Psychological Causes, Correlates and Costs of Gambling

Laura Liljequist, Ph.D. is an Assistant Professor in the Department of Psychology in the College of Humanities and Fine Arts at Murray State University, Murray, Kentucky

Attention must be brought to the problem of pathological gambling and all of its victims.

urrent epidemiological studies indicate that the vast majority of Americans report engaging in some form of gambling behavior. Most gamble as a form of recreation, but some develop serious gambling-related psychological problems. Is it possible to predict who will eventually suffer ill effects related to gambling? Are there some members of our society who are more vulnerable? Do vulnerabilities to excessive, damaging gambling behavior lie within individuals or do external factors play a role in determining who develops gambling-related problems? In reviewing the recent literature, this paper will explore these questions and offer some conclusions about the psychological causes, correlates and costs of gambling.

interpretation of any body of research. In the gambling literature, this is true as well. Although increasing the number of gambling levels described may allow for greater precision, it becomes problematic when attempting to compare results across studies that have typically used fewer levels. Further, it has yet to be demonstrated empirically that the various levels of gambling represent distinct, non-overlapping categories rather than points along a single continuum. Although imperfect for the reasons outlined, a description of the most common groupings or levels of gamblers follows.

Pathological Gambling
As indicated above, many people who gamble never develop serious negative psychological symptoms related to their gambling. Some gamblers, however, eventually enter into a pattern of gambling that disrupts their lives. Of the levels of gamblers, pathological gamblers may be the most well-defined, as the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) has established ten behavioral criteria and set the diagnostic threshold at meeting five of these ten criteria.5 The criteria set forth for this disorder are similar to those outlined for the substance dependence disorders, such as alcohol or cocaine dependence.6 Among the ten diagnostic criteria, the DSM-IV behaviorally describes such symptoms as tolerance (gambling increasing amounts of money to get the same high) and withdrawal (feeling restless or irritable when trying to stop gambling).7 Other symptoms include resorting to illegal acts to obtain money for gambling, borrowing money from family members to cover gambling debts
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Levels of Gambling
In describing various types of gamblers, most authors divide people into different groups depending on the nature of their gambling behavior and the number of gambling-related problems they have experienced. Gamblers are categorized into levels ranging from those who have never wagered to the most severely disturbed gamblers. Aside from the clearly defined group of gamblers labeled pathological gamblers, there is no uniform terminology nor are there consistent definitions for the remaining levels. In fact, there has been a lack of consensus as to the appropriate number of levels into which researchers should group gamblers. Most authors have categorized people into three or four levels based on their gambling behavior,1,2,3 while a recent national study used as many as five levels.4 Unfortunately, shifting definitions and labels bring confusion to the analysis and

and lying to family and friends about the extent of gambling behavior. Pathological gamblers may be preoccupied with thoughts of gambling, gamble to relieve feelings of sadness and may have made unsuccessful attempts to stop gambling. Their gambling may cost them important personal relationships or even jobs. The final criterion of pathological gambling is a behavior referred to as chasing, which is present when an individual continues to gamble, after losing, in an attempt to recoup their losses. Chasing is perhaps the one symptom that distinguishes pathological gambling from other addictive disorders, having no substance dependence counterpart, and is seen by some as the hallmark of this disorder.8 For gamblers meeting the criteria for a diagnosis of pathological gambling, their gambling behavior is persistent and interferes with their social or occupational functioning. As any combination of five of these symptoms is sufficient for a diagnosis, two pathological gamblers may have five completely different symptoms, yet still both warrant a diagnosis. It is interesting to note that in the field studies preceding the fourth revision of the DSM, the authors chose to set the cut-off at a minimum of five symptoms, despite the fact that a cut-off of four of the ten symptoms accurately classified 95 percent of pathological gamblers.9 The higher cut-off has implications for interpreting prevalence data, described later in this paper, with respect to pathological gambling. Certainly, one possible result is an underestimate of the true prevalence of pathological gambling. The DSM-IV criteria further do not require that the five symptoms be observed in a limited period of time.10 It is possible to have an accumulation of disturbed gambling behaviors across many days, weeks, or years. This reflects the conceptualization of pathological gambling as a chronic pattern

of behavior. There is research to support that pathological gambling develops over a period of many years.11 Further, most pathological gamblers struggle with their disorder for many years, alternating between periods of active gambling, remission and relapse, much the same as individuals with substance dependence disorders. Unlike the substance dependence disorders, however, the DSM-IV does not suggest that an individual will always carry a diagnosis of pathological gambling, once so diagnosed. Conversely, for individuals with substance dependence diagnoses, even after years of exhibiting no active symptoms, they retain the diagnosis, with a note that the disorder is in full or partial remission. The fact that the Pathological Gambling diagnosis appears in a section of the DSMIV entitled Impulse Control Disorders, Not Elsewhere Classified further indicates that pathological gambling is viewed as a problem of impulse control.12 Pathological gambling was previously conceptualized as a compulsive behavior, which suggests that although the behavior is repetitive, it is not pleasurable nor voluntary. Impulse control problems, in contrast, are often guilty pleasures, sometimes illegal and almost always harmful in excess, from which individuals attempt to refrain. Black and Moyer found that many pathological gamblers, recruited from the community, had multiple additional impulse control problems or disorders, such as excessive shopping and extreme sexual promiscuity.13 In assessing individuals presenting for treatment with a measure of obsessivecompulsive disorder symptoms, Blaszczynski discovered that pathological gamblers did not report high levels of compulsive behavior, rather their responses suggested problems with impulsivity.14 Finally, a study of adolescents found a correlation between two measures of impulsivity and problem gambling.15 Thus,

conceptualizing pathological gambling as an impulse control problem is appropriate.

Problem Gambling
Sometimes referred to as disordered gambling, the next level of gamblers are most often labeled problem gamblers. Disordered gambling is a less precise term, as pathological gambling is codified as a psychological disorder and can, therefore, also be considered disordered gambling. Problem gamblers meet some, but not all of the diagnostic criteria set out for pathological gamblers. Of the ten DSM-IV criteria, problem gamblers may have anywhere from one to four of the symptoms outlined above, but have never exceeded the threshold of five symptoms. At least one study divided problem gamblers into two groups: at risk gamblers and problem gamblers, with the former displaying one or two symptoms and the latter acknowledging three or four, however this division is the exception, not the rule.16 It may be that problem gamblers are qualitatively different from the pathological gamblers and will never experience the full syndrome of pathological gambling. It is possible, however, that problem gambling and pathological gambling are only quantitatively, rather than qualitatively, different. In this case, problem gambling may be viewed as part of a progression to the more serious and disruptive pathological gambling. Some authors have written that pathological gambling is developed over many years, with individuals reporting an average of eight to nine years of gambling problems prior to meeting the full criteria for pathological gambling, suggesting such a progressive course.17 Koran described the progression to pathological gambling as a movement through a series of predictable phases, from the initial winning phase, into a losing phase and finally, a desperation phase. One might argue that a

subset of problem gamblers is merely in the losing phase, and eventually will progress to the final desperation phase. Additional evidence for such a progression is the finding of a relationship between problem gambling in adolescence and later, more severe gambling problems in adulthood.18 A prospective study of adolescents further demonstrated that gambling behavior at age thirteen predicted problem gambling at age seventeen. 19 More longitudinal research that follows adult problem gamblers for many years is needed to determine whether a progressive model of gambling problems is appropriate.

Non-problem Gambling
While some researchers studying problem and pathological gamblers have considered anyone not falling into the previous two levels as non-problem gamblers, this category combines two distinct groups: non-gamblers and social gamblers. Members of the former group, the non-gamblers, have never engaged in gambling of any sort. Defining who belongs in this group is deceptively easy, as anyone who reports that they have never gambled would be included. If a single, global question is used to screen gamblers from non-gamblers, however, too many people may be categorized as non-gamblers. Research has suggested that many people do not consider playing the lottery or using scratch cards to be gambling.20,21 It may be that participating in office sports pools or other seemingly-innocuous betting events may be similarly perceived as non-gambling activities. Therefore, multiple questions about specific gambling activities must be used to accurately classify people as nongamblers. People that make up the latter group, the social gamblers, have participated in various gambling activities for social and recreational purposes. This group is also

sometimes referred to as low risk gamblers.22 There is some disagreement about whether these individuals have ever experienced an ill-effect of gambling. Most researchers categorize people as social gamblers if they have experienced none of the DSM-IV criteria for pathological gambling.23,24,25 As previously stated, deciding on a single, consistent definition would aid research as results from studies categorizing gamblers according to these levels would be comparable across studies. It is important, too, to separate the nongamblers from the social gamblers, as these are meaningfully distinct groups. Certainly, someone who never gambles cannot become a problem nor pathological gambler. Therefore, a better understanding of problem and pathological gamblers may come from comparing these groups to social gamblers rather than to non-gamblers. One fascinating research question that has yet to be asked is: what allows some individuals to remain social gamblers for a lifetime, never experiencing even a single adverse consequence of their gambling activity? To date, no examination of such protective factors has been undertaken.

