2
Gambling Concepts and Nomenclature

Terms used to describe behaviors in similar contexts or venues have an influence on how those behaviors are defined and viewed. Understanding the extent and nature of pathological gambling, as well as its social and economic impact, requires as clear a definition as possible. A discrete, acceptable, and useful definition of pathological gambling would be based on a nomenclature applicable in a wide diversity of contexts (American Psychiatric Association, 1994). Nomenclature refers to a system of names used in an art or science and is critical in conceptualizing, discussing, and making judgments about pathological gambling and related behaviors. A nomenclature inclusive of pathological gambling must be suitable for use in scholarly research, clinical diagnosis and treatment, and community and other social contexts. The nomenclature must also reflect a variety of perspectives because research scientists, psychiatrists, other treatment care clinicians, and public policy makers tend to frame questions about gambling differently, depending on their disciplinary training, experience, and special interests. In the absence of an agreed-upon nomenclature, these and other groups interested in gambling and gambling problems have developed different paradigms or world views from which to consider these matters. Consequently, the act of gambling has been considered



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--> 2 Gambling Concepts and Nomenclature Terms used to describe behaviors in similar contexts or venues have an influence on how those behaviors are defined and viewed. Understanding the extent and nature of pathological gambling, as well as its social and economic impact, requires as clear a definition as possible. A discrete, acceptable, and useful definition of pathological gambling would be based on a nomenclature applicable in a wide diversity of contexts (American Psychiatric Association, 1994). Nomenclature refers to a system of names used in an art or science and is critical in conceptualizing, discussing, and making judgments about pathological gambling and related behaviors. A nomenclature inclusive of pathological gambling must be suitable for use in scholarly research, clinical diagnosis and treatment, and community and other social contexts. The nomenclature must also reflect a variety of perspectives because research scientists, psychiatrists, other treatment care clinicians, and public policy makers tend to frame questions about gambling differently, depending on their disciplinary training, experience, and special interests. In the absence of an agreed-upon nomenclature, these and other groups interested in gambling and gambling problems have developed different paradigms or world views from which to consider these matters. Consequently, the act of gambling has been considered

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--> by various observers to provide evidence of recreational interest, diminished mathematical skills, poor judgment, cognitive distortions, mental illness, and moral turpitude. These varied views have stimulated debate and controversy. Historically, the word ''gambling" referred to playing unfairly or cheating at play. A gambler was defined as a fraudulent gamester, sharper, or rook who habitually plays for money, especially extravagantly high stakes (Oxford English Dictionary, second edition, 1989). In modern times, gambling has come to mean wagering money or other belongings on chance activities or events with random or uncertain outcomes (Devereux, 1979). Gambling in this sense implies an act whereby the participant pursues a monetary gain without using his or her skills (Brenner and Brenner, 1990). This is the dictionary definition of gambling as well (Oxford English Dictionary, second edition, 1989). Throughout history, however, gambling also has involved activities requiring skill. For example, a bettor's knowledge of playing strategies can improve his or her chances of winning in certain card games; knowledge of horses and jockeys may improve predictions of probable outcomes in a horse race (Bruce and Johnson, 1996). The use of such skills may reduce the randomness of the outcome but, because of other factors that cannot be predicted or analyzed, the outcome remains uncertain. As used in this report, the term "gambling" refers both to games of chance that are truly random and involve little or no skill that can improve the odds of winning, and to activities that require the use of skills that can improve the chance of winning. By its very nature, gambling involves a voluntary, deliberate assumption of risk, often with a negative expectable value. For example, in casino gambling the odds are against the gambler because the house takes its cut; thus, the more people gamble, the more likely they are to lose. Role of Risk-Taking in the Gambling Experience Throughout history, scholars and writers have theorized about why human beings gamble. These explanations have encompassed evolutionary, cultural, religious, financial, recreational, psychological, and sociological perspectives (Wildman,

