B Diagnostic and Statistical Manual of Mental Disorders Criteria for Pathological Gambling

Criteria from the 1980 DSM-III

Disorders of Impulse Control Not Elsewhere Classified: Pathological Gambling

The essential features are a chronic and progressive failure to resist impulses to gamble and gambling behavior that compromises, disrupts, or damages personal, family, or vocational pursuits. The gambling preoccupation, urge, and activity increase during periods of stress. Problems that arise as a result of the gambling lead to an intensification of the gambling behavior. Characteristic problems include loss of work due to absences in order to gamble, defaulting on debts and other financial responsibilities, disrupted family relationships, borrowing money from illegal sources, forgery, fraud, embezzlement, and income tax evasion.

Commonly these individuals have the attitude that money causes and is also the solution to all their problems. As the gambling increases, the individual is usually forced to lie in order to obtain money and to continue gambling, but hides the extent of the gambling. There is no serious attempt to budget or save money. When borrowing resources are strained, antisocial behavior in order to obtain money for more gambling is likely. Any



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--> B Diagnostic and Statistical Manual of Mental Disorders Criteria for Pathological Gambling Criteria from the 1980 DSM-III Disorders of Impulse Control Not Elsewhere Classified: Pathological Gambling The essential features are a chronic and progressive failure to resist impulses to gamble and gambling behavior that compromises, disrupts, or damages personal, family, or vocational pursuits. The gambling preoccupation, urge, and activity increase during periods of stress. Problems that arise as a result of the gambling lead to an intensification of the gambling behavior. Characteristic problems include loss of work due to absences in order to gamble, defaulting on debts and other financial responsibilities, disrupted family relationships, borrowing money from illegal sources, forgery, fraud, embezzlement, and income tax evasion. Commonly these individuals have the attitude that money causes and is also the solution to all their problems. As the gambling increases, the individual is usually forced to lie in order to obtain money and to continue gambling, but hides the extent of the gambling. There is no serious attempt to budget or save money. When borrowing resources are strained, antisocial behavior in order to obtain money for more gambling is likely. Any

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--> criminal behavior—e.g., forgery, embezzlement, or fraud—is typically nonviolent. There is a conscious intent to return or repay the money. Associated features. These individuals most often are overconfident, somewhat abrasive, very energetic, and "big spenders"; but there are times when they show obvious signs of personal stress, anxiety, and depression. Age at onset and course. The disorder usually begins in adolescence and waxes and wanes, tending to be chronic. Impairment. The disorder is extremely incapacitating and results in failure to maintain financial solvency or provide basic support for oneself or one's family. The individual may become alienated from family and acquaintances and may lose what he or she has accomplished or attained in life. Complications. Suicide attempts, association with fringe and illegal groups, and arrest for nonviolent crimes that may lead to imprisonment are among the possible complications. Predisposing factors. These may include: loss of parent by death, separation, divorce, or desertion before the child is 15 years of age; inappropriate parental discipline (absence, inconsistency, or harshness); exposure to gambling activities as an adolescent; a high family value on material and financial symbols; and lack of family emphasis on saving, planning, and budgeting. Prevalence. No information. Sex ratio. The disorder is apparently more common among males than females. Familial pattern. Pathological Gambling and Alcoholism are more common in the fathers of males and in the mothers of females with the disorder than in the general population. Differential diagnosis. In social gambling, gambling with friends is engaged in mainly on special occasions and with predetermined acceptable losses. During a manic or hypomanic episode loss of judgment and excessive gambling may follow the onset of the mood disturbance. When manic-like mood changes occur in Pathological Gambling they typically follow winning. Problems with gambling are often associated with Antisocial Personality Disorder and in Pathological Gambling antisocial behavior is frequent. However, in Pathological Gambling any

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--> antisocial behavior that occurs is out of desperation to obtain money to gamble when money is no longer available and legal resources have been exhausted. Criminal behavior is rare when the individual has money. Also, unlike the individual with Antisocial Personality Disorder, the individual with Pathological Gambling usually has a good work history until it is disrupted because of the gambling. Diagnostic Criteria for Pathological Gambling The individual is chronically and progressively unable to resist impulses to gamble. Gambling compromises, disrupts, or damages family, personal, and vocational pursuits, as indicated by at least three of the following: arrest for forgery, fraud, embezzlement, or income tax evasion due to attempts to obtain money for gambling default on debts or other financial responsibilities disrupted family or spouse relationship due to gambling borrowing of money from illegal sources (loan sharks) inability to account for loss of money or to produce evidence of winning money, if this is claimed loss of work due to absenteeism in order to pursue gambling activity necessity for another person to provide money to relieve a desperate financial situation The gambling is not due to Antisocial Personality Disorder. Criteria from the 1987 DSM-III-R Impulse Control Disorders Not Elsewhere Classified: Pathological Gambling The essential features of this disorder are a chronic and progressive failure to resist impulses to gamble, and gambling behavior that compromises, disrupts, or damages personal, family, or vocational pursuits. The gambling preoccupation, urge, and