Assessment of Gambling Levels

Thus far, the various levels of gambling have primarily been assessed by first determining whether an individual has ever participated in any gambling activities and if so, assessing the number of DSM-IV symptoms of pathological gambling the individual acknowledges. Just as the defining of behavioral criteria for a diagnosis of pathological gambling has enhanced communication among professionals and made possible empirical study of affected individuals, so too has the development of a consistent and accurate way to measure those criteria. Standardization of psychological assessment instruments is critical as it allows for greater

precision in measurement, comparability of results across studies and quantification of otherwise qualitative constructs. Several measures that systematically assess for the DSM criteria have been developed, but by far the most frequently used is the South Oaks Gambling Screen (SOGS).26 The SOGS was the first standardized measure of pathological gambling and was developed to correspond to the DSM-III criteria.27 The SOGS has been shown to be a reliable and valid measure of pathological gambling.28 Scores are typically interpreted as follows: individuals scoring a five or higher are considered probable pathological gamblers, individuals scoring a three to four are considered probable problem gamblers and individuals scoring less are considered non-problem gamblers. Another measure, used in a national telephone survey of gambling behavior and attitudes, was developed to reflect the newer DSM-IV criteria.29 Scores correspond to the number of symptoms the individual admits. The NORC Diagnostic Screen (NODS) has also proven both reliable and valid.30 The NODS, like the SOGS, is designed to be administered primarily in interview format, either in person or in a telephone survey. A problem with all such measures, particularly when asking about sensitive or embarrassing matters, symptoms or problems, is that respondents are prone to deny undesirable personal qualities. As lying about the extent of gambling behavior is, itself, a symptom of pathological gambling, one expects that denial on measures such as the SOGS and NODS will be especially problematic. Although respondent denial may lead to underestimates of the true prevalence of various levels of gambling, others have charged that the SOGS has a high false positive rate, leading to spuriously high prevalence estimates.31 The high false positive rate may be due to the subjective

wording of the questions, possessing few behavioral or quantitative anchors. Nevertheless, both the SOGS and the NODS have demonstrated acceptable utility in the study of problem gambling behavior.

Prevalence
Prevalence refers to the proportion of individuals in a population with a particular characteristic at a given point in time. The characteristic of interest may be a behavior, a demographic variable, a diagnosis or any one of a number of other characteristics. Prevalence figures are usually reported as estimates as it is not possible to gather information from every member of a population. Instead, a representative subset of the larger population is surveyed and information from that subset is used to make generalizations about the larger group. Different prevalence estimates are reported depending on the time frame of interest. For example, lifetime prevalence refers to the proportion of individuals who exhibit or experience a characteristic at any point in their lifetime, but may or may not currently possess that characteristic. Past-year prevalence refers to the proportion who have exhibited or experienced the characteristic in the past year. When used with no timemodifier, the term prevalence refers to the number of individuals who, at the time of the survey, possessed the characteristic of interest. It is important to take note of how the term is being used when interpreting prevalence statistics.

Changes in Prevalence Data with Changes in Gambling Laws

It is clear that gambling opportunities have increased in the United States over the past twenty-five years. In 1998, 47 states had some form of gambling, and many had multiple types of opportunities. This represents an increase of ten times the number of gambling opportunities available

in 1976.32 Gambling opportunities have likewise increased in many other countries, including Great Britain, Canada, Australia and Russia. What is less clear is the impact of these increased opportunities. Some authors cite statistics that suggest that the longer gambling has been legal in an area, the higher the rate of pathological gamblers.33,34 Another study found a relationship between the number of video poker machines in Louisiana parishes and the number of Gamblers Anonymous chapters and meetings in those parishes.35 One cannot interpret such relationships to mean that legalizing gambling causes more problem and pathological gambling, rather it may mean that individuals who are prone to gambling excesses move to areas that afford gambling opportunities. Further, other authors report no changes in the prevalence of pathological gambling following changes, even after the opening of a casino in the community.36 A national survey that compared gambling prevalence rates from 1976 to 1998, found that there has been an increase in lifetime prevalence of gambling.37 In 1976, 68 percent of adults had wagered at some point in their lifetime, whereas in 1998, a full 86 percent of adults report that they have gambled in their lifetimes. However, when asked whether they had gambled in the past year, the proportion of adults who said yes were similar in 1976 and 1998, with past-year prevalence figures of 61 and 63 percent, respectively.38 A survey of college students revealed past-year gambling prevalence rates of 91 percent of men and 84 percent of women.39 A second study of college students reported a part-year gambling prevalence rate of 92 percent overall. 40 This college data is consistent with other significant changes in gambling patterns over the past twenty-five years that emerged in the NORC study, including the finding that women were more likely to report

lifetime gambling behavior. Other researchers have noted that women are becoming more likely to suffer gamblingrelated problems as well. 41 Finally, although senior citizens were much more likely to report both lifetime and past-year wagering in 1998 than 1976, they were still gambling less than those in younger age groups.42 Increased numbers of senior citizens reporting lifetime gambling behavior may simply represent the aging of the population, such that individuals who were in their 40s and 50s during the first survey are now over 65 years old. The types of gaming activities in which people are engaging have also changed. There have been increases in the numbers of people participating in lottery and casino gambling, but decreases in the numbers playing bingo and betting on pari-mutuel events, such as horse- and dog-racing.43 College students who gambled in the past year were most likely to have wagered at gaming machines (67%) or to have bought lottery tickets (63%).44 Fully twelve percent of these college students reported gambling at least weekly or daily. Certainly, the availability of state lotteries and casinos has increased greatly. Further, surveys of attitudes toward different types of gambling show that people hold the most positive attitudes toward the lottery, followed by casinos.45 Attitudes toward horse-racing are the least positive, based on these surveys. Further, attitudes of men and women generally differ, with men holding more positive attitudes for all surveyed forms of gambling except for the lottery, where men and women hold equally positive attitudes.46 Many possibilities exist for changing patterns in gambling prevalence statistics. Legalization of gambling activities may create changes in peoples perceptions of the social acceptability of these activities, much the way changes in the law before and after Prohibition influenced the public view of

alcohol. As mentioned previously, attitudes about gambling may influence behavior. In community surveys of attitudes toward gambling following the opening of gaming venues, approval of gambling increased.47 Further, the increased numbers of women gambling, coupled with highest approval of lottery on attitude surveys by women suggests that these two variables may account for some of the changes in gambling patterns. Certainly the relentless advertising of the lottery, which is not subject to the same restrictions as cigarette and alcohol advertising, but rather is government-funded and government-sanctioned, may play a role.48 Among teens in the UK, the majority (72%) reported that gambling was a bad idea, but that the lottery (76%) and scratchcards (57%) were a good idea. 49 Again, this suggests that not only do most people approve of lottery and scratchcard use, but that many may not even view these activities as gambling. Finally, some authors have suggested that there has been a deliberate effort made to feminize gambling, citing such industry efforts as marketing to women, making venues clean and safe and even providing child care services at some casinos.50

Prevalence Information by Level of Gambling

The lifetime prevalence of pathological gambling has been difficult to ascertain with precision. The DSM-IV reports a range of one to three percent lifetime prevalence of pathological gambling.51 While reporting prevalence using a range is appropriate, the upper end of this range may be too high, based on recent epidemiological studies. It seems that the lifetime prevalence of pathological gambling among adults hovers around one percent of the population. A recent national telephone survey, using the NODS to identify levels of gambling, found that 1.2% of the sample met the criteria for

pathological gambling.52 Another regional epidemiological study identified 0.9% of participants as pathological gamblers.53 Although nationally and regionallyrepresentative surveys are reporting prevalence rates near one percent, one survey of college students found that three percent, of whom 80 percent were men, scored in the probable-pathological range on the SOGS.54 In contrast to pathological gamblers, problem gamblers represent a more sizable proportion of the population. Using the definition of problem gamblers as those who meet between one and four of the DSM-IV criteria for pathological gambling, it appears that approximately nine percent of individuals can be classified as problem gamblers at some point in their lives. Two recent epidemiological studies have found identical proportions of problem gamblers. In a regional study, 9.2% of respondents could be considered problem gamblers.55 In a national study, people meeting one or two of the DSM-IV criteria were labeled at risk gamblers, comprising 7.7% of the sample, and those meeting three or four criteria were labeled problem gamblers, comprising 1.5% of the sample.56 Combined, these two groups meet the working definition of problem gambling, for the purposes of this paper, and represent 9.2% of the total sample. Prevalence estimates for non-problem gamblers again vary depending on the definition used. In the NORC national survey, lifetime social gamblers were termed low risk gamblers and made up 75.1% of the sample, while lifetime non-gamblers represented a mere 14.4% of the sample.57 Approximately 51 percent of respondents in a regional survey reported having placed bets at least twice in their lifetimes, but never having suffered gambling-related problems.58 The remaining 39 percent, then, gambled once or not at all. Unfortunately,

the data in this latter survey do not permit a determination of the prevalence of nongamblers in this sample.