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--> 1998). A current and widely disseminated theory is that people engage in gambling because it has the capacity to create excitement (Boyd, 1976; Steiner, 1970). People seek stimulation and try to optimize their subjective experience by shifting sensations. Sensation-seeking and shifting these experiences, as a basic and enduring human drive, can be compared to a child's exploration of his or her environment to develop fundamental mastery of skills and satisfy curiosity. The experiences that humans regularly seek include novelty, recreation, and adventure (Zuckerman, 1979; Ebstein et al., 1996; Benjamin et al., 1996). To paraphrase William Arthur Ward, a 20th century American philosopher, the person who risks nothing, has nothing. Indeed, it is common for individuals to take risks in life. Risk-taking underlies many human traits that have high significance for evolutionary survival, such as wanting and seeking food (Neese and Berridge, 1997). Moreover, risk-taking is reinforced by the emotional experiences that follow, such as relief from boredom, feelings of accomplishment, and the "rush" associated with seeking excitement. Individuals vary considerably in the extent to which they take risks. Some limit their risk-taking to driving a few miles over the posted speed limit, whereas others actively pursue mountain climbing, skydiving, or other exciting sports with a high risk of harm. Gambling is neither a financially nor a psychologically risk-free experience. In addition to the possibility that gamblers will lose their money, they also risk experiencing a variety of adverse biological, psychological, and social consequences from gambling (American Psychiatric Association, 1994). Personal aspirations and the social setting, however, can affect the likelihood of an individual's engaging in risky behavior, since aspirations will influence the perceived benefits and constraints of the risky situation. The potential payoff of betting stimulates innate risk-taking tendencies. Although exceptions exist, games with the highest "action," such as high-stakes poker and dice games, serve as more powerful stimuli to accelerate a player's risk-taking by increasing the payoff if the bet is won. Even those not normally inclined to buy a lottery ticket, for example, often may do so when several million dollars in winnings are at stake (Clotfelter and Cook, 1989). The simple association between gambling and action, including the prospects of "winning big," which characterizes most

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--> popular gambling activities, can maintain stable gambling behaviors despite incredible odds against winning (Lopes, 1987). Medicalization of Pathological Gambling Understanding of the adverse consequences of excessive gambling has undergone profound change. For most of history, individuals who experienced adverse consequences from gambling were viewed as gamblers with problems; today, we consider them to have psychological problems. This change is analogous to the change in the understanding of alcoholics and alcoholism, and it has been reflected in, or stimulated by, the evolving clinical classification and description of pathological gambling in the various editions, between 1980 and 1994, of the Diagnostic and Statistical Manual of Mental Disorders (called DSM) published by the American Psychiatric Association. Changes over time in the DSM reflect a desire to be more scientific in determining appropriate criteria for pathological gambling by accounting for its similarities to other addictions, especially substance dependence (American Psychiatric Association, 1980, 1987, 1994; Lesieur, 1988; Rosenthal, 1989; Lesieur and Rosenthal, 1991). Today pathological gambling is understood to be a disorder characterized by a continuous or periodic loss of control over gambling, a preoccupation with gambling and with obtaining money with which to gamble, irrational thinking, and a continuation of the behavior despite adverse consequences. The official medicalization of excessive gambling is marked by its inclusion in the DSM (American Psychiatric Association, 1980, 1987, 1994). It is not surprising, however, that some scholars (e.g., Szasz, 1970, 1987, 1991) have objected to medicalizing certain socially or culturally offensive behaviors in general, and gambling intemperance in particular (Rosecrance, 1985).1 Never- 1   For a discussion of nonmedical models for understanding excessive gambling, see the section on other theories and conceptualizations of pathological gambling later in this chapter.

