Gambling Disorder: Comorbidity, Stigma, Family Impact, and Treatment

Abstract

Gambling disorder has become an increased concern with the growing legalized opportunities. This review describes what addiction is and the debate of it being a brain disease or a choice. The similarities and differences between substance use and behavioral disorders will be reviewed and explained as well as the new Diagnostic and Statistical Manual of Mental Health Disorders (DSM) changes. Comorbidity of mental health and substance use disorders are described along with treatment options that are available. Childhood experiences and personality have been explored with several predictors leading to problem gambling later in life such as attention deficit/hyperactivity disorder (ADHD), impulsivity, and family history. Stigma and family play a large role in the problem gamblers treatment and recovery and also has an effect on increased comorbid disorders. Although there has been increased research and knowledge about problem gambling, there still needs to be more awareness made on the detrimental effects it can have on the individual and their family.

What is Addiction?

Understanding gambling disorder begins with an understanding of addictions. The term addiction is used widely to characterize a tendency to indulge in certain types of behavior which continues despite negative consequences even if they are harmful to the individual (Szalavitz, 2016; Eysenck, 1997). Addiction is often referred to substance abuse but it can also be related to behaviors such as sex, food, gambling, sports, travel, or even work (Eysenck, 1997) when it has adverse consequences (Grant, Potenza, Weinstein, & Gorelick, 2010). The meaning, content, and definition of addiction also changes according to culture, politics, history, and science foundations (Rise, Halkjelsvik, & Kovac, 2015). The American Society of Addiction Medicine (ASAM) (2011) states that addiction is a primary and prolonged disease of brain reward, memory, motivation and related circuitry. Dysfunction in these areas can lead to negative psychological, biological, spiritual, and social expressions. These are often reflected in the individuals pathological pursuing of reward and/or relief through the engagement of substance use or other negative behaviors.

Addiction is characterized by five dimensions: an inability to consistently abstain from use, impairment in behavioral control, craving for the drug or experience, a diminished recognition of significant problems with one’s relationships and/or behaviors, and having a dysfunctional emotional response (ASAM, 2011). Although there may be unwanted consequences, the behavior also often has certain benefits on the individual which continues the behavior in question (Eysenck, 1997). Because the individual receives certain benefits from substance use or other behaviors, they continue with the behavior which reinforces the addiction and makes it more difficult to wean away from it.

For a person with addiction, the brain resets its priorities around the addictive behavior which then replaces healthy or self-care related behaviors (ASAM, 2011; Szalavitz, 2016). Addiction is associated with impaired executive functioning in areas such as learning, impulse control, perception, and judgement. Addiction should be seen as more than a behavioral disorder; it includes other aspects such as emotions, cognitions, and interactions (ASAM, 2011). Behaviors associated with addiction are often easier to recognize over the other aspects. Some addiction behavioral signs can include excessive use and/or behaviors related to addiction, excessive time lost in use or recovering from effects of use and/or behaviors, continued use and/or behaviors, focus on rewarding aspects of use and/or behaviors, and lack of ability or readiness to take action. Cognitive changes may include preoccupation with use and/or behavior, altered evaluations of benefits or rewards, and the belief that negative events that happen are not caused by use and/or behaviors but by outside causes. The emotional changes are more complex because some individuals may use or engage in addictive behaviors because they are seeking euphoria or positive reinforcements where others may be seeking relief from dysphoria (ASAM, 2011). Engaging in substance use and/or behaviors like gambling allow the individual an emotional escape into a pattern of recurrent reinforcement that may affect the frontal cortex and nucleus accumbens which are involved in motivating behavior (Szalavitz, 2016). An individual with addiction will often put their desire for their drug or behavior above nearly everything else and may violate norms or behave unethically to ensure they have access to what they desire. The greater the reward is for the individual, the more they are willing to put in effort to gain the reward which in turn leads to increased negative consequences they are willing to endure to obtain that reward (Volkow, Koob, & McCellan, 2016).

Addiction: Brain disease or Brain Development?