Prevalence among Adolescents

As with tobacco and alcohol legislation, states have placed age limits on legalized gambling. Adolescents, defined as teens under the age of eighteen, are largely not legally allowed to enter casinos, purchase lottery or scratchcards, wager on bingo nor place bets on pari-mutuel events.59 Nevertheless, paralleling findings that age restrictions do not eliminate adolescent tobacco and alcohol use,60 studies have consistently reported that, despite the laws, adolescents are gambling.61,62,63 Overall, adolescents gamble less than adults.64 Their pattern of gambling differs, as well, with adolescents more likely to report betting on card games or sporting events or playing the lottery. One alarming finding, from a survey of adolescents in the UK, found a large proportion (24.1%) of adolescents reported either playing the lottery or using scratchcards at least once a week.65 Many were only eleven or twelve years old. Further, Griffiths and Sutherland indicate that these statistics may be low, as the data were gathered in schools, and another significant finding from their survey revealed a positive correlation between adolescent gambling and school truancy. Therefore, adolescent gamblers may have been underrepresented in this school-based sample.66 In a second survey of teens in the UK, fully 48 percent reported that they had played the lottery at some point, while another 30 percent admitted having used scratchcards.67 Although surveys show lottery play to be more common among teens than other forms of gambling, in a review of the adolescent gambling literature, Kaminer and Petry68 report that adolescent casino gambling is increasing and that age restrictions are not being enforced. This

contradicts the findings of a national study of adolescent gambling, however, that reported fewer than one percent of adolescents were gambling in casinos.69 Regardless of the level of their casino participation, it is clear that adolescents are gambling, which by definition, is illegal behavior and should be cause for some concern. Not only are adolescents gambling, but they are also developing gambling-related problems.70,71,72,73 The prevalence of pathological gambling among adolescents has been a source of some debate, with some authors reporting higher rates in teens than adults.74,75 and others reporting similar rates as adults.76 Wood and Griffiths found a slightly lower rate of problem gambling among teens surveyed in the UK, with six percent each meeting the criteria for their gambling behavior with lottery and scratchcards.77 This lower figure must be viewed cautiously, however, as the researchers were assessing for problem gambling on two specific gambling activities, rather than gambling in general, as is typically assessed. Part of the problem in identifying a prevalence figure may be that although it is technically permissible to apply the DSM-IV criteria to adolescents,78 the criteria themselves may not have the same meaning for dependent children, with limited earning potential and few assets, as for adults. Obviously, identifying the best estimate among adolescents has implications for the lifetime prevalence rates reported earlier. If two percent of teens are gambling pathologically now, then in twenty years, one would expect the lifetime prevalence estimate to include that two percent plus those who became pathological gamblers as adults. Teens have not typically been included in the national surveys upon which such lifetime prevalence estimates have been based. Therefore, it is unclear whether the adults surveyed have not reported their

youthful gambling behavior or whether there is currently an historical shift, such that more teens are gambling today, which will eventually be reflected in higher lifetime prevalence rates uncovered in national surveys in the near future.

Problem Gambling and Other Psychological Disorders

Comorbidity is a term that refers to the presence of more than one diagnosable psychological disorder in an individual at a single point in time. For example, an individual might simultaneously be diagnosed with Attention-Deficit Hyperactivity Disorder and Alcohol Abuse, or another person may suffer from both Major Depressive Disorder and Generalized Anxiety Disorder. These conditions would be said to be comorbid. Pathological and problem gamblers have high rates of comorbid psychological disorders. Reported rates of comorbidity vary depending on the population sampled and the sampling technique used, but some conclusions are still possible. Further, among pathological gamblers, the lifetime prevalence of other psychological disorders (two disorders at any point in their lifetime, not necessarily overlapping) is higher than the comorbid prevalence (two disorders overlapping in time). For example, in a sample of pathological gamblers recruited from the community, 90 percent met the criteria for at least one additional psychological disorder in their lifetime.79 In a study of gamblers presenting for treatment of their gambling problem, the lifetime prevalence of other psychological disorders was similarly high (84%).80 Still others have found that as the severity of gambling problems increases, so too does the likelihood of having another DSM-IV diagnosis.81,82 Even recreational gamblers were more likely than nongamblers to have a DSM-IV diagnosis.83 Regardless of the population or sampling

method, it is clear that there exist strong relationships between pathological gambling and other psychological disorders.

Alcohol and Substance Dependence

Alcohol and other substance dependence disorders share many of the same diagnostic criteria as those set out for pathological gambling.84 Both involve severe life disruptions related to a voluntary, repetitive and, at least initially, enjoyable behavior. Like pathological gambling, these disorders may be viewed as impulse control disorders, where the impulse to engage in drinking or gambling overwhelms the individuals attempts to suppress it, leading to cravings and a brief sense of relief upon succumbing to the impulse. One might argue there are other similarities such as the secretive and often shameful nature of the behavior, leading to difficulties admitting the problem. Treatment challenges, which will be discussed more fully later in this paper, are likewise similar, with many advocating abstinence for substance abusers and gamblers as the only appropriate treatment goal. Gamblers Anonymous has been modeled after other twelve step programs, which have sprung up in the wake of Alcoholics Anonymous. Alcohol- and substance-use disorders were among the three most common comorbid psychological disorders in a community sample of pathological gamblers.85 In a second community sample, high rates of comorbidity between pathological gambling and alcohol and nicotine dependence were reported.86 Among alcohol dependent clients, nine percent also met the criteria for pathological gambling.87 This figure is considerably higher than the one to three percent of pathological gamblers expected in the general population. Further, among those alcoholics with comorbid pathological gambling as compared to alcoholics with no

gambling problems, the age of onset of alcoholism was younger, the duration of their alcoholism was longer and treatment of their alcoholism was less successful, as measured by a greater number of detoxification hospital admissions.88 Finally, among adolescents with pathological gambling, alcohol and substance abuse problems frequently cooccur.89 The relationship between substance dependence and pathological gambling may be the result of factors within the individual or outside the individual. Individual explanations typically point to genetic predispositions, personality characteristics or moral weaknesses. A genetic contribution to alcohol dependence has been welldocumented. A recent examination of twins has demonstrated that genetic factors explain a significant proportion of the variance in gambling behavior as well.90 Another possibility is that multiple disorders have an interaction or multiplicative effect, such that each becomes more severe and intractable by the mere presence of a second disorder. The interaction explanation may merit further study. Still another individualistic explanation is that perhaps some individuals have poor impulse control, making them more vulnerable to multiple impulse-control disorders. Although many have tried to establish the presence of an addictive personality, a thorough review of the literature does not support such a conclusion.91 Adopting an individualistic explanation is appealing, as it locates the problem within the vulnerable individual, leaving the rest of us to drink alcohol and gamble with no fear of harmful consequences. Conversely, if these disorders exist on a continuum, shaped in part by external factors, then everyone is potentially vulnerable.92 The second interpretation regards behavioral excesses as shaped by

contingencies in the environment. According to this view, early experiences with alcohol and gambling influence the pattern and persistence of these behaviors, at least in part. This hypothesis, with respect to gambling, will be explored in greater detail in subsequent sections of this paper, and is a controversial one, but one with as much empirical support as the former individualistic explanation.

toward other impulse control problems as well.96,97 A study of college students found significant correlations among behavioral addictions, including gambling, video game use, Internet use and television viewing.98 Another disorder for which impulsive behavior is one of the hallmark symptoms is Attention-Deficit Hyperactivity Disorder.99 Among adolescents with problem gambling, ADHD is a frequent comorbid diagnosis.100

Other Impulse Control Problems

Just as pathological gambling and alcohol and substance dependence can be conceptualized as behavioral excesses driven by poor impulse control, other behavioral excesses can be problematic as well. Often referred to as addictions,93 these persistent and repetitive enactments of behavioral patterns can be as disruptive to an individuals functioning as those already outlined. Some examples are promiscuous sexual behavior, referred to popularly as sex addiction, shopping, Internet and video game addictions. As clinicians begin to see clients with such consistent patterns of behavior, research follows. Upon review of a body of research and subsequent epidemiological or field study, these behavioral disorders are codified in the DSM-IV. Those that currently appear are kleptomania (failing to resist the impulse to steal), pyromania (failing to resist the impulse to set fires) and trichotillomania (failing to resist the impulse to pull out ones own hair.)94 Those impulse control problems that have not yet been labeled and included can, nevertheless, be diagnosed. Any single repetitive behavior that sufficiently interferes with an individuals ability to function occupationally or socially, or is extremely distressing, can be diagnosed as an Impulse Control Disorder, Not Otherwise Specified.95 Several authors have found that individuals with pathological gambling tend

