Pathological gambling has been described as a chronic and progressive mental illness. The disorder is rather common, estimated to affect 1 to 2% of the population and roughly 4 to 6% of all gamblers, with younger gamblers perhaps at higher risk for the disease.1 In the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, pathological gambling is listed in the section “Impulse-Control Disorders Not Elsewhere Classified.” Since the word “addiction” is not used in the DSM-IV, the question arises as to whether pathological gambling might be like addictions to chemicals—cocaine addiction, heroin addiction, etc.

It is clear that the word “addiction” is being used less and less with respect to alcohol and other drugs, now that the differences between intentional drug “abuse” and pathological chemical dependence (“dependence” as described in the DSM-IV) are being articulated and recognized. More and more scientists and clinicians understand that the term “addiction” (as sometimes applied to exercise, food, knitting, and cell phone use, for example) is not scientific, is imprecise, and is misunderstood by the public, leading to increased stigma against those with the disease of dependence. (This topic has been covered in earlier commentaries for this magazine, but is again important because of recent media documentaries on “addiction.”)

Differences with chemical dependence

Pathological gambling is characterized by persistent and recurrent maladaptive patterns of gambling behavior, and it leads to impaired functioning, reduced quality of life, and high rates of bankruptcy, divorce, and incarceration. However, this disorder lacks some of the key characteristics of chemical dependence. For example, there is as yet no strong scientific evidence for a direct involvement of the mesolimbic dopamine system in gambling-related problems, as there is with cocaine, heroin, and alcohol dependence.

Serious gambling problems, according to some recent studies, are transitory in many individuals. A recent study points out that DSM-assessed pathological gamblers do not always follow a chronic and persisting course.2 More than one-third of pathological gamblers do not exhibit any gambling–related problems when they are looked at in a follow-up year, and they “recover,” most without formal treatment. Even though Gamblers Anonymous groups mainly promote gambling abstinence, it might be the case that many of the most seriously affected gamblers are able to regain control of their gambling over time.

Medications seem to help those gamblers with the most persistent symptoms. Naltrexone (used in treating alcohol-dependent patients), naltrexone augmented with antidepressants, and lithium (for gamblers with bipolar illness) are apparently helpful. The fact that such drugs work suggests that there might be similar brain mechanisms involved in chemical dependence and pathological gambling, and the main neurotransmitter that overlaps with both conditions is serotonin. More studies, especially those involving brain imaging, might help to determine whether and how these two conditions are related.

Looking ahead

Shall we throw away the book and declare Gamblers Anonymous useless, since pathological gambling has not been shown to be an “addiction”? If many gamblers get better on their own, shall we close down formal treatment opportunities because they're not needed? Of course not, for the serious nature of out-of-control gambling (mainly disruption of an individual's life and family) dictates that there must be some way to help these people.

The next step will be for scientists to show some serious brain pathology associated with the disease so that medical insurance will cover the costs of its treatment.