Pathological Gambling and Poly-Behavioral Addiction

Summary: What Happens in Vegas (losing) - Stays in Vegas (your money) Recently, I visited Atlantic City for a family reunion and while driving on the Atlantic City Express Way I noticed a flashing - neon road sign that read, "You drive - you speed - you lose." After spending a week there, I told my relatives that the sign should read, "You drive - to Atlantic City - You lose," as speeding is optional. Whether it is in Las Vegas, Atlantic City, or even at home on your own computer - with some online gambling website, what eventually happens is that approximately 20 million Americans develop gambling problems wagering and eventually losing approximately $0.5 trillion dollars annually (Feigelman, 1998). Someone has to pay those 24-hour electric bills. Approximately 2 million Americans are pathologic gamblers, 3 million adults can be considered problem gamblers and an additional 15 million are considered at-risk for problem gambling (NGISC, 1999). But who are the real losers? Findings from the 1999 Gambling Impact and Behavior Study reported that direct and indirect costs to American society from problem and pathologic gambling (e.g., health care, bankruptcy, criminal costs, etc.) are approximately $5 billion per year. That means that we the taxpayers are the real losers. The only "Winners," are the Casino owners, stockholders, and others invested in the Gaming industry.

What Happens in Vegas (losing) - Stays in Vegas (your money) Recently, I visited Atlantic City for a family reunion and while driving on the Atlantic City Express Way I noticed a flashing - neon road sign that read, "You drive - you speed - you lose." After spending a week there, I told my relatives that the sign should read, "You drive - to Atlantic City - You lose," as speeding is optional. Whether it is in Las Vegas, Atlantic City, or even at home on your own computer - with some online gambling website, what eventually happens is that approximately 20 million Americans develop gambling problems wagering and eventually losing approximately $0.5 trillion dollars annually (Feigelman, 1998). Someone has to pay those 24-hour electric bills. Approximately 2 million Americans are pathologic gamblers, 3 million adults can be considered problem gamblers and an additional 15 million are considered at-risk for problem gambling (NGISC, 1999). But who are the real losers? Findings from the 1999 Gambling Impact and Behavior Study reported that direct and indirect costs to American society from problem and pathologic gambling (e.g., health care, bankruptcy, criminal costs, etc.) are approximately $5 billion per year. That means that we the taxpayers are the real losers. The only "Winners," are the Casino owners, stockholders, and others invested in the Gaming industry. In two large national U.S. surveys, 36%-39% (success rates) of the individuals with a lifetime history of DSM-IV pathological gambling did not experience any gambling-related problems in the past year (NGISC, 2002). In other words, 61%-64% (failure rates) of the individuals who had tried to quit gambling - had relapsed back into a lifestyle of pathological gambling within a year. This article purports that the poor prognosis in treating patients with pathological gambling addiction (which progressively expands the market for pathological gambling) may possibly be due to not diagnosing and treating other poly-behavioral addictions simultaneously. This systematic under-diagnostic standard in the field of addictions could be due to the lack of diagnostic tools and resources that are presently available and incapable of resolving the complexity of assessing and treating a patient with multiple behavioral and substance abuse addictions. The Addictions Recovery Measurement System (ARMS) is proposed as a first step in fighting this global War on Poly-behavioral Addictions. Pathological Gambling and Diagnosis Although most people can gamble occasionally, (e.g., occasional Saturday night social poker games, betting on major sporting events with friends, and/ or playing a slot machine while on vacation, etc.), many as noted above lose control. Pathological Gambling, according to Diagnostic and Statistical Manual of Mental Disorders Fourth Edition Text Revision (DSM-IV-TR, 2000) is characterized by recurrent and persistent gambling behavior that disrupts family, personal, or vocational pursuits. It also involves continuous or periodic loss of control; a preoccupation with obtaining money for gambling; irrational behavior; and continuation of this behavior in spite of adverse consequences (Rosenthal, 1992). Screening for Pathological Gambling Several screening tools are available to assist counselors and therapists with diagnosing this condition - such as the South Oaks Gambling Screen (Lesieur & Blume, 1987), and the LIE/BET questionnaire (Johnson, 1997). The following section was adapted from the Addictions Recovery Measurement System (ARMS) - Behavioral Risk Assessment (Slobodzien, 2005). Gambling Practice Screen Instructions: Following are groups of statements that are numbered. Please read each group of statements carefully. Then pick out the one statement in each group that is most true for you, and circle the number beside the statement that you pick. 1. I have never gambled with more than $100.00 on any one- day, and it was purely for social entertainment. My gambling has never resulted in adverse consequences to others or myself. 