Mood Disorders
Major Depressive Disorder is a prominent mood disorder characterized by depressed mood, along with a host of other physical, emotional and cognitive symptoms. Of particular concern among individuals suffering from major depression is the risk of suicide. The link between pathological gambling and major depression is well-established. In a group of pathological gamblers presenting for treatment of their gambling behavior, the average score on a measure of depression was in the moderate to severe range.101 This implies that the majority of these pathological gamblers were also experiencing the full syndrome of major depression. Further, Black and Moyer found mood disorders to be among the three most common comorbid disorders in a community sample of pathological gamblers.102 In a regional epidemiological study, major depression was a frequent comorbid condition with pathological gambling.103 These researchers were able to establish that the onset of depression preceded the gambling behavior, which strongly suggests that pathological gambling did not cause depression in this sample. Nationally, the proportion of pathological gamblers who reported a depressive episode in the past year was also substantial (11.6%) and

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greater than would be expected in the general population.104 Raghunathan and Pham manipulated peoples moods, creating either sad, anxious or neutral conditions, and looked at the effect of mood on participants decisionmaking. They found that people who were sad favored high-risk, high-reward choices over those with neutral mood, who, in turn, preferred these risky gambles more than those with anxious mood. It is reasonable to conclude, based on this experiment, not only that people who are sad tend toward risky gambles, but that depressed mood causes changes in decision-making and choice to gamble.105 An interesting complement to this finding is the work done by Kyngdon and Dickerson, who randomly assigned volunteers to either an alcohol or placebo group and studied their subsequent gambling behavior. Based on previously-completed psychological tests, the researchers discovered that high scores on depression predicted continued gambling in the placebo group only, further supporting the notion that many people gamble to relieve feelings of sadness and perhaps depression. 106 The diagnostic criteria for pathological gambling, themselves, include one symptom further establishing this link, by stating that the pathological gambler gambles as a way of escaping from problems or of relieving a dysphoric mood.107 Although not all studies assessed for the full syndrome of major depression, many have reported a link between pathological gambling and suicidal thoughts and behavior.108,109,110,111 Seven out of ten communities surveyed, using a case study approach, reported either increases in suicide rates or perceptions of such increases following the opening of casinos in their community.112 Further, suicide rates in Louisiana parishes were significantly correlated with per capita spending on the lottery, but not video-poker, even when

controlling for certain demographic variables derived from previous research. 113 More persuasive evidence of this link comes from Beaudoin and Cox, who interviewed adults presenting for treatment of gamblingrelated difficulties and found that one-half (50.9%) had thought about suicide within the previous year and 15.8% had attempted suicide. Of those that had made suicide attempts, the majority (68.6%) reported they had done so because of their gambling problems.114 In a review of the literature, Petry and Armentano report similar figures, with between 48 to 70 percent of pathological gamblers acknowledging thoughts of suicide and between 13 and 20 percent attempting suicide.115

Anxiety Disorders
Fewer researchers have documented a connection between pathological gambling and the anxiety disorders. One anxiety disorder, obsessive-compulsive disorder (OCD), includes compulsions, which are repetitive behaviors performed to reduce feelings of anxiety. These behaviors are not performed to provide pleasure, rather they are typically perceived by the individual afflicted with OCD as unusual, unreasonable or distressing.116 Although once thought of as a compulsive behavior, driven by or performed to reduce feelings of anxiety, empirical evidence has failed to support pathological gambling as a compulsion.117,118,119,120 In a study that manipulated participants moods, those made to feel anxious least preferred high-risk, high-reward choices, similar to gambling scenarios.121 This indicates that individuals do not choose to gamble in order to reduce feelings of anxiety. In fact, they tend to move away from risky gambles, perhaps due to their feelings of anxiety. Another study found a negative correlation between scores on a measure of anxiety and gambling behavior

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in patrons of betting establishments.122 Again, as anxiety increases, wagering decreases. Therefore, this finding is not inconsistent with the failure to establish a link between anxiety and pathological gambling. One study did report an association between pathological gambling and anxiety disorders, but this relationship was specific to phobias.123 The survey method used allowed these researchers to determine that the onset of the specific phobia pre-dated the onset of the gambling disorder. Phobias are unique to the anxiety disorders in that a person becomes distressed and anxious only while in the presence of the specific phobic object, and functions with little or no anxiety outside of contact with that object.

Factors Predicting Disordered Gambling

A number of correlates of problem and pathological gambling have been reported in the literature. Although correlational statistics do not permit inferences about the causes of disordered gambling behavior, they do allow us to predict who will gamble and who is at risk for developing gamblingrelated difficulties. A smaller number of experimental studies that do permit causal inferences have also been conducted. As established in the previous section, one predictor of gambling problems is the presence of other psychological disorders, namely alcohol- or substance-related disorders, other impulse control problems, mood or personality disorders. Other predictors explored have been demographic variables;127,128,129,130 personality characteristics;131,132 poor understanding of probability theory or cognitive errors;133,134,135,136,137 attitudes and beliefs about gambling;138 and factors related to the gambling experience itself.139,140,141,142

Personality Disorders
Personality disorders are described as maladaptive lifelong patterns of perceiving and relating to the world.124 In particular, individuals with personality disorders experience profound difficulties in their interpersonal relationships. Black and Moyer found that fully 87 percent of a community sample of pathological gamblers met the diagnostic criteria for at least one personality disorder. While such high rates of personality disorders are not uncommon in psychiatric samples, it is extremely unusual to find such an alarming rate in a community sample.125 In a psychiatric sample of pathological gamblers, an even greater rate of personality disorders was found (93%).126 Most of these individuals met the criteria for more than one personality disorder. In fact, the higher their SOGS score, the greater the number of personality disorders for which they could be diagnosed.

Demographic Variables
Historically, most gamblers have been men. The gender gap may have narrowed in recent years, with more women reporting both lifetime gambling and past-year gambling.143 Whether women are beginning to experience gambling-related problems at the same rates of men remains open to debate, as most of the current research still suggests that men have more disordered gambling behavior. The DSM-IV reports that among pathological gamblers, males outnumber females by a two to one margin.144 In two regional surveys of community members who could be classified as probable-pathological gamblers, approximately three times as many males as females were considered pathological gamblers.145,146 In a survey of

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college students, past-year gambling was high for both men and women, but of those meeting the criteria for pathological gambling, nearly 80 percent were male.147 However, one recent national epidemiological survey reports figures that contradict these other reports, finding no significant differences in the rates of males versus females in the problem and pathological gambling groups.148 Similarly, a survey of British lottery players found no differences in lottery spending between men and women.149 As discussed earlier in this paper, one reason for the changing rates of gambling among various sub-groups of society may be the changing perceptions about gambling. In a study that compared women who gambled to those who did not gamble, the primary predictor of gambling was the perceptions of the social acceptability of gambling. Women who gambled were more likely to have friends and family members who gambled.150 As was the case with womens use of alcohol and tobacco, as activities become more socially acceptable for women, women engage in these activities at greater rates. Several studies report that individuals with lower incomes are more likely to be pathological gamblers.151,152 This is also the case for adolescent gamblers, with the poorest adolescents being at the greatest risk for problem gambling.153 Conversely, among college students, level of gambling behavior was related to having high disposable income.154 In contrast, in a study of British lottery players there was no relationship between socio-economic status and lottery spending.155 Thus, the relationship between income and gambling behavior may not exist for all types of gambling activities nor all age groups. African-Americans seem to be at higher risk for developing pathological gambling patterns, based on survey data.156 However, in a survey of a gambling on the British

lottery, ethnicity did not predict greater spending.157 These same surveys affirm that disordered gambling behavior is also more common among younger, divorced or unmarried individuals. Finally, individuals within 50 miles of a casino appear to be at higher risk for pathological gambling.158

Personality Characteristics
One personality variable that has been frequently studied in relation to gambling is sensation-seeking, or the tendency to seek out risky and exciting experiences. Sensation-seeking has failed to predict gambling behavior in some studies,159 but has been found to be positively correlated with gambling-related problems in others.160 One study even found a negative relationship between sensation-seeking and gambling behavior, such that as people became more likely to seek out dangerous and exciting experiences, they were less likely to gamble.161 As the data are contradictory and inconsistent, it is reasonable to conclude that no relationship between sensation-seeking and gambling has been established. Other personal variables that have been studied in relation to disordered gambling behavior are self-esteem, loneliness and social support. Among college students, no relationship between self-esteem and gambling problems was found.162 In a study of women, no differences were found between gamblers and non-gamblers on the variables of loneliness nor social support.163 What did vary between these two groups of women, however, were their perceptions of the social acceptability of gambling. Women who gambled were more likely to have friends and family members who gambled.164 Although there have been many attempts to identify personality characteristics that are predictive of problem or pathological gambling, few, if any, consistent findings have emerged. This

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suggests that there may not be a particular type of person who is more prone to becoming a problem or pathological gambler.