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--> theless, in the United States and elsewhere, although not in all nations or cultures, people with serious gambling problems are now described as suffering from a disorder that reflects a psychiatric illness or disease state. And despite significant gaps in research and a generally deficient state of scholarly literature, pathological gambling is known to be a robust phenomenon (Shaffer et al., 1997) that also is complex in its origins and accompanying disorders, and in its negative social and economic effects. Moreover, all these factors can be affected by traditional, contemporary, and constantly emerging gambling-related technologies. Conceptualizing gambling behavior on a simple continuum ranging from no gambling to pathological gambling may provide a useful model for developing a public health system of treatment, but it is insufficiently detailed to provide a scientific explanation of the emergence of pathological gambling. The list of important terms used in this report for gambling behaviors suggests that they cover a wide range (see Box 2-1). These terms are important to the discussion of prevalence in Chapter 3. When considering the range of gambling involvement, it is important to note that today about 20 percent of Americans do not gamble at all; that most gamblers do so for social or recreational reasons without experiencing any negative consequences; and that cooccurrences with other types of problems, as well as negative social and economic effects experienced by individual gamblers and their families, theoretically increase with the level, chronicity, and severity of gambling problems. In other words, once gamblers cross the threshold and enter into the range of problem gambling (described as Level 2 in Box 2-1) they begin to manifest adverse effects; since there are far more problem gamblers than pathological gamblers, most adverse affects are believed to be experienced or caused by problem gamblers. Although this increasing relationship is often asserted or implied in the literature, neither an increasing association nor a progressive gambling behavior continuum is supported by available research. Moreover, the range of different gambling behaviors is believed to be dynamic: for example, social or recreational gamblers can become problem gamblers; problem gamblers can become pathological gamblers, return to a level of social or recreational gam-

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--> Box 2-1 Important Gambling Terms Used by the Committee Compulsive gambling: The original lay term for pathological gambling, it is still used by Gamblers Anonymous and throughout much of the self-help treatment community. Disordered gambling: Inspired by language in DSM pertaining to Disorders of Impulse Control and used by Shaffer et al. (1997) in their meta-analysis to serve as a conceptual container for the panoply of terms associated with gambling-related problems and pathology. The term is used occasionally in this report to describe the combination of problem and pathological gambling. Excessive gambling: Reference to an amount of time or money spent gambling that exceeds an arbitrarily defined acceptable level. Intemperate gambling: Synonymous with excessive gambling. Level 0 gambling: No gambling at all. Level 1 gambling: Social and/or recreational gambling (see below) with no appreciable harmful effects. Level 2 gambling: Synonymous with problem gambling. bling, or even discontinue gambling.2 In addition, the time involved in shifting from one level to another is commonly believed to be subject to extreme variance, although this has not been empirically demonstrated. 2   There is no direct empirical evidence supporting either the possibility that pathological gamblers can or cannot return to and remain in a state of social or recreational gambling. This pattern has been observed, however, among people with alcohol, heroin, cocaine, and other addictions (e.g., Shaffer and Jones, 1989). Nevertheless, the percentage of those who seek treatment and do return successfully to social or recreational gambling is likely to be so small that clinicians generally and accurately believe that it is not likely. Therefore, they are reluctant to consider this possibility as part of treatment efforts. In practice, pathological gamblers attending Gamblers Anonymous or undergoing forms of treatment other than self-help usually consider themselves as "recovering" from, but not ever cured of, their gambling disorder.

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--> Level 3 gambling: Synonymous with pathological gambling as defined in DSMIV in which 5 or more criteria out of 10 are present. Pathological gambling: A mental disorder characterized by a continuous or periodic loss of control over gambling, a preoccupation with gambling and with obtaining money with which to gamble, irrational thinking, and a continuation of the behavior despite adverse consequences. Probable pathological gambler: A common reference in prevalence research studies and other gambling literature to a person who is suspected of being a pathological gambler on the basis of some criteria, but who has not been clinically evaluated as such. Problematic gambling: Synonymous with either disordered gambling or excessive gambling. Problem gambling: Gambling behavior that results in any harmful effects to the gambler, his or her family, significant others, friends, coworkers, etc. Some problem gamblers would not necessarily meet criteria for pathological gambling. Recreational gambling: Gambling for entertainment or social purposes, with no harmful effects. Social gambling: Synonymous with recreational gambling. Contemporary Pathological Gambling The assumption underlying the existing research is that gambling problems exist and can be measured (Volberg, 1998). Despite agreement among researchers at this fundamental level and a widely recognized and accepted definition of Level 3 (pathological gambling) as described in Box 2-1, there is widespread disagreement about the conceptualization, definition, and measurement of Level 2 (problem gambling). Conceptual and methodological confusion is common in emerging scientific fields (Shaffer, 1986, 1997b), but debate about problem gambling creates public confusion and uncertainty about gambling problems and their effects on society (Volberg, 1998). For example, in considering excessive gambling behavior, clinicians and the majority of researchers in the United States and