Disease is defined as a disorder of structure or function that produces specific symptoms or affects a specific location that is not a direct result of a physical injury (English Oxford Living Dictionaries website, 2017). Recent research explains that addiction may benefit better from being considered and treated as an acquired disease of the brain because of the signs and symptoms that are displayed (Leyton, 2013). Addiction falls into the disease model in the sense that it often persists (Heyman, 2013) and neural changes in the brain are distinct and extreme enough to have it viewed as pathological (Berridge, 2016). It can cause problems enough to be categorized as a disease because the issues have an intense compulsivity and carry lethal consequences. Berridge (2016) explains that addiction is a brain disease of temptation and choice. The addiction does not replace choice but rather it distorts it by amplifying temptation to a more intense level.

Although drugs are often the focus, the essence of addiction is not actually the drug but rather the individual’s hyper-active brain response. Children and adolescents that have evidence of structural or functional changes in their frontal cortical regions or that display traits of impulsivity or novelty seeking may be at a higher risk for addiction (Volkow et al., 2016). Neurobiological research has shown that addiction is gradual and has an onset predominately during adolescence when the brain is sensitive. Cortical networks and prefrontal sections of the brain that are critical for self-regulation and judgement do not fully develop until and individual reaches 21 to 25 years of age which makes an adolescent brain less able to cognitively control strong emotions and desires (Volkow et al., 2016). Known addictive drugs and behaviors activate the reward regions in the brain which then cause increases in dopamine (Volkow et al., 2016). With repeated experiences of reward, the dopamine cells stop firing in response to the reward itself and start to fire at its anticipation.

One of the main grounds of the disease model is that addictions change the brain; however, brains are designed to change. Neuroscientists who endorse the disease model view the realities of brain changes due to addiction as pathological or extremes; they show changes in the brain because of addiction which is nothing like normal learning or development (Lewis, 2016; Szalavitz, 2016). An addiction-related change in the brains system mediates the anticipation and experiences of reward, systems accountable for memory and perception, and executive systems for cognitive control (Lewis, 2016; Leyton, 2013). This model provides a knowledge base and research programs for developing pharmaceuticals that may help in reducing withdrawal symptoms (Lewis, 2016) along with the development of more effective treatment and prevention methods as well as to more informed public health policies (Volkow et al., 2016; Szalavitz, 2016).

Addiction has been seen as a brain disease for decades but there are some who disagree with the concept because there is evidence that many factors may contribute to the manifestation of addiction: biological, psychological, sociocultural, and spiritual (ASAM, 2011). Being susceptible to addiction may differ based on the individual’s vulnerability to various factors including genetics, environment, development (Volkow et al., 2016) or the possibility of an addictive personality (Eysenck, 1997). The addictions field has struggled with differing views of theoretical origin of addiction; it is a primary progressive disease, results of self-medicating an affective disorder, a symptom of character pathology, or moral weakness (Shaffer & Robbins, 1991) which makes it difficult to agree on whether addiction is a disease or learned behavior.

There are several reasons to question the validity of the disease model. First, many former addicts feel they were never sick or that they are now cured (Lewis, 2016). Second, most endorsements of the model come from the rehabilitation industry and Big Pharma which both benefit with the most profits due to beliefs that addicts need long-term treatment. Lastly, there is more funding for those who take a disease approach model in research than those who take a different approach (Lewis, 2016). Because of the questions of its validity, the disease model has been challenged and others have been proposed. Addiction may be viewed as a choice instead of pathology because although it may not be a good choice, it may be considered rational in the short-term by temporarily providing pleasure or relief (Lewis, 2016). Although there have been many individuals with addiction who have found the disease model to provide some relief from self-blame and self-hate, the reverse side of feeling no responsibility for their actions is that they can be treated like an animal or a child by others (Szalavitz, 2016). Individuals described as ill or as having an illness are often disempowered and kept there through hiring practices, policing policies, and support programs that are to help those who cannot help themselves (Graham, Young, Valach, & Wood, 2008). The idea of addiction as an illness often has layers of implications and assumptions which labels individuals as sick and without the capacity to control their actions.

