The Clinical Picture

Descriptions of the clinical course of pathological gambling date back to 1892 (Quinn, 1892). The traditional description of the disorder has included four phases: the reaction to winning, losing, desperation, and hopelessness (Custer, 1982; Custer and Milt, 1985; Lesieur and Rosenthal, 1991). Recent research has suggested an alternative model, with as many as six phases of development into and out of a gambling addiction: initiation, positive consequences, negative consequences, turning points, active quitting, and relapse prevention (Shaffer and Jones, 1989; Shaffer, 1997; Prochaska et al., 1992; Marlatt et al., 1988). Clinical studies suggest that, as gambling progresses toward a pathological state, there is frequently an increase in the amounts wagered and the time devoted to gambling and a corresponding increase in depression, shame, and guilt (Rosenthal, 1992). Studies primarily of gamblers seeking help suggest that as many as 20 percent will attempt suicide (Moran, 1969; Livingston, 1974; Custer and Custer, 1978; McCormick et al., 1984; Lesieur and Blume, 1991; Thompson et al., 1996), and two out of three help seekers have turned to criminal activities to support their gambling (Lesieur et al., 1986; Brown, 1987; Lesieur, 1989). Pathological gambling can exacerbate other mental disorders, and stress-related physical illnesses are common (Lorenz and Yaffee, 1986). Chapters 4 and 5 discuss these issues in more detail.

Pathological gambling differs from the social and recreational gambling of most adults. Social or recreational gamblers are those who gamble for entertainment and typically do not risk more than they can afford (Custer and Milt, 1985; Shaffer et al., 1997). If they should chase their losses, they do so only briefly and have little preoccupation with gambling. In pathological gambling, however, players generate adverse consequences for themselves and others involved in their life. Clinicians report that, although money is important, male pathological gamblers often say they are seeking action, an aroused euphoric state that may be similar to the high from cocaine or other stimulating drugs. Pathological gamblers report a "rush" characterized by sweaty palms, rapid heartbeat, and nausea or queasiness. This can be experienced while gambling, in anticipation of gambling, or in response to



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