities. And they need to know what those are so they can prevent them as much as possible. But when they can't prevent them, we all get sick. For example, they need to have a plan to deal with them to prevent any further harm or to mitigate them. So, for example, when I'm sick or when I'm exhausted because I get really cranky, when I haven't had enough sleep, I shut my office door. That way people aren't popping in all the time, and I'm less likely to respond with irritability because I have less input. Gambling is a large problem for millions of people. It not only impacts finances, but also relationships, health and mental Health People tend to gamble for two main reasons, excitement or escape. Money is not always the end goal for gamblers. Oftentimes it's not. It can be a potent reinforcer. But most of the time people are gambling for excitement or escape. Gamblers will often have distorted cognitions about the likelihood they will win. Adolescents who develop a problem with gambling are more likely to develop pathological gambling issues in adulthood. Protective factors that we want to enhance in adults and in any clients we have Whether or not they have gambling disorder or not. We want to enhance social support, healthy coping skills, educate them about gambling if they're at risk or if they have any interest in it so they know how to set limits on bets, and encourage people, regardless of their diagnosis, to have other hobbies, interests and goals. All of these protective factors are protective for a myriad of mental health as well as addictive problems problems. And we really want to enhance them in all of our clients. If this podcast helps you help your clients or yourself, please support us by purchasing your ceus@allce.com or getting your agency to sponsor an episode. A direct link to the on demand CEUs for this podcast is@allce.com podcast that's allce.com podcastceus to sponsor an episode of Counselor Toolbox and reach over 50,000 clinicians per week, go to allceus.com Sponsor thank you.