The strongest argument that addiction is not a brain disease is that individuals with addiction can clearly plan ways to obtain their drug of choice; whether it is substance or behaviors, and make the attempts they feel they need to hide their addiction from others (Szalavitz, 2016). Although there is evidence supporting both sides of the argument, there are questions that still need more research. The disease model needs to show that the addiction changes the brain in ways that are different from normal changes that occur throughout an individual’s life (Lewis, 2016). Alternatives to the disease model on the other hand do not take into account brain development but rather focus mostly on environment, experiences, and biology (Lewis, 2016; Graham et al., 2008).

What is Gambling Disorder?

The term addiction has been traditionally used when referring to substance use but there has been extensive research to show behavioral addictions have many parallels with substance addiction (Chamberlain et al., 2016). By studying behavioral addictions such as gambling disorder it can provide a model to investigate underlying neural mechanisms that may be related to addiction without the influences of substance abuse. The main feature of behavioral addictions is the inability to resist impulses, drives, or temptations in order to perform acts that are harmful to the individual or others (Grant et al., 2010). These are often characterized by a recurrent pattern of behaviors which interfere with functioning in other aspects of the individual’s life. An individual with a behavioral addiction often has feelings of arousal or tension before engaging in the behavior followed by relief, pleasure, or gratification while engaging in the behavior (Grant et al., 2010). Behavioral addictions such as pathological gambling result from repetition of the activity that provides pleasure through stimulating the pleasure centers of the brain; the nucleus accumbens and the ventral tegmental area (Weiland, 2015). When an individual experiences a negative emotion that triggers their behavioral addiction, they immediately look for ways to numb the negative feelings they are experiencing and to provide temporary relief. These behaviors often decrease some of the individual’s anxiety but may also increase shame and remorse (Weiland, 2015).

Pathological gambling is characterized by the inability to resist recurring urges to gamble excessively despite harmful consequences (Ramos-Grille, Goma-i-Freixanet, Aragay, Valero, & Valles, 2015) and is the most studied addiction of the behavioral addictions (Yau & Potenza, 2015). Although many can participate in gambling activities as a pleasant social activity, there is a group of individuals who become seriously involved in terms of money wagered and time spent even despite negative consequences (Hodgins, Stea, & Grant, 2011). Gambling problems often begin in childhood with non-white males having higher rates and starting at an earlier age (Grant et al., 2010). As many as 85% of adolescents have reported engaging in gambling activities with up to 15% being at risk for a gambling disorder (Dussault et al., 2016). Males are 4.1 times more likely to screen for problem gambling than females (Sherba & Martt, 2015). Females tend to have a telescoping phenomenon which means they start with the addictive behavior later but have a shorter period of time between engagement and addiction (Gavriel-Fried, Peled, & Ajzenstadt, 2015). Females tend to experience more stigma with a gambling disorder diagnosis due to not meeting social gender expectations. Not meeting these societal expectations increases suicide attempts, anxiety, depression, and lower self-esteem (Gavriel-Fried et al., 2015). Female gamblers are often referred to as escape gamblers because they tend to gamble to escape boredom, hardship, loneliness, and household duties.

There have been several changes from when gambling problems was first recognized in the Diagnostic and Statistical Manual of Mental Health Disorders Version III (DSM-III) (Grant & Chamberlain, 2015) until the most recent version DSM-5 (Wardell, Quilty, & Hendershot, 2015; Denis et al., 2016). A diagnostic criterion for gambling disorder was first introduced in 1980 under a diagnosis of pathological gambling (Stinchfield et al., 2016) as a Disorder of Impulse Control (Grant & Chamberlain, 2015) in the DSM-III. It was later revised in 1987 for the DSM-III-R and again slightly in the DSM-IV in 1994 (Stinchfield et al., 2016). Pathological gambling was recommended for inclusion into the addictive disorder section of the DSM-5 based on its biological and similarities with other addictive disorders such as substance use (Xian, Giddens, Scherrer, Eisen, & Potenza, 2013). In 2013, the DSM-5 was released and it had several changes to a diagnosis of pathological gambling. These revisions were: (a) renaming pathological gambling with gambling disorder; (b) reclassifying from an impulse control disorder to substance-related and addictive disorder; (c) elimination of committing illegal acts as criterion; (d) reduction of the threshold for diagnosis to four criteria from five; and (e) specification that symptoms occur within a 12 month time frame (Stinchfield et al., 2016). The most important change that has occurred in the most recent version of the DSM is the reclassifying from impulse control disorder to the substance-related and addictive disorder category. This new title and category lend increased credence to the concept of behavioral disorders which shows that individuals may be convulsively and dysfunctionally engaged in behaviors that may not include substance use (Yau & Potenza, 2015). Although this has been a step in the right direction for identifying and helping those with problem gambling, more research needs to be done in specific areas such as internet gaming disorder to be included in future revisions (Denis et al., 2016).