Attitudes
It is reasonable to expect that people who hold favorable attitudes about gambling would be more likely, themselves, to wager. Using the Gambling Attitudes and Beliefs Survey (GABS),165 researchers examined the relationship between gambling attitudes and behavior among college students.166 Gambling behavior, as measured by scores on the SOGS, was significantly correlated with GABS scores, such that more positive attitudes about gambling were correlated with greater problem gambling behavior.167 Attitudes toward gambling have been assessed in other studies as well, with some interesting results.168 Among pathological gamblers, a substantial proportion (19%) reported unfavorable attitudes toward gambling. However, this leaves the majority reporting either positive or neutral attitudes toward gambling. Further, one might suspect that the negative attitudes were shaped by their gambling-related problems, and therefore may be a result, rather than a cause of their pathological gambling. However, in the previously-cited investigation,169 the participants were college students, presumably in earlier stages of the progression toward disordered gambling, whereas in the latter study, participants were adult community members of varying ages. Thus, it is likely that many of the identified pathological gamblers in the community survey were older, with longer gambling histories than the college students. Therefore, these data may not be as inconsistent as they initially appear. Longitudinal analyses of attitudes and gambling behavior, that examine the relationship between gambling attitudes and

behavior across the varying levels of gambling behavior are indicated. Community attitudes have also been a focus of study, in which community members are surveyed following the opening of gaming establishments.170,171 Six months before and, again, one year after the opening of a casino in a Canadian community, researchers surveyed the attitudes and gambling behaviors of residents of that community.172 Positive attitudes toward the casino had increased since its opening. However, no change in the average amount of money spent on gambling was found, suggesting that positive attitudes did not lead to increased gambling, however the standard deviation in gambling expenditures increased significantly. This indicates that while for the majority of residents there were no changes in gambling expenditures, a smaller segment of the population spent far greater amounts on gambling. Because the data were not analyzed for the correlation between monies spent and approval of the casino, it is not possible to conclude whether there was a relationship between attitudes and gambling behavior in this sample. Further analysis would be instructive.

Physiological Arousal
Physiological arousal is linked to the experience of emotion. Because the various emotions such as joy, fear and anger create similar physiological changes, it is not possible to determine which emotion an individual is experiencing solely from their heart rate, blood pressure or other physiological indices. One can hypothesize emotion from a combination of physiological arousal and environmental conditions, however, such that an increase in heart rate in the presence of a man-eating shark implies fear and an increase following winning the lottery implies joy. In a study of females gambling on electronic machines,

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heart rate was monitored as a measure of physiological arousal.173 Heart rates were found to be higher while the women were actively wagering than heart rates before or after the gambling session, regardless of the outcome of the wager. Further, the heart rates for the winning group were higher than for the losing group.174 Another study confirmed these findings and expanded upon them. In an experiment that manipulated win-loss ratios on a computer-simulated gambling task, researchers monitored heart rates, as an index of physiological arousal of participants while playing.175 They discovered that arousal was greatest during the first few wagers, then tapered off throughout the remainder of the gambling session. Further, heart rates were greatest while participants were winning, suggesting that winning is a more arousing experience than losing. One might draw a parallel between these two findings and the experience of drug users. The early wagers produce the most arousal, just as the first few drug experiences create the greatest highs. Perhaps individuals persist in both activities in an attempt to recapture those initial pleasurable feelings. Creating even greater persistence among gamblers, then may be the sporadic wins that cause a brief increase in arousal.

Cognitive Variables
The decision to gamble, and to continue gambling despite losses, is a cognitive one. Although most people probably prefer to think of themselves as rational, logical decision-makers, it has been pointed out that the decision to gamble is irrational, because gambling is not associated with gains over time.176 Assuming that the primary motivation to gamble is to win money, rather than for excitement or entertainment, this statement is valid. In all commercial games of chance, profit depends upon a lower rate of return than investment.

Gaming venues publish average rates of return, all of which are substantially lower than 100 percent, and the published odds of winning lottery jackpots place the likelihood of winning a large sum in the fractional millions. Researchers have studied this inconsistency in human behavior, with particular emphasis on understanding the type of decision-making processes and cognitive errors involved in choosing to wager.177,178,179,180,181 Several authors have catalogued the various cognitive errors that operate during gambling.182,183 These cognitions are considered errors in thinking because they demonstrate either superstitious or magical thinking or poor understanding of the laws of probability. Many problem gamblers are reported to hold beliefs that they can manipulate outcomes in their favor through lucky items, by achieving certain mental states or by enacting various rituals.184 Other cognitive errors to which gamblers are said to be prone are the gamblers fallacy, chasing, selective memory, hindsight bias and attributional biases.185 The gamblers fallacy is the belief that a series of losses predicts that a big win is imminent. Chasing, one of the symptoms of pathological gambling, can be defined as either a belief that the only way to recover gambling losses is to keep playing, or a behavior in which the person continues to play in order to recover losses. Recalling only ones big wins, while ignoring big losses is selective memory whereas, when one evaluates decisions as good or bad based on whether they led to a win or a loss, one is using hindsight bias. Finally, attributing wins to skill while attributing losses to external events overestimates dispositional factors while underestimating situational factors in winning.186 All of these beliefs are irrational, in the sense that gambling, by definition, involves uncertain outcomes. Gambling outcomes can not be controlled

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nor predicted, despite gamblers beliefs to the contrary. In an experiment that manipulated winloss ratios on a computer-simulated gambling task, researchers counted the number of irrational statements made by participants instructed to think aloud while playing.187 Participants were randomly assigned to either ascending (early disproportionate losses followed by later disproportionate wins), descending (early wins followed by later losses) or truly random win-loss ratio conditions. These researchers considered any verbalizations that demonstrated a lack of understanding of probability theory to be irrational. They found that participants made more irrational than rational comments while playing.188 Further, participants in the descending condition made more irrational statements than those in the other conditions, suggesting that early gambling wins may lead to more cognitive errors. Some additional indirect evidence of cognitive errors influencing gambling behavior can be inferred from the behavior of a group of male college students in a computersimulated gambling task.189 In this experiment, regardless of condition, participants wagered more money following losses than following wins, suggesting the gamblers fallacy, described above, at work. Walters and Contri examined a very specific cognitive phenomenon with respect to gambling, that of cognitive expectancies. Cognitive expectancies are stable beliefs that individuals hold about the likely outcomes of different behaviors. Based on prison inmates responses to a gambling expectancy questionnaire, gambling expectancies were found to be located along two bipolar dimensions: arousing-sedating and positive-negative.190 These dimensions parallel those found in the alcohol and substance abuse literature. When inmates were then divided into levels of gamblers,

based on their SOGS scores, differences in the expectancies of non-gamblers, social gamblers and problem and pathological gamblers were apparent. The non-gamblers and social gamblers expected less positive, negative and arousing experiences from gambling, while the pathological gamblers expected more of all three of these experiences. Only the pathological gamblers expected equivalent negative and positive outcomes, while the other three groups negative expectancies outweighed their positive expectancies.191 Because gambling is not associated with gains over time, expecting equivalent positive and negative outcomes is a cognitive error. Another conclusion is possible as well. Rather than an expectation of a positive outcome motivating people to gamble, perhaps negative expectancies suppress gambling behavior in people who do not display disordered gambling.

Gambling Experience Variables

When interviewed, many pathological gamblers report big wins early in their gambling history.192 This finding has led some researchers to speculate about the role of operant conditioning in establishing and maintaining gambling behavior. Operant conditioning proposes that behavior is strengthened, or becomes more likely to be repeated when followed by a positive outcome. For example, money is a frequent reinforcer used by employers, parents and others interested in encouraging specific behaviors. Money is also the desirable outcome of most gambling pursuits. Therefore, it is reasonable to conceptualize wagering as the behavior and winning the wager as the reinforcement of that behavior. Some of the behavior patterns of gamblers conform to the principles of operant conditioning.193 It is an established principle of reinforcement that behavioral persistence, or continued responding in the