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--> activity increase during periods of stress. Problems that arise as a result of the gambling lead to an intensification of the gambling behavior. Characteristic problems include extensive indebtedness and consequent default on debts and other financial responsibilities, disrupted family relationships, inattention to work, and financially motivated illegal activities to pay for gambling. Associated features. Generally, people with Pathological Gambling have the attitude that money causes and is also the solution to all their problems. As the gambling increases, the person is usually forced to lie in order to obtain money and to continue gambling. There is no serious attempt to budget or save money. When borrowing resources are strained, antisocial behavior in order to obtain money is likely. People with this disorder are often overconfident, very energetic, easily bored, and "big spenders"; but there are times when they show obvious signs of personal stress, anxiety, and depression. Age at onset and course. The disorder usually begins in adolescence in males, and later in life in females. It waxes and wanes, but tends to be chronic. Impairment. The disorder is extremely incapacitating and results in failure to maintain financial solvency or provide basic support for oneself or one's family. The person may become alienated from family and acquaintances. Complications. Psychoactive Substance Abuse and Dependence, suicide attempts, association with fringe or illegal groups (more common in males), civil actions, and arrest for typically nonviolent crimes involving only property are among the possible complications. Predisposing factors. Among the predisposing factors are inappropriate parental discipline (absence, inconsistency, or harshness); exposure to gambling activities as an adolescent; and a high family value placed on material and financial symbols and a lack of family emphasis on saving, planning, and budgeting. Females with this disorder more likely than others to have a husband with Alcohol Dependence or who is absent from the home. Prevalence. Recent estimates place prevalence at 2%-3% of the adult population.

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--> Sex ratio. The disorder is more common among males than females. Familial pattern. Pathological Gambling and Alcohol Dependence are more common among the parents of people with Pathological Gambling than in the general population. Differential diagnosis. In social gambling, gambling is with friends, and acceptable losses are predetermined. During a manic or hypomanic episode, loss of judgment and excessive gambling may follow the onset of the mood disturbance. When manic-like mood changes occur in Pathological Gambling, they are generally related to winning streaks, and they are usually followed by depressive episodes because of subsequent gambling losses. Periods of depression tend to increase as the disorder progresses. Problems with gambling are often associated with Antisocial Personality Disorder, and in Pathological Gambling antisocial behavior is frequent. In cases in which both disorders are present, both should be diagnosed. Diagnostic Criteria for 312.31 Pathological Gambling Maladaptive gambling behavior, as indicated by at least four of the following: (1)   frequent preoccupation with gambling or with obtaining money to gamble (2)   frequent gambling of larger amounts of money or over a longer period of time than intended (3)   a need to increase the size or frequency of bets to achieve the desired excitement (4)   restlessness or irritability if unable to gamble (5)   repeated loss of money by gambling and returning another day to win back losses ("chasing") (6)   repeated efforts to reduce or stop gambling (7)   frequent gambling when expected to meet social or occupational obligations (8)   sacrifice of some important social, occupational, or recreational activity in order to gamble

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--> (9)   continuation of gambling despite inability to pay mounting debts, or despite other significant social, occupational, or legal problems that the person knows to be exacerbated by gambling Criteria from the 1994 DSM-IV Impulse-Control Disorders Not Elsewhere Classified: Pathological Gambling Diagnostic Features The essential feature of Pathological Gambling is persistent and recurrent maladaptive gambling behavior (Criterion A) that disrupts personal, family, or vocational pursuits. The diagnosis is not made if the gambling behavior is better accounted for by a Manic Episode (Criterion B). The individual may be preoccupied with gambling (e.g., reliving past gambling experiences, planning the next gambling venture, or thinking of ways to get money with which to gamble) (Criterion Al). Most individuals with Pathological Gambling say that they are seeking ''action" (an aroused, euphoric state) even more than money. Increasingly larger bets, or greater risks, may be needed to continue to produce the desired level of excitement (Criterion A2). Individuals with Pathological Gambling often continue to gamble despite repeated efforts to control, cut back, or stop the behavior (Criterion A3). There may be restlessness or irritability when attempting to cut down or stop gambling (Criterion A4). The individual may gamble as a way of escaping from problems or to relieve a dysphoric mood (e.g., feelings of helplessness, guilt, anxiety, depression) (Criterion A5). A pattern of "chasing" one's losses may develop, with an urgent need to keep gambling (often with larger bets or the taking of greater risks) to undo a loss or series of losses. The individual may abandon his or her gambling strategy and try to win back losses all at once. Although all gamblers may chase for short periods, it is the long-term chase that is more characteristic of individuals with Pathological Gambling (Criterion A6). The individual may lie to family members, therapists, or others to conceal the extent of involve-