Similarities/Differences between Gambling Disorder and Substance Use Disorder

There are many similarities as well as differences between gambling disorder (behavioral addiction) and substance use disorder (substance addiction). Both disorders tend to have an onset in adolescence, and have a history that exhibits chronic, relapsing patterns; additionally, many individuals are able to recover without formal treatment (Grant et al., 2010). Many individuals often report having urges or cravings prior to engaging in the behavior and tend to experience decreased anxiety, positive mood state, or a high feeling that is similar to substance intoxication. Individuals with problem gambling behaviors often experience a decrease in positive mood when behaviors are repeated over time; the need to intensify the behavior increases to receive the same mood effect which is comparable to substance tolerance (Grant et al., 2010). Studies have shown similar characteristics between gambling disorder and substance use disorder such as decreased performance on inhibition, cognitive flexibility, time estimation, spatial working memory, decision-making, and planning tasks (Grant & Chamberlain, 2015). Withdrawal in gambling disorder often represents as anxiousness and irritability when the gambler tries to quit or cut back (Wareham & Potenza, 2010), although there does not seem to be reports of serious medical or physiological withdrawal states from behavioral addictions (Grant et al., 2010) as they do in substance disorders.

Another similarity is financial and family problems the behavioral addiction may place on the individual. As with substance addiction, many individuals have impaired control and functioning, will embezzle, write bad checks, steal, and/or commit criminal acts to have the funds for their addiction or be able to cope with the negative consequences (Grant et al., 2010; Chamberlain et al., 2016). These behaviors often cause significant family stress and will disrupt the family dynamic. Family members of the problem gambler may experience feelings or betrayal, anger, and distrust (Ingle, Marotta, McMillan, & Wisdom, 2008) toward the gambler which are also present in families of individuals with substance use (Jazaeri & Habil, 2012). Data collected from a national online support service for gambling (Dowling, Rodda, Lubman, & Jackson, 2014) found family members are most likely to report negative impacts on their relationship with the problem gambler (96%), emotional distress (98%), financial problems (91%), physical health problems (77%), decreased social life (92%), and lower work capacity (84%). These percentages show that an individual’s problem gambling habits not only affect themselves but those around them as well.

There is evidence that personality features and neurotransmitter similarities in behavioral and substance addictions exist. Both addiction types yield high scores of impulsivity and sensation-seeking and low scores of harm avoidance on self-report measures (Grant et al., 2010). There may also be similar cognitive features such as both will tend to discount rewards quickly and perform disadvantageously during decision making tasks. In a study of pathological gamblers and abstinent alcohol-dependent participants, Goudriaan, Oosterlaan, De Beurs, and Van Den Brink, (2006) found that both gamblers and alcoholics showed a decrease in performance on inhibition tests, planning tasks, and cognitive flexibility. Several neurotransmitter systems in the pathophysiology of behavioral and substance addictions have been identified. The main areas are with serotonin levels which helps control behavior inhibition (Grant et al., 2010) and dopamine which controls motivation, learning, and salience of stimuli or rewards (Chamberlain et al., 2016). Lower ventral striatal neuronal activity has been shown with pathological gamblers while engaged in simulated gambling (Reuter et al., 2005) which is similar to alcohol-dependent individuals while processing monetary rewards (Wrase et al., 2007). Weakened ventral striatal activation has been known to be linked to the activation of cravings that are associated with behavioral and substance addictions.