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absence of a reinforcer, is created by reinforcing only some of the instances of the behavior, but not all of them. This is referred to as partial or intermittent reinforcement. Animals and people will work harder and for longer periods of time when reinforced on partial reinforcement schedules. Certainly, gambling payouts occur on such intermittent schedules. That gambling persistence is created in this way is the contention of Delfabbro and Winefield.194 Further, according to their analysis of within-session characteristics, regular players exhibit habitual playing patterns, reminiscent of the automatic nature of animal behavior on a particular reinforcement contingency schedule. For instance, researchers discovered that while small wins increase gambling responses, large wins decrease responding. Although this pattern may strike those unfamiliar with the principles of operant conditioning as inconsistent with the brief description provided earlier in this section, it actually lends even greater support.195 When an individual must make multiple behavioral responses before being reinforced, they typically pause briefly after reinforcement, because the next instance of the behavior is unlikely to be reinforced. Rather, they will have to gamble multiple times before another win. The smaller reinforcers come on a more frequent schedule than the larger wins and therefore dont require a pause before continued gambling. Griffiths criticized the above analysis as too simplistic and suggested that there are other reinforcers present in gambling scenarios. He proposed that near misses also act to create behavioral persistence. Near misses, as he described, occur when the first three numbers, out of four, on a scratchcard match. Another example of a near miss is coming close to winning in black jack or having your horse come in second place, after leading for much of the

race.196 Delfabbro and Winefield agreed with this addition to their model, stating that near misses are like small reinforcers, creating persistence with no pause.197 The value of various reinforcers also influences which behavior is performed. At times, competing or incompatible behaviors may both earn reinforcement, and therefore the relative value of each reinforcer is weighed to make a choice of behavior. Impulse control problems typically involve choices between immediate and delayed reinforcers, with the competing responses being either succumbing to or resisting the behavioral impulse. For example, the delayed reinforcers of not gambling might be saving money for a large purchase or a vacation, while the immediate reinforcers of gambling might be increases in physiological arousal or feelings of pleasure. Staying home at night to get some rest in order to keep ones job may be weighed against the immediate reinforcer of alcohol or drugs. Delayed rewards, even when potentially larger than the immediate rewards, are often devalued, or discounted. Petry and Casarella studied this phenomenon among substance abusers with and without gambling problems. Although substance-abusers, as expected, discounted delayed rewards more than controls with no substance nor gambling problems, substance-abusers with gambling problems discounted delayed rewards significantly more. Participants with gambling problems discounted delayed rewards at a rate of three times that of nonproblem-gambling substance-abusers and ten times the rate of controls.198 Again, this suggests that the reinforcement value of gambling is sufficiently great to exert a great deal of control over an affected individuals behavior. Also supporting an operant conditioning analysis of gambling behavior is the work of Coventry and Norman. 199 Participants

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played a computer-simulated gambling task after being randomly assigned to conditions where win-loss ratios were manipulated to fall in either ascending (disproportionate early losses followed by disproportionate later wins), descending (early wins followed by later losses) or truly random patterns. Although the total number of wins and losses was the same across conditions, when later asked to evaluate their overall performance, participants in the descending condition rated their proportion of wins too high while those in the ascending condition rated their success rate too low. 200 This suggests that the early wins were either noticed more, better remembered or more influential. Again, this bolsters support for the notion that early gambling wins create greater behavioral persistence. Conceptualizing gambling behavior, and even problem gambling, as shaped by factors in the gambling situation is controversial. This view proposes that with exposure to gambling, and the right combination of practice and reinforcement, virtually anyone can learn the behavior and possibly move to the next level of gambling. Given the absence of data supporting personality features as contributory, it is possible that disordered gambling behavior is, at least in part, shaped by events in the environment, not by characteristics within individuals.

Correlates of Problem Gambling among Adolescents

Among both adolescent and college student gamblers, parental gambling is a significant predictor of gambling behavior.201,202 In fact, among adolescents, for whom gambling is illegal, many of the teens surveyed reported that their parents bought lottery tickets and scratchcards for them.203 This type of parental approval and sanctioning helps explain the relationship

between parental gambling and adolescent gambling problems. Several authors have found higher rates of school problems among teens with gambling problems.204,205 Of course, one cannot determine, based on these data, whether their gambling problems cause school difficulties or whether their problems at school, lead these teens to seek other pursuits. Nevertheless, there are positive correlations between problem gambling among teens and poor academic achievement or school failure, truancy, and school suspension.206,207 Although some authors who have written about adolescent pathological gambling have reported no relationship between gambling and delinquency,208 others have noted higher rates of other problem behaviors among teens who gamble.209,210 It may be that while teens who are problem and pathological gamblers are not arrested at higher frequencies than other teens, therefore not qualifying for the label delinquent, they are engaging in illegal behaviors at higher rates, but are not being detected by law enforcement. For example, Griffiths and Sutherland found that teens who gambled used cigarettes, alcohol and drugs at higher frequencies than nongambling teens, all of which are illegal activities for teens.211 In a review of the adolescent gambling literature, Kaminer and Petry also note higher rates of drug use among teens who gamble.212 Further, these authors report aggressive behavior, stealing, prostitution and drug sales as more common among adolescent gamblers than nongamblers. These statistics are alarming and, when coupled with data that suggest that early gambling behavior predicts later gambling problems in teens,213 it appears that more active attempts to intervene with teen gamblers are critical.

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Psychological Costs of Gambling

Although typically thought of in financial terms, costs can be financial, societal, or personal. The divisions among these various types of costs are, at times, somewhat blurred. Although a discussion of financial costs will be reserved for economists, personal and social costs are appropriate for psychological study. Further, as was true in the discussion of risk factors for problem gambling, much of the data reported as costs are correlational in nature, limiting firm conclusions that gambling causes these conditions. Nevertheless, a discussion of some additional correlates of gambling follows. As described in earlier sections of this paper, there are multiple personal costs associated with pathological gambling. Among these are poorer physical and mental health,214,215,216,217218,219 higher rates of cigarette, alcohol and drug use,220,221 and higher rates of suicide.222,223,224 As these correlates have already been described in detail, no further discussion is necessary. Social costs can be thought of as correlates of problem gambling that have an impact on individuals other than the pathological gambler, whether these be family members, employers or the community. Higher rates of divorce are found among pathological gamblers.225 Although some pathological gamblers attribute the dissolution of their marriages to their gambling problems, six times as many of their spouses report gambling was a significant factor in their divorces. The greater number of spouses reporting gambling as a contributory factor reflects a data collection strategy that cut through the denial of the pathological gamblers, or at least allowed for multiple family perspectives of the impact of gambling on marital stability.226 Pathological gambling creates conditions found in many abusive and

neglectful homes, such as parental stress and draining of financial resources from the family budget.227 Based on case study reports from ten communities following the opening of gaming venues, six of the communities reported increases in domestic violence and child neglect, but no increases in child physical nor sexual abuse.228 Also affecting family stability is the finding that pathological gamblers are more likely to have lost a job in the twelve months prior to a national survey.229 Increased rates of bankruptcy and personal debt are also found among pathological gamblers.230 Crime statistics have also been occasionally linked to pathological gambling, however the relationships are somewhat complex. Pathological gamblers are more likely than others to have been arrested or incarcerated in their lifetime.231 Among ten case studies of communities with gaming venues, all ten reported increases in drug- and alcohol-related crime.232 When the number of gambling opportunities by community were correlated with different types of crimes, only grand theft auto and robbery showed significant relationships.233 However, these relationships disappeared when other social variables were entered into the analysis. In a study of community perceptions of gambling, Nevada residents perceived both positive and negative aspects to the casinos in their state.234 Almost all of those surveyed believed that legalized gambling created more jobs, and many also thought it made their state a better place to live. The majority of respondents also stated they believed that people gambled more than they can afford. Other perceptions varied based on certain demographic characteristics, namely education and urban versus rural living.235 Urban residents and respondents with less education perceived greater social costs of legal gambling venues. These participants were more likely to state that

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they believed, as a result of the casinos, that people worked less, that children were negatively influenced and that a greater criminal element was brought into their community. This analysis is interesting, as it suggests that gambling may have different effects on different segments of a community. Further, the costs may not be shared equally by different segments of the population.236

Barriers to Psychological Treatment of Gambling Disorders

It has been reported that fewer than ten percent of pathological gamblers seek treatment for their gambling problems.237 By the time these gamblers seek treatment, their gambling problem has gone on for years, they likely have other comorbid psychological disorders, their social support systems are exhausted and they may be in financial ruin.238 Further, characteristics of the disorder itself make it resistant to treatment. For example, lying and denial of gambling problems are symptoms of the disorder. However, in many treatment models, admitting ones behavior and being honest with oneself and ones therapist is an early goal, if not a requirement, for successful treatment. Not only do characteristics of the disorder and those affected create barriers to treatment, but there are deficits in the mental health field as well. In a review of the gambling treatment literature in 1999, Petry and Armentano reported that, at that time, there were fewer than 150 clinicians certified to treat disordered gambling. Nationwide, according to their analysis, there were fewer than 100 gambling treatment programs and of those, only 21 were state supported.239 Waiting lists at some of these facilities are as long as six months, because there are so few programs. The lack of treatment programs, particularly government-funded programs, has been

attributed to a lack of awareness by policymakers of the extent of pathological gambling costs.240 Clinicians are struggling to provide effective treatment to this population but they, too, face many challenges. Very little has been written to guide clinicians, and few treatment outcome studies exist.241 Much of what has been recommended to clinicians is not based on original research with pathological gamblers, but instead are adaptations of existing alcohol- and substance-dependence treatments.242,243 Based on the limited literature available, most advocate a multi-modal treatment approach. The modalities most often recommended are a combination of cognitive-behavioral treatment approaches and peer support groups like Gamblers Anonymous (GA).244,245,246 Based on a review of the published treatment outcome studies, Viets reported that up to two-thirds of gamblers treated with cognitivebehavioral approaches show decreases or abstention in their gambling. She also acknowledged that although GA is a frequent treatment recommendation, it remains largely untested empirically.247 It is clear that much more research in the area of treatment of disordered gambling must be conducted, including studies that collect long-term follow-up data from treatment participants.