2. Gambling is sometimes a part of my recreational activities, but I have never gambled with more than $1000.00 on any one-day. Periodically I have suffered from some negative consequences, but I have never lost control over this behavior. 3. I have gambled with more than $1000.00 on any one-day and/ or I have a continuous or periodic loss of control over gambling behaviors; and/ or a preoccupation with gambling and obtaining money for gambling; and/ or a pattern of continuing to gamble in spite of adverse consequences. Interpretation: 1 = (At-Risk-For Problem Gambling) 2 = (Problem Gambling) 3 = (Pathological Gambling) Note: If after reading the above, you started rationalizing to yourself, "Well I only lost $99.00 yesterday or $990.00 last week, (As my old graduate professor use to say) STOP BULL-SH#%ting yourself and go see a therapist. Pathological Gambling, other Behavioral Addictions and Co-morbidity Although it is important to recognize the high incidence of alcohol abuse and depression (suicide) in gamblers (Phillips, 1997), along with cocaine abuse (Teitelbaum, 2001), people also develop simultaneous dependencies on certain life-functioning activities such as sex addictions, food addictions, and religious addictions that can be just as life threatening as depression and just as socially and psychologically damaging as alcoholism. "Although considered private recreational matters by some, gambling and having sex are gaining the spotlight in the addiction arena, and with the growing availability of casino entertainment, lotteries, prostitution, internet pornography, and 900 numbers, gambling and sex are interpreted, labeled, and treated by addiction recovery specialists," (James, 2002). Sexual Addiction affects an estimated three to six percent of the U.S. population. Sexual addiction takes many forms to include obsessions with pornography and masturbation to engaging in cyber-sex, voyeurism, affairs, rape, incest, and sex with strangers. Though solitary forms of this addiction may not be overtly risky, they can be part of a pattern of distorted thinking and identity conflict that can escalate to involve harming the self and others. An example of a Sexual Disorder (NOS) or Not Otherwise Specified in the DSM-IV-TR, (2000) includes: distress about a pattern of repeated sexual relationships involving a succession of lovers who are experienced by an individual only as things to be used. The defining elements of this kind of addiction are its secrecy and escalating nature, often resulting in diminished judgment and self-control (Carnes, 1994). Binge-eating also can produce feelings of reward in the brain just like gambling, sex, and drugs. Likewise, 30.5% of American adults suffer from morbid obesity or being 100 lbs. or more above ideal body weight. Some do suffer from hormonal or metabolic disorders, but most obese individuals simply consume more calories than they burn due to an out of control overeating Food Addiction lifestyle pattern. Hyper-obesity resulting from gross, habitual overeating is considered to be more like the problems found in those ingrained personality disorders that involve loss of control over appetite of some kind (Orford, 1985). Binge-eating Disorder episodes are characterized in part by a feeling that one cannot stop or control how much or what one is eating (DSM-IV-TR, 2000). Although most addicts have cross-addictions, the relationship between pathological eating disorders and compulsive gamblers is presently unknown. Compulsive religiosity or Religious Addiction sometimes accompanies other addictions as the religious addict is seeking to lessen guilt and shame by seeking rewarding behaviors. Since it is impossible to expect treatment for one addiction to be beneficial when other addictions co-exist, the initial therapeutic intervention for any addiction needs to include an assessment for other addictions. The correlation between religious addiction and other substance abuse and behavioral addictions such as chemical dependency, alcoholism, pathological gambling, and sex addictions needs further study. Williams (1993) suggests that religious addicts experience three of the same symptoms as other addicts: craving or the need for a fix; the loss of control; and continual use. Johnson and VanVonderen (1991) define Religious Addiction as "the state of being dependent on a spiritually mood-altering system." In a change intended to encourage mental health professionals to view patients' religious experience more seriously, the DSM-IV included an entry entitled, "Religious or Spiritual Problem" (Steinfels 1994). One type of psycho-religious problem involves patients who intensify their adherence to religious practices to an obsessive-compulsive and sometimes delusional mental state of mind. I personally had the unique