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--> abroad rely on well-established psychiatric classifications (nosologies) and descriptions (nosographies) of pathological gambling that have evolved over the past 20 years (American Psychiatric Association, 1980, 1987, 1994). However, debate is ongoing as to their validity, as well as about broader conceptualizations of excessive gambling ranging from problem to pathological (Rosenthal, 1989; Shaffer et al., 1997; Rosecrance, 1985). A number of competing conceptual models and definitions have arisen to explain the origins of these behaviors. Compounding this classification difficulty is the wide variety of labels or terms found in the literature to describe people with gambling problems. For these reasons it can be useful to conceptualize progressively harmful gambling behaviors on a continuum similar to the progressive stages and harmful effects of alcoholism, including: abstinence, social or controlled drinking, problem drinking with loss of control (disruption of work and social functions but minimal organ damage), and severe problem drinking with organ damage. To ensure clarity and consistency in our use of such labels and terms in this report, they are defined in Box 2-1. The following section focuses on the medical conceptualization of pathological gambling, beginning with a discussion of how it differs from problem gambling. Pathological Gambling Versus Problem Gambling Although clinicians and researchers concur that understanding the nature, scope, and severity of gambling-related problems is important, there is much variation in the language used to designate various levels of gambling involvement and their consequences. For example, investigators often use the terms "problem gambling," "at-risk gambling," "potential pathological gambling," "probable pathological gambling," "disordered gambling,'' and "pathological gambling." Some authors have used terms for adolescents that are different from the terms generally used for adults (e.g., Volberg, 1993; Winters et al., 1993). The labeling difficulty arises in part because epidemiologists and clinical researchers do not use the same terminology. Also, various terms arise when investigators characterize broadly defined samples of extreme gamblers. Nevertheless, the frequency and

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--> intensity of problems associated with gambling can range from none to a lot. Thus, in the absence of rigorously achieved and convincing validity data, any classification label is inherently arbitrary to some degree and may be too simple to describe such a complex and multidimensional concept as gambling severity (Walker and Dickerson, 1996). This issue, however, is encountered in all psychiatric classifications, not just pathological gambling. The challenge is to establish agreed-on terminology so that researchers, clinicians, and others in the field can communicate precisely. Imprecise terms, such as "potential pathological gamblers" or "probable pathological gamblers," among other terms, have been promulgated by research relying on a variety of instruments. Use of various terms has contributed substantially to confusion about what constitutes Level 2 problem gambling. Some people have criticized the fact that the American Psychiatric Association's DSM-IV designates only one term to connote a gambling disorder (pathological gambling), because it does not adequately serve investigations that need to describe individuals who are experiencing less extreme difficulties. Since people who meet at least one but less than five of the DSM-IV criteria suggested for a diagnosis of pathological gambling have experienced some level of difficulty, they also warrant attention. However, their problems are extremely variable and range from trivial to serious. Furthermore, these individuals may be progressing toward a pathological state, or they may be pathological gamblers in remission who are recovering (i.e., they met DSM-IV criteria for having been a pathological gambler sometime during their lifetime, but they do not currently meet the criteria suggested for such a diagnosis). The term "pathological" is defined in the Oxford English Dictionary as "caused by or evidencing a mentally disturbed condition." In 1980, the American Psychiatric Association adopted the term "pathological gambling" as the official nomenclature in the DSM-III to describe excessive gambling as an impulse disorder (the DSM criteria are discussed in the next section). Sometimes the terms ''pathological" and "compulsive" are used interchangeably; however, "compulsive" is the historical and lay term and the one used by Gamblers Anonymous (1997). But for most researchers and many clinicians, the notion of compulsive gambling