Summary and Conclusions

The statistics reported in this paper suggest that the most vulnerable members of our society are at the highest risk for developing gambling-related problems, including pathological gambling. Risk factors point to the young, the poor and the mentally ill as most likely to experience disordered gambling. Because pathological gamblers represent only one to three percent of the population, yet account for 15 percent of the monies spent on gambling,248 these

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most vulnerable members bear the greatest burden, both financially and psychologically, of gambling. Gambling tax revenue provided by this segment must be carefully examined and policymakers must weigh the social costs, perhaps shifting some of the revenues to treatment programs for problem and pathological gamblers. It may not be that only vulnerable individuals are at risk for developing gambling-related problems, as the research on cognitive errors and operant conditioning indicates. This research paints a more chilling picture, such that there may be factors within the gambling situation that contribute to gambling-related problems. Based on findings that early wins create behavioral persistence among non-problemgamblers in experimental studies, and research proposing that near misses can act as smaller reinforcers, anyone who gambles and has these specific early experiences in their gambling history may be prone to problems. Advertisers take advantage of these principles, with popular slogans for the lottery as You cant win if you dont play! Although the slogan may not be false, it frames ones thinking about gambling in a very distorted way, because equally accurate would be the statement, you cant lose if you dont play. Of course, the majority of people gamble with no ill effects. Those that do suffer from pathological gambling represent a minority of gamblers. However, the cost to those few affected individuals is great, as is the cost to their families, friends, employers and communities. Despite these costs, treatment availability lags behind. Attention must be brought to the problem of pathological gambling and all of its victims.

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Endnotes
1. Renee M Cunningham-Williams, Linda B. Cottler, Wilson M. Compton III and Edward L. Spitznagel, Taking Chances: Problem Gamblers and Mental Health DisordersResults From the St. Louis Epidemiologic Catchment Area Study American Journal of Public Health 88 (1998): 1093. 2. Jeff Powell, Karen Hardoon, Jeffrey L. Derevensky and Rina Gupta, Gambling and Risk-Taking Behavior Among University Students, Substance Use and Misuse 34 (1999): 1168. 3. Ken C. Winters, Phillis Bengston, Derek Dorr, and Randy Stinchfield, Prevalence and Risk Factors of Problem Gambling Among College Students, Psychology of Addictive Behaviors 12 (1998): 127. 4. Gambling Impact and Behavior Study: Final Report to the National Gambling Impact Study Commission, (Chicago: National Opinion Research Center, 1999), 25. 5. Diagnostic and Statistical Manual of Mental Disorders, 4th ed. (Washington, DC: American Psychiatric Association, 1994), 618. 6. Ibid., 181. 7. Ibid., 618. 8. Robert B. Breen and Marvin Zuckerman, Chasing in Gambling Behavior: Personality and Cognitive Determinants, Personality and Individual Differences 27 (1999): 1098. 9. National Opinion Research Center, 14.

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10. American Psychiatric Association (1994), 617. 11. L. M. Koran, Obsessive-Compulsive and Related Disorders in Adults: A Comprehensive Clinical Guide (Cambridge, UK: Cambridge University Press, 1999), 230. 12. American Psychiatric Association (1994), 609. 13. Donald W. Black and Trent Moyer, Clinical Features and Psychiatric Comorbidity of Subjects with Psychological Gambling Behavior, Psychiatric Services 49 (1998): 1437. 14. Alex Blaszczynski, Pathological Gambling and Obsessive-Compulsive Spectrum Disorders, Psychological Reports 84 (1999): 108. 15. Frank Vitaro, Louise Arsenaeult and Richard E. Tremblay, Impulsivity Predicts Problem Gambling in Low SES Adolescent Males, Addiction 94 (1999): 571. 16. National Opinion Research Center, 25.

and Maintenance of Lottery and Scratchcard Gambling in Adolescence, Journal of Adolescence 21 (1998): 270. 22. National Opinion Research Center, 25. 23. Ibid., 25. 24. Powell, et al, 1168. 25. Glenn D. Walters and Douglas Contri, Outcome Expectancies for Gambling: Empirical Modeling of a Memory Network in Federal Prison Inmates, Journal of Gambling Studies 14 (1998): 175. 26. Henry R. Lesieur and Sheila B. Blume The South Oaks Gambling Screen (SOGS): A new instrument for the identification of pathological gamblers, American Journal of Psychiatry, 144 (1987): 1184-1188. 27. Diagnostic and Statistical Manual of Mental Disorders, 3rd ed. (Washington, DC: American Psychiatric Association, 1980) 291. 28. Lesieur and Blume, 1184-1188. 29. National Opinion Research Center, 17.

17. Koran, 229-230. 30. Ibid., 19. 18. Vifrah Kaminer and Nancy M. Petry, Gambling Behavior in Youths: Why We Should Be Concerned, Alcohol and Drug Abuse 50 (1999): 167-168. 19. Vitaro, et al, 567. 20. Jeffrey I. Kassinove, Development of the Gambling Attitude Scales: Preliminary Findings, Journal of Clinical Psychology 54 (1998): 767. 21. Richard T. A. Wood and Mark D. Griffiths, The Acquisition, Development 31. Koran, 231. 32. National Opinion Research Center, 2. 33. Koran, 232. 34. Nancy M. Petry and Christopher Armentano, Prevalence, Assessment, and Treatment of Pathological Gambling: A Review, Psychiatric Services 50 (1999): 1021.

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35. Frank Campbell and David Lester, The Impact of Gambling on Suicidal Behavior in Louisiana, Omega 38 (1999): 127. 36. Richard Govoni, G. Ron Frisch, Nicholas Rupcich and Heather Getty, First Year Impacts of Casino Gambling in a Community, Journal of Gambling Studies 14 (1998): 357. 37. National Opinion Research Center, 5.

Social Isolation and Womens Electronic Gaming Machine Gambling, Journal of Gambling Studies 14 (1998): 264. 51. American Psychiatric Association (1994), 617. 52. National Opinion Research Center, 25. 53. Cunningham-Williams, et al, 1095. 54. Winters, et al, 130.

38. Ibid., 5. 55. Cunningham-Williams, et al, 1094. 39. Winters, et al, 130. 56. National Opinion Research Center, 25. 40. Powell, et al, 1168. 57. Ibid., 25. 41. National Opinion Research Center, 7. 58. Cunningham-Williams, et al, 1095. 42. Ibid., 7. 43. Ibid., 5. 44. Winters, et al, 130. 45. Kassinove, 765. 46. Ibid., 766. 47. Govoni, et al, 350. 61. Griffiths and Sutherland, 424. 48. Mark Griffiths and Ian Sutherland, Short Communication: Adolescent Gambling and Drug Use Journal of Community and Applied Social Psychology 8 (1998): 426. 49. Richard T. A. Wood and Mark D. Griffiths, The Acquisition, Development and Maintenance of Lottery and Scratchcard Gambling in Adolescence, Journal of Adolescence 21 (1998): 268. 50. Karen Trevorrow and Susan Moore, The Association Between Loneliness, 62. Kaminer and Petry, 167. 63. National Opinion Research Center, 58. 64. Ibid., 58. 65. Griffiths and Sutherland, 424. 66. Ibid., 426. 67. Wood and Griffiths, 268. 68. Kaminer and Petry, 167. 60. National Household Survey of Drug Abuse, Statistical Abstract of the United States 1992, 12th ed. (National Institute of Drug Abuse, U.S. Department of Commerce, Bureau of the Census), 1992. 59. Pathological Gambling: A Critical Review, (Washington, DC: National Academy Press, 1999), 283.

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69. National Opinion Research Center, 59. 70. Kaminer and Petry, 167.

84. American Psychiatric Association (1994), 181. 85. Black and Moyer, 1435.

71. National Opinion Research Center, 59. 86. Cunningham-Williams, et al, 1095. 72. Steven D. Thurber and Robert A. Dahmes, Impulse Control Disorders Not Elsewhere Classified, In Child and Adolescent Psychological Disorders: A Comprehensive Textbook , edited by S. D. Netherton, D. Holmes and C. E. Walker (New York: Oxford University Press, 1999): 446. 73. Wood and Griffiths, 269. 89. Thurber and Dahmes, 446. 74. Kaminer and Petry, 167. 75. Vitaro, et al, 573. 76. National Opinion Research Center, 60. 77. Wood and Griffiths, 268. 78. American Psychiatric Association (1994), 617. 79. Black and Moyer, 1437. 80. Carole M. Beaudoin and Brian J. Cox, Characteristics of Problem Gambling in a Canadian Context: A Preliminary Study Using a DSM-IV-based questionnaire, Canadian Journal of Psychiatry 44 (1999): 486. 81. Alex Blaszczynski and Zachary Steel, Personality Disorders Among Pathological Gamblers, Journal of Gambling Studies 14 (1998): 61. 82. Cunningham-Williams, et al, 1094. 83. Ibid., 1095. 90. Seath A. Eisen, Nong Lin, Michael J. Lyons, Jeffrey F. Scherrer, Kristin Griffith, William R. True, Jack Goldberg and Ming T. Tsuang, Familiam Influences on Gambling Behavior: An Analysis of 3359 Twin Pairs, Addictions 93 (1998): 1382. 91. Glenn D. Walters, The Addiction Concept: Working Hypothesis or SelfFulfilling Prophecy? (Needham Heights, NJ: Allyn and Bacon (1999): 205-213. 92. 93. Ibid., 211. Ibid., 1. 87. Michael Lejoyeux, Nathalie Feuche, Sabrine Loi, Jacquelyn Solomon and Jean Ades, Study of Impulse-Control Disorders Among Alcohol-Dependent Patients, Journal of Clinical Psychiatry 60 (1999): 302. 88. Ibid., 304.