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--> ment with gambling (Criterion A7). When the individual's borrowing resources are strained, the person may resort to antisocial behavior (e.g., forgery, fraud, theft, or embezzlement) to obtain money (Criterion A8). The individual may have jeopardized or lost a significant relationship, job, or educational or career opportunity because of gambling (Criterion A9). The individual may also engage in "bailout" behavior, turning to family or others for help with a desperate financial situation that was caused by gambling (Criterion A10). Associated Features and Disorders Distortions in thinking (e.g., denial, superstitions, overconfidence, or a sense of power and control) may be present in individuals with Pathological Gambling. Many individuals with Pathological Gambling believe that money is both the cause of and solution to all their problems. Individuals with Pathological Gambling are frequently highly competitive, energetic, restless, and easily bored. They may be overly concerned with the approval of others and may be generous to the point of extravagance. When not gambling, they may be workaholics or "binge" workers who wait until they are up against deadlines before really working hard. They may be prone to developing general medical conditions that are associated with stress (e.g., hypertension, peptic ulcer disease, migraine). Increased rates of Mood Disorders, Attention-Deficit/Hyperactivity Disorder, Substance Abuse or Dependence, and Antisocial, Narcissistic, and Borderline Personality Disorders have been reported in individuals with Pathological Gambling. Of individuals in treatment for Pathological Gambling, 20% are reported to have attempted suicide. Specific Culture and Gender Features There are cultural variations in the prevalence and type of gambling activities (e.g., pai go, cockfights, horse racing, the stock market). Approximately one-third of individuals with Pathological Gambling are females. Females with the disorder are more apt to be depressed and to gamble as an escape. Females are underrepresented in treatment programs for gambling and repre-

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--> sent only 2%-4% of the population of Gamblers Anonymous. This may be a function of the greater stigma attached to female gamblers. Prevalence The limited data available suggest that the prevalence of Pathological Gambling may be as high as 1%-3% of the adult population. Course Pathological Gambling typically begins in early adolescence in males and later in life in females. Although a few individuals are "hooked" with their very first bet, for most the course is more insidious. There may be years of social gambling followed by an abrupt onset that may be precipitated by greater exposure to gambling or by a stressor. The gambling pattern may be regular or episodic, and the course of the disorder is typically chronic. There is generally a progression in the frequency of gambling, the amount wagered, and the preoccupation with gambling and obtaining money with which to gamble. The urge to gamble and gambling activity generally increase during periods of stress or depression. Familial Pattern Pathological Gambling and Alcohol Dependence are both more common among the parents of individuals with Pathological Gambling than among the general population. Differential Diagnosis Pathological Gambling must be distinguished from social gambling and professional gambling. Social gambling typically occurs with friends or colleagues and lasts for a limited period of time, with predetermined acceptable losses. In professional gambling, risks are limited and discipline is central. Some individuals can experience problems associated with their gambling (e.g.,

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--> short-term chasing behavior and loss of control) that do not meet the full criteria for Pathological Gambling. Loss of judgment and excessive gambling may occur during a Manic Episode. An additional diagnosis of Pathological Gambling should only be given if the gambling behavior is not better accounted for by the Manic Episode (e.g., a history of maladaptive gambling behavior at times other than during a Manic Episode). Alternatively, an individual with Pathological Gambling may exhibit behavior during a gambling binge that resembles a Manic Episode. However, once the individuals is away from the gambling, these manic-like features dissipate. Problems with gambling may occur in individuals with Antisocial Personality Disorder; if criteria are met for both disorders, both can be diagnosed. Diagnostic Criteria for 312.31 Pathological Gambling Persistent and recurrent maladaptive gambling behavior as indicated by five (or more) of the following: (1)   is preoccupied with gambling (e.g., preoccupied with reliving past gambling experiences, handicapping or planning the next venture, or thinking of ways to get money with which to gamble) (2)   needs to gamble with increasing amounts of money in order to achieve the desired excitement (3)   has repeated unsuccessful efforts to control, cut back, or stop gambling (4)   is restless or irritable when attempting to cut down or stop gambling (5)   gambles as a way of escaping from problems or of relieving a dysphoric mood (e.g., feelings of helplessness, guilt, anxiety, depression) (6)   after losing money gambling, often returns another day to get even ("chasing" one's losses) (7)   lies to family members, therapist, or others to conceal the extent of involvement with gambling (8)   has committed illegal acts such as forgery, fraud, theft, or embezzlement to finance gambling

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--> (9)   has jeopardized or lost a significant relationship, job, or educational or career opportunity because of gambling (10)   relies on others to provide money to relieve a desperate financial situation caused by gambling The gambling behavior is not better accounted for by a Manic Episode. Source: American Psychiatric Association (1980): Diagnostic and Statistical Manual of Mental Disorders, Third Edition. Washington, DC: American Psychiatric Association. American Psychiatric Association (1987): Diagnostic and Statistical Manual of Mental Disorders, Third Edition Revised. Washington, DC: American Psychiatric Association. American Psychiatric Association (1994): Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Washington, DC: American Psychiatric Association.