Comorbid Disorders 

Gambling disorders are frequently comorbid with substance and alcohol use disorders (Hartmann & Blaszczynski, 2016) as well as many psychiatric disorders including anxiety, depression (Haydock et al., 2015), and attention deficit hyperactivity disorder (ADHD) (Rush, Bassani, Urbanoski, & Castel, 2008). A majority of problem gamblers (57.5%) have comorbid substance use, 37.9% had a mood disorder, and 37.4% had an anxiety disorder (Hartmann & Blaszczynski, 2016). The question is whether the comorbid condition mediates the development or precedes the onset of a gambling disorder. Problem gambling and comorbid disorders have the potential to develop through three possible mechanisms: the consequence of gambling-related stressors; comorbid substance or psychiatric conditions as a factor to predispose impaired control; or an independent third factor (Hartmann & Blaszczynski, 2016). Gambling may be viewed as an emotional escape that is manifested by poor coping skills when a comorbid disorder is present before the onset of problem gambling (Haydock et al., 2015).  Gambling problems before the onset of a comorbid disorder may be considered a response to negative outcomes such as financial problems, feelings of guilt, and social isolation. Other underlying common factors that may contribute to the link between problem gambling and substance or psychiatric disorders could be impulsivity (Jamieson et al., 2011; Lawrence, Luty, Bogdan, Sahakian, & Clark, 2009; Fatseas et al., 2016), socio-economic disadvantage (Haydock et al., 2015), and socio-family risks (Dussault et al., 2016).

Many problem gamblers report having poor impulse control (Dowling, Merkouris, & Lorains, 2016) which predisposes the individual to psychotic disorders and increased risk taking behaviors (Haydock et al., 2015). An impulsive personality is characterized by four factors: the drive for immediate reinforcement; the tendency to act without considering negative consequences; insensitive to punishments; and a lack of inhibitory control (Dussault et al., 2016). These response patterns put impulsive individuals at greater likelihood of problem gambling through risky behaviors, loss of control, and a decreased ability to recognize negative outcomes (Fatseas et al., 2016). Impulsivity present at an early age is often a strong predictor for gambling problems in adulthood (Dussault et al., 2016; Dowling et al., 2016; (Hodgins & Holub, 2015). Increased impulsivity at age 14 has shown depression and problem gambling at ages 17 and 23 (Hartmann & Blaszczynski, 2016) which displays evidence that impulsivity in childhood may be strongly associated with gambling disorder in emerging adults (Hodgins & Holub, 2015). Problem gamblers with impulse control often report more intense urges and gambling-related thoughts and distress (Dowling et al., 2016). Depression symptoms tend to also be elevated in this population because they are more likely to encounter adverse situations and have poor emotion regulation (Dussault et al., 2016). Dussault et al. (2016) found that individuals who follow a joint trajectory of depressed symptoms and gambling problems show increased impulsivity at an early age compared to those who follow a single trajectory. This finding further suggests the strong link of impulsivity at a young age predicting gambling disorder later in life.

Childhood Attention Deficit Hyperactivity Disorder (ADHD) has been linked to later problem gambling based on impulsivity and personality traits associated with ADHD (Haydock et al., 2015; Lawrence et al., 2009; Hartmann & Blaszczynski, 2016; Fatseas et al., 2016). The prevalence of ADHD in individuals seeking treatment for gambling problems is 9.3% (Dowling et al., 2016) which explains the showing of an increase in self-transcendence and a decrease in cooperativeness and self-directedness (Fatseas et al., 2016). Children with a history of ADHD display a significantly lower ability to delay gratification as adults and exhibit a lower inhibitory control than those without ADHD histories. Individuals with a history of ADHD often have an increase in preference for risky decisions and small immediate rewards which suggests they will perform poorly during decision making tasks (Abouzari, Oberg, Gruber, & Tata, 2015). ADHD-related impulsivity increases the chances of higher rates of gambling, increased severity in gambling habits (Fatseas et al., 2016), psychiatric comorbidity, suicide attempts, and personality disorders (Dowling et al., 2016). Approximately 20% to 30% of individuals with problem gambling have a history of ADHD at some point in their life (Fatseas et al., 2016); another 18% missed the criteria threshold by one point (Waluk, Youssef, & Dowling, 2016). Pathological gamblers with comorbid ADHD tend to be more sensitive to immediate rewards, pay little attention to negative outcomes (Dowling et al., 2016) and report the presence of anxiety, at least two affective, or substance use disorders (Waluk et al., 2016). The prevalence rates of past or current ADHD in many problem gamblers seeking treatment emphasize the need for treatment programs to address individual treatment needs and outcomes. Programs should focus on individual case formulations, treatment planning and selection, objectives and expectations, length and success, compliance, likelihood of relapse, and number of attempts when developing treatment plans for individuals presenting with gambling disorder and ADHD history (Waluk et al., 2016).