opportunity of writing my doctoral dissertation on religious addiction entitled, "Hawaii and Christian Religious Addiction." During that process, I discovered a significant relationship between self-appointed, authoritarian church leaders and religious addictive beliefs, behaviors and symptoms (Slobodzien, 2004). The fundamental nature of all addiction is the addicts' experience of helplessness and powerlessness over an obsessive-compulsive behavior, resulting in their lives becoming unmanageable. The addict may be out of control. They may experience extreme emotional pain and shame. They may repeatedly fail to control their behavior. They may suffer one or more of the following consequences of an unmanageable lifestyle: a deterioration of some or all supportive relationships; difficulties with work, financial troubles; and physical, mental, and/ or emotional exhaustion which sometimes leads to psychiatric problems and hospitalization. Addictions tend to arise from the same backgrounds: families with co-dependency including multiple addictions; lack of effective parenting; and other forms of physical, emotional and sexual trauma in childhood. Since it is impossible to expect treatment for one addiction to be beneficial when other addictions co-exist, the initial therapeutic intervention for any addiction needs to include an assessment for other addictions. Each of the above behavioral addictions has also developed their own 12-step support groups based on the Alcoholic Anonymous- philosophy: 1. Gamblers Anonymous (http://www.gamblersanonymous.org) 2. Food Addicts Anonymous (http://www.foodaddictsanonymous.org/) Overeaters Anonymous (http://www.oa.org/) 3. Religious Addiction/ Spiritual Abuse (www.christiansurvivors.com) (http://www.christians-in-recovery.org/) 4. Sex Addicts Anonymous (http://www.sexaa.org/) The high incidence of co-morbidity of pathological gambling and other behavioral and substance abuse addictions and psychiatric disorders are well documented. Pathological gambling is highly co-morbid with substance use, mood, anxiety, and personality disorders, suggesting that treatment for one condition should involve assessment and possible concomitant treatment for comorbid conditions (J Clin Psychiatry 2005;66:564-574). Addictions and other mental disorders as a rule do not develop in isolation. The National Co-morbidity Survey (NCS) that sampled the entire U.S. population in 1994, found that among non-institutionalized American male and female adolescents and adults (ages 15-54), roughly 50% had a diagnosable Axis I mental disorder at some time in their lives. This survey's results indicated that 35% of males will at some time in their lives have abused substances to the point of qualifying for a mental disorder diagnosis, and nearly 25% of women will have qualified for a serious mood disorder (mostly major depression). A significant finding of note from the NCS study was the widespread occurrence of co-morbidity among diagnosed disorders. It specifically found that 56% of the respondents with a history of at least one disorder also had two or more additional disorders. These persons with a history of three or more co-morbid disorders were estimated to be one-sixth of the U.S. population, or some 43 million people (Kessler, 1994). Poor Prognosis We have come to realize today more than any other time in history that the treatment of lifestyle diseases and addictions such as compulsive gambling are often a difficult and frustrating task for all concerned. Repeated failures abound with all of the addictions, even with utilizing the most effective treatment strategies. But why do 47% of patients treated in private treatment programs (for example) relapse within the first year following treatment (Gorski,T., 2001)? Have addiction specialists become conditioned to accept failure as the norm? There are many reasons for this poor prognosis. Some would proclaim that addictions are psychosomatically- induced and maintained in a semi-balanced force field of driving and restraining multidimensional forces. Others would say that failures are due simply to a lack of self-motivation or will power. Most would agree that lifestyle behavioral addictions are serious health risks that deserve our attention, but could it possibly be that patients with multiple addictions are being under diagnosed (with a single dependence) simply due to a lack of diagnostic tools and resources that are incapable of resolving the complexity of assessing and treating a patient with multiple addictions? Diagnostic Delineation Thus far, the DSM-IV-TR has not delineated a diagnosis for the complexity of multiple behavioral addictions (such as pathological gambling and sex addiction) and substance addictions. It has reserved the Poly-substance Dependence diagnosis for a person who is repeatedly using at least three groups of substances during the same 12-month period, but the criteria for this diagnosis do not involve any behavioral addiction symptoms. In the Psychological Factors Affecting Medical Condition's section (DSM-IV-TR, 2000); maladaptive health behaviors such as pathological gambling (e.g., overeating, unsafe sexual practices, excessive alcohol and drug use, etc.) may be listed on Axis I only if they are significantly affecting the course of treatment of a medical or mental condition. Since successful treatment outcomes in all addictions are dependent on thorough assessments, accurate diagnoses, and comprehensive individualized treatment planning, it is no wonder that repeated rehabilitation failures and low success rates are the norm instead of the exception in the addictions field, when the latest DSM-IV-TR does not even include a diagnosis for multiple addictive behavioral disorders. Treatment clinics need to have a treatment planning system and referral network that is equipped to thoroughly assess multiple addictive and mental health disorders and related treatment needs and comprehensively provide education/ awareness, prevention strategy groups, and/ or specific addictions treatment services for individuals diagnosed with multiple addictions. Written treatment goals and objectives should be specified for each separate addiction and dimension of an individuals' life, and the desired performance outcome or completion criteria should be specifically stated, behaviorally based (a visible activity), and measurable. New Proposed Diagnosis To assist in resolving the limited DSM-IV-TRs' diagnostic capability, a multidimensional diagnosis of "Poly-behavioral Addiction," is proposed for more accurate diagnosis leading to more effective treatment planning. This diagnosis encompasses the broadest category of addictive disorders that would include an individual manifesting a combination of substance abuse addictions, and other obsessively-compulsive behavioral addictive behavioral patterns to pathological gambling, religion, and/ or sex / pornography, etc.). Behavioral addictions such as pathological gambling are just as damaging - psychologically and socially as alcohol and drug abuse. They are comparative to other life-style diseases such as diabetes, hypertension, and heart disease in their behavioral manifestations, their etiologies, and their resistance to treatments. They are progressive disorders that involve obsessive thinking and compulsive behaviors. They are also characterized by a preoccupation with a continuous or periodic loss of control, and continuous irrational behavior in spite of adverse consequences. Poly-behavioral addiction would be described as a state of periodic or chronic physical, mental, emotional, cultural, sexual and/ or spiritual/ religious intoxication. These various types of intoxication are produced by repeated obsessive thoughts and compulsive practices involved in pathological relationships to any mood-altering substance, person, organization, belief system, and/ or activity. The individual has an overpowering desire, need or compulsion with the presence of a tendency to intensify their adherence to these practices, and evidence of phenomena of tolerance, abstinence and withdrawal, in which there is always physical and/ or psychic dependence on the effects of this pathological relationship. In addition, there is a 12 - month period in which an individual is pathologically involved with three or more behavioral and/ or substance use addictions simultaneously, but the criteria are not met for dependence for any one addiction in particular (Slobodzien, J., 2005). In essence, Poly-behavioral addiction is the synergistically integrated chronic dependence on multiple physiologically addictive substances and behaviors (e.g., using/ abusing substances - nicotine, alcohol, & drugs, and/or acting impulsively or obsessively compulsive in regards to gambling, food binging, sex, and/ or religion, etc.) simultaneously. New Proposed Theory The Addictions Recovery Measurement System's (ARMS) theory is a nonlinear, dynamical, non-hierarchical model that focuses on interactions between multiple risk factors and situational determinants similar to catastrophe and chaos theories in predicting and explaining addictive behaviors and relapse. Multiple influences trigger and operate within high-risk situations and influence the global multidimensional functioning of an individual. The process of relapse incorporates the interaction between background factors (e.g., family history, social support, years of possible dependence, and co-morbid psychopathology), physiological states (e.g., physical withdrawal), cognitive processes (e.g., self-efficacy, cravings, motivation, the abstinence violation effect, outcome expectancies), and coping skills (Brownell et al., 1986; Marlatt & Gordon, 1985). To put it simply, small changes in an individual's behavior can result in large qualitative changes at the global level and patterns at the global level of a system emerge solely from numerous little interactions. The ARMS hypothesis purports that there is a multidimensional synergistically negative resistance that individual's develop to any one form of treatment to a single dimension of their lives, because the effects of an individual's addiction have dynamically interacted multi-dimensionally. Having the primary focus on one dimension is insufficient. Traditionally, addiction