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--> as a description of pathological gamblers is a technical misnomer (Lesieur and Rosenthal, 1991). In the psychiatric lexicon, a compulsive behavior is involuntary and "ego-dystonic"—that is, external or foreign to the self. The DSM-IV defines compulsions as "repetitive behaviors or mental acts, the goal of which is to prevent or reduce anxiety or stress, not to provide pleasure or gratification" (American Psychiatric Association, 1994:418). It is an "unwilling" attempt to rid oneself of discomfort and pain. In some cases, individuals perform rigid, stereotyped acts according to idiosyncratically elaborated rules without being able to indicate why they are doing them. Examples of a compulsion would include repetitive hand washing or the irresistible urge to shout an obscenity (see American Psychiatric Association, 1980, 1987, 1994). Pathological gamblers, in contrast, typically experience gambling as ego-syntonic and pleasurable until late in the disorder. The DSM-IV provides a widely accepted definition of and diagnostic criteria for pathological gambling, but the term "problem gambling" is somewhat more difficult to conceptualize and define. In much of the research literature, problem gambling is used as an overlay to include pathological gambling (Shaffer et al., 1997). In fact, the concepts are inextricable, because on the continuum of gambling behaviors pathological gambling encompasses problem gambling (i.e., all pathological gamblers have been problem gamblers). Moreover, pathological and problem gamblers can experience varying levels of problem chronicity over time. However, problem gambling is most commonly characterized as describing those individuals who meet less than five DSM-IV criteria for a diagnosis of pathological gambling (Lesieur and Rosenthal, 1998). Shaffer and his colleagues considered these as cases that could be "in-transition" and described in-transition gamblers as moving either toward or away from pathological states; however, they also noted that in-transition gamblers may not necessarily be in an earlier stage of the disorder. It is important to note that these authors observed that in-transition gamblers may never develop the attributes of pathological gambling; in-transition gamblers may languish in this state or begin to move toward recovery. The concept of a continuum of problem severity implies that

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--> people can be located at a point on a continuum. They can move from that point, developing more or less serious difficulties. This analysis suggests that gambling problems reflect an underlying unidimensional construct. Although individuals can theoretically move across a continuum of problem severity and some scholars believe that gambling problems may best be conceptualized as a developmental continuum of gambling behaviors with respect to frequency and intensity, there is no empirical evidence that actual progression of the illness is linear (Shaffer et al., 1997). Moreover, clinicians and the self-help treatment community believe that pathological gamblers cannot successfully return to a level of social or recreational gambling. Development of the DSM Criteria Largely through the efforts of Robert Custer, pathological gambling was first included in the DSM in 1980 (see DSM-III in Appendix B). Custer had treated pathological gamblers and written about their illness for several years (Custer, 1980; Custer and Custer, 1978). For the first inclusion in DSM-III, there was no testing of criteria beforehand. Instead, inclusion was based on his clinical experience and those of other treatment professionals. The original DSM-III criteria started with a statement about progressive loss of control and then listed seven items. Three or more had to be met for a diagnosis of pathological gambling. The emphasis was on damage and disruption to the individual's family, personal, or vocational pursuits and issues that had to do with money (five of the seven original criteria fell into this latter category). There also was added an exclusion criterion: "not caused by antisocial personality disorder." The DSM-III criteria were criticized for their unidimensionality, emphasis on external consequences, and middle-class bias (Lesieur, 1984). With the revision of the diagnostic manual in 1987 (DSM-III-R), it was decided to emphasize the similarity to substance dependence, literally by copying the criteria, substituting "gambling" for "use of a substance." This can be clearly seen from an earlier published draft of DSM-III-R when the two sets of criteria are placed side by side (Rosenthal, 1989:103). The only item that appears different, item 5 in the finalized version, seems

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