Depression and anxiety symptoms represent a major problem that repeatedly co-occurs with gambling problems. Approximately half of individuals with gambling problems also present with symptoms of major depressive disorder (Dussault et al., 2016) and approximately 40% struggle with anxiety (“Gambling Addiction Often Co-Occurs With Other Disorders,” 2013). Depression and anxiety have been shown to predate the onset of pathological gambling and predict the onset and prediction of gambling problems (Dowling et al., 2016). Among individuals with a comorbid depression or anxiety disorder present before the onset of gambling problems, gambling may be a manifestation of poor coping skills or an emotional escape (Hartmann & Blaszczynski, 2016). Low skill gambling activities such as gaming machines may be used more frequently by individuals suffering from anxiety as a way to distract their heightened arousal state through dissociative states. High skill activities such as casino table games and sports betting tend to appeal to those suffering from depression in an effort to increase arousal states or overcome dysp horia (Hartmann & Blaszczynski, 2016). Many individuals with a gambling disorder seek or report that they need psychiatric hospitalization because of depression and suicidality related to devastating financial problems and guilt (Grant & Chamberlain, 2015).

Suicide has been identified as the tenth leading cause of death in 2010 in the United States (Manning et al., 2015). As many as 24% of individuals with gambling disorder in treatment have reported attempting suicide due to gambling related consequences (Grant & Chamberlain, 2015) and 17% reported making an attempt (Manning et al., 2015). Thoughts of suicide may rise from heightened impulsivity in the context of despair or desperation from negative consequences due to gambling behaviors such as increased debt (Manning et al., 2015). Gender differences have been found between lifetime suicidal attempts and ideation. Females are almost twice as likely to have attempted suicide which may be correlated to the severity of their problems such as mental health diagnosis (Manning et al., 2015). Severity of gambling problems, lifetime prevalence of psychiatric disorders, and prevalence of cluster B personality disorders have all been shown to be significant factors in suicidal ideation and attempts among problem gamblers (Bischof et al., 2015). Grant, Derbyshire, Leppink, and Chamberlain (2014) found that there is also an increased risk of suicide in individuals who displayed a lower level of gambling pathology which could be attributed to a mood or anxiety disorder. This finding further emphasizes the importance of treating possible mental illnesses along with gambling problems.

Pathological gambling frequently co-occurs with many forms of substance use (Xian, Giddens, Scherrer, Eisen, & Potenza, 2013) and individuals who seek treatment for substance use disorders (SUDs) may be at an increased risk for developing a gambling disorder (Grant & Chamberlain, 2015). The highest odds ratio of co-occurrence of behavioral and substance addictions has been seen in gambling and alcohol use disorders (Li, Gu, & Sui, 2010) where 18% to 50% of first degree relatives of individuals with gambling disorder report alcohol use disorder (Grant & Chamberlain, 2015). Clinical studies have shown that 52% of those in gamblers anonymous (GA) report drug and/or alcohol abuse, and 35% to 63% of those seeking gambling disorder treatment have screened positive for a lifetime substance use disorder (Grant & Chamberlain, 2015; Denis et al., 2016). When accounting for age, Hartmann and Blaszczynski (2016) report that tobacco use, alcohol consumption, and cannabis use before the age of 15 years predicts increased gambling participation and expenditure in young adulthood. When compared to non-gamblers, recreational gamblers are 1.3 times more likely to have an alcohol-related disorder and 1.2 times more likely to report nicotine dependence (Okunna, Rodriguez-Monguio, Smelson, & Volberg, 2016). A review of the US-National Epidemiological Survey on Alcohol and Related Conditions (NESARC) found that over a three year period, female gamblers were at an increased risk for developing nicotine dependence for stress relief whereas male gamblers were at an increased risk for alcohol use disorder for stress relief and emotional arousal (Hartmann & Blaszczynski, 2016). Recreational gambling has been associated with the use of substances such as marijuana, illicit drugs such as cocaine and heroin, and the misuse of prescription drugs such as painkillers and sleeping pills (Okunna et al., 2016; Sherba & Martt, 2015).