treatment programs have failed to accommodate for the multidimensional synergistically negative effects of an individual having multiple addictions, (e.g. nicotine, alcohol, and obesity, etc.). Behavioral addictions interact negatively with each other and with strategies to improve overall functioning. They tend to encourage the use of tobacco, alcohol and other drugs, help increase violence, decrease functional capacity, and promote social isolation. Most treatment theories today involve assessing other dimensions to identify dual diagnosis or co-morbidity diagnoses, or to assess contributing factors that may play a role in the individual's primary addiction. The ARMS' theory proclaims that a multidimensional treatment plan must be devised addressing the possible multiple addictions identified for each one of an individual's life dimensions in addition to developing specific goals and objectives for each dimension. Considering that addictions involve unbalanced life-styles operating within semi-stable equilibrium force fields, the ARMS philosophy promotes that positive treatment effectiveness and successful outcomes are the result of a synergistic relationship with "The Higher Power," that spiritually elevates and connects an individuals' multiple life functioning dimensions by reducing chaos and increasing resilience to bring an individual harmony, wellness, and productivity. Partnerships and coordination among service providers, government departments, and community organizations in providing treatment programs are a necessity in addressing the multi-task solution to poly-behavioral addiction. I encourage you to support the mental health and addiction programs in America, and hope that the (ARMS) resources can assist you to personally fight the War on pathological gambling disorders within poly-behavioral addiction. Gamblers Anonymous: http://www.gamblersanonymous.org Alcoholics Anonymous: http://www.alcoholics-anonymous.org/ References American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Washington, DC, American Psychiatric Association, 2000, p. 787 & p. 731. Bandura, A. (1977), Self-efficacy: Toward a unifying theory of behavioral change. Psychological Review, 84, 191-215. Feigelman W, Wallisch LS, Lesieur HR. Problem gamblers, problem substance users and dual-problem individuals: an epidemiological study. Am J Public Health 1998;88:467-70. Gambling impact and behavior study: final report to the National Gambling Impact Study Commission. Chicago: National Opinion Research Center, University of Chicago,1999. Gorski, T. (2001), Relapse Prevention In The Managed Care Environment. GORSKI-CENAPS Web Healthy People 2010. Retrieved June 20, 2005, from: http://www.healthypeople.gov/ James, M. Kelly, Pleasure Principles: The Social Construction of Gambling and Sex Addiction Treatment. (Dissertation, 2002). Johnson EE, Hamer R, Nora RM, Tan B, Eisenstein N, Engelhart C. The Lie/Bet Questionnaire for screening for pathological gamblers. Psychol Rep 1997;80:83-8. Publications. Retrieved June 20, 2005, from: www.tgorski.com Lesieur HR, Blume SB. The South Oaks Gambling Screen (SOGS): a new instrument for the identification of pathological gamblers. Am J Psychiatry 1987;144:1184-8. Lienard, J. & Vamecq, J. (2004), Presse Med, Oct 23;33(18 Suppl):33-40. Marlatt, G. A. (1985). Relapse prevention: Theoretical rationale and overview of the model. In G. A. Marlatt & J. R. Gordon (Eds.), Relapse prevention (pp. 250-280). New York: Guilford Press. Kessler, R.C., McGonagle, K.A., Zhao, S., Nelson, C.B., Hughes, M., Eshleman, S., Wittchen, H. H,-U, & Kendler, K.S. (1994). Lifetime and 12-month prevalence of DSM-III-R psychiatric disorders in the United States: Results from the national co morbidity survey. Arch. Gen. Psychiat., 51, 8-19. National Gambling Impact Study Commission: Gambling Impact and Behavior Study, 1997-1999: United States: ICPSR Version (computer file). Ann Arbor, Mich, Interuniversity Consortium for Political and Social Research, 2002 Orford, J. (1985). Excessive appetites: A psychological view of addiction. New York: Wiley. Phillips DP, Welty WR, Smith MM. Elevated suicide levels associated with legalized gambling. Suicide Life Threat Behav 1997;27:373-8. Slobodzien, J. (2005). Poly-behavioral Addiction and the Addictions Recovery Measurement System (ARMS), Booklocker.com, Inc., p. 5. Teitelbaum, Scott, Edwards, Drew W., Gold, & Mark S. An Introduction to Compulsive Gambling. 2001 James Slobodzien, Psy.D., CSAC, is a Hawaii licensed psychologist and certified substance abuse counselor who earned his doctorate in Clinical Psychology. The National Registry of Health Service Providers in Psychology credentials Dr. Slobodzien. He has over 20-years of mental health experience primarily working in the fields of alcohol/ substance abuse and behavioral addictions in medical, correctional, and judicial settings. He is an adjunct professor of Psychology and also maintains a private practice as a mental health consultant. For more info see the book: Poly-Behavioral Addiction and the Addictions Recovery Measurement System, By James Slobodzien, Psy.D., CSAC