94. American Psychiatric Association (1994), 612, 618. 95. 96. Ibid., 621. Black and Moyer, 1438.

97. Joshua L. Greenberg, Stephen E. Lewis and David K. Dodd, Overlapping Addictions and Self-Esteem Among College

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Men and Women, Addictive Behavior 24 (1999): 569. 98. Ibid., 566.

112. National Opinion Research Center, 74. 113. Campbell, et al, 238. 114. Beaudoin and Cox, 485.

99. American Psychiatric Association (1994), 83. 100. Thurber and Dahmes, 446. 101. Blaszczynski, 110.

115. Petry and Armentano, 1021. 116. American Psychiatric Association (1994), 418. 117. Black and Moyer, 1438.

102. Black and Moyer, 1434. 118. Blaszczynski, 112. 103. Cunningham-Williams, et al, 1094. 119. Koran, 228. 104. National Opinion Research Center, 29. 120. Raghunathan and Tuan Pham, 56-75. 105. Rajagopal Raghunathan and Michel Tuan Pham, All Negative Moods Are Not Equal: Motivational Influences of Anxiety and Sadness on Decision Making, Organizational Behavior and Human Decision Processes 79 (1999): 59. 106. Andrew Kyngdon and Mark Dickerson, An Experimental Study of the Effect of Prior Alcohol Consumption on a Simulated Gambling Activity Addiction 94 (1999): 704. 107. American Psychiatric Association (1994), 618. 108. Beaudoin and Cox, 486. 127. National Opinion Research Center, 26. 109. Frank Campbell, Chris Simmons and David Lester, The Impact of Gambling Opportunities on Compulsive Gambling, The Journal of Social Psychology 139 (1999): 235-238 110. National Opinion Research Center, 74. 129. Trevorrow and Moore, 273. 111. Petry and Armentano, 1021. 130. Winters, et al, 131. 128. S. Reid, S. J. Woodford, R. Roberts, J. F. Golding and A. D. Towell, HealthRelated Correlates of Gambling on the British National Lottery, Psychological Reports 84 (1999): 247-254. 121. Ibid., 56. 122. Kenny R. Coventry and Beverley Constable, Physiological Arousal and Sensation-Seeking in Female Fruit Machine Gamblers, Addiction 94 (1999): 427. 123. Cunningham-Williams, et al, 1094. 124. American Psychiatric Association (1994), 629. 125. Black and Moyer, 1436. 126. Blaszczynski and Steel, 60-61.

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142. Walters and Contri, 186. 131. Greenberg, et al, 565. 143. National Opinion Research Center, 7. 132. Jeff Powell, Karen Hardoon, Jeffrey L. Derevensky and Rina Gupta, Gambling and Risk-Taking Behavior Among University Students, Substance Use and Misuse 34 (1999): 1169. 133. Kenny R. Coventry and Anna C. Norman, Arousa, erroneous Verbalizations and the Illusion of Control During a Computer-Generated Gambling Task British Journal of Psychology 89 (1998): 636. 134. Koran, 230. 150. Trevorrow and Moore, 280. 135. Kyngdon and Dickerson, 706. 151. National Opinion Research Center, 26. 136. Tony Toneatto, Cognitive Psychopathology of Problem Gambling, Substance Use and Misuse 34 (1999): 15931604. 137. Walters and Contri, 187-188. 138. Breen and Zuckerman, 1102. 139. Paul H. Delfabbro and Anthonyh H. Winefield, Poker-machine Gambling: An Analysis of Within Session Characteristics British Journal of Psychology 90 (1999a): 435. 140. Mark D. Griffiths, The Psychology of the Near-Miss (Revisited): A Comment on Delfabbro and Winefield (1999) British Journal of Psychology 90 (1999): 442. 141. Nancy Petry and Thomas Casarella, Excessive Discounting of Delayed Rewards in Substance Abusers with Gambling Problems, Drug and Alcohol Dependence 56 (1999): 31. 152. National Academy Press, 99. 153. Vitaro, et al, 573. 154. Winters, et al, 131. 155. Reid, et al, 247-254. 156. Cunningham-Williams, et al, 1094. 157. Reid, et al, 247-254. 158. National Opinion Research Center, 27. 159. Breen and Zuckerman, 1099. 160. Powell, et al, 1173. 161. Coventry and Constable, 427. 162. Greenberg, et al, 568. 163. Trevorrow and Moore, 276. 144. American Psychiatric Association (1994), 617. 145. Black and Moyer 1435. 146. Cunningham-Williams, et al, 1093. 147. Winters, et al, 131. 148. National Opinion Research Center, 27. 149. Reid, et al, 247-254.

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164. Ibid., 280. 165. Kassinove, 763-771. 166. Breen and Zuckerman, 1105. 167. Ibid., 1106. 168. National Opinion Research Center, 28. 169. Breen and Zuckerman, 1101. 170. Govoni, et al, 350. 171. Wesley S. Roehl, Quality of Life Issues in a Casino Destination, Journal of Business Research 44 (1999): 223. 172. Govoni, et al, 352. 173. Coventry and Constable, 429. 174. Ibid., 429. 175. Coventry and Norman, 635. 176. Ibid., 629. 177. Ibid., 636. 178. Koran, 234. 179. Kyngdon and Dickerson, 706. 180. Toneatto, 1597. 181. Walters and Contri, 186-189. 182. Koran, 231. 183. Toneatto, 1596. 184. Ibid., 1596. 185. Ibid., 1597.

186. Ibid., 1597. 187. Coventry and Norman, 632. 188. Ibid., 642. 189. Kyngdon and Dickerson, 706. 190. Walters and Contri, 175. 191. Ibid., 187. 192. Ibid., 174. 193. Delfabbro and Winefield, 437. 194. Ibid., 435. 195. Ibid., 435. 196. Griffiths, 442. 197. Defabbro and Winefield, 425. 198. Petry and Casarella, 31. 199. Coventry Norman, 629-645. 200. Ibid., 636. 201. Winters, et al, 132. 202. Wood and Griffiths, 268. 203. Ibid., 270. 204. Griffiths and Sutherland, 425. 205. Kaminer and Petry, 167. 206. Griffiths and Sutherland, 425. 207. Kaminer and Petry, 167. 208. Thurber and Dahmes, 446.

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209. Griffiths and Sutherland, 425. 210. Kaminer and Petry, 167. 211. Griffiths and Sutherland, 424. 212. Kaminer and Petry, 168. 213. Vitaro, et al, 571. 214. Black and Moyer, 1436. 215. Beaudoin and Cox, 486. 216. Blaszczynski, 112. 217. Blaszczynski and Steel, 65. 218. Cunningham-Williams, et al, 10941095. 219. National Opinion Research Center, 29.

229. Ibid., 30. 230. Ibid., 29. 231. Ibid., 29. 232. Ibid., 75. 233. David Lester, Legal Gambling and Crime, Psychological Reports 83 (1998): 382. 234. Roehl, 227. 235. Ibid., 227. 236. Ibid., 228. 237. Koran, 232. 238. Ibid., 229. 239. Petry and Armentano, 1022.

220. Reid, et al, 247-254. 240. National Academy Press, 220. 221. Winters, et al, 133. 241. Ibid., 192. 222. Beaudoin and Cox, 485-486. 242. Koran, 234. 223. Campbell and Lester, 237-238. 224. National Opinion Research Center, 74. 225. Ibid., 37. 226. Ibid., 47. 244. Koran, 234. 227. Violet E. Horvath, Gambling and Child Maltreatment: An Emerging Problem, Poster presented as part of the meeting of the American Professional Society on the Abuse of Children, Chicago, 14 July 2000. 228. National Opinion Research Center, 74. 245. National Academy Press, 224. 246. Viets, 266. 247. Ibid., 266. 248. American Psychiatric Association (1994), 33. 243. Vanessa C. Lopez Viets, Treating Pathological Gambling, In Treating Addictive Behaviors, 2nd ed., edited by W. R. Miller and N. Heather (New York: Plenum Press, 1998) 267.

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