Family Impact

There is already strong evidence indicating gambling problems can have major negative personal consequences on the gambling individual, but there is also growing evidence of the impact problem gambling can have on family relationships (Dowling, Suomi, Jackson, & Lavis, 2016; Dowling, Rodda, Lubman, & Jackson, 2014; Ingle, Marotta, McMillan, & Wisdom, 2008). Roughly 18% of the population has reported that they have a family member or friend with problem gambling, but the impact on families has received little attention in research (Dowling et al., 2016; Hing, Tiyce, Holdsworth, & Nuske, 2013). Most of the current information on family impact focuses on intimate partners and children of the problem gambler but there can also be effects on extended family members as well as close friends of the problem gambler (Dowling et al., 2016; Dowling et al., 2014; Ingle et al., 2008). Significant others often experience increased levels of conflict, financial hardships, poor communication, and problems with other addictions, relationship and sexual dissatisfaction, lost time at work, emotional distress, and family violence (Salonen, Alho, & Castren, 2016). Children of problem gamblers have also reported being exposed to a range of stressors such as emotional and financial deprivation, inconsistent discipline, physical isolation, abuse/neglect, poor role modelling, and reduced stability and security (Dowling et al., 2016). These stressors may increase their risk for developing conduct and antisocial problems, depression, and gambling problems. The overall impact of problem gambling on the family could lead to anger, depression, anxiety, decreased trust, reduced quality time, and relationship breakdowns (Dowling et al., 2016).

Family involvement is an effective tool during the recovery and relapse treatment process (Ingle et al., 2008) as well as encouraging the individual to seek professional help (Hing et al., 2013). Many problem gamblers under-report family impacts of their gambling behaviors, thinking that if the problem is not disclosed then it has no impact. Approximately one-third of those seeking treatment for problem gambling deny their gambling has had any impact on their family members (Dowling et al., 2016). Preventive and intervention efforts may help in increasing the gamblers awareness of the familial impact even if they are currently unaware of the gambling problem. Providing the understanding of the impact the problem gamblers actions has on their family, can increase awareness that the support from their family may play a crucial role in their recovery and can be a central agent for change (Hing et al., 2013).

Many concerned significant others report they did not know of the gambling problem due to the individual’s denial, thoughts of the problem being handled, or misinterpreting what the problem actually was (Hing et al., 2013). Providing knowledge, skills, and support to the concerned significant others may help the problem gambler as well as the family in the resolution process. The family of the problem gambler often experience many of the same adverse effects that the gambler themselves experiences which makes their involvement crucial. Some of these effects may be emotional disturbances, poor physical health, lower social support, and impaired social life (Dowling et al., 2016). Embarrassment, denial, guilt, and shame may be major barriers in why many concerned significant others or other family members do not seek help for themselves or their loved one (Hing et al., 2013). Many concerned significant others turn to web-based and non-professional sources of help because of feelings of shame and wanting to solve the problem themselves. Others feel it is easier to ignore the problem than to face it until they were negatively impacted financially, emotionally, and physically (Hing et al., 2013).

Treatment Options

There are several successful treatment options for the problem gambler and their concerned significant others. These treatment options, however, do not come without strengths, weaknesses, support, and criticism. Some include: concerned significant others involved in treatment with and without the problem gambler (Hing et al., 2013), gamblers anonymous (Dowling et al., 2016), SMART Recovery (“SMART Recovery,” 2013), medication, cognitive behavioral therapy (Petry, 2009), and motivational enhancement interventions (Yau & Potenza, 2015). Each of these treatment methods have shown positive and negative effects on the recovery of the problem gambler but because gambling disorder is a relatively new disorder, more research should be conducted, especially in regard to comorbid disorders.

Treatment programs often do not address comorbid disorders and in most cases are separated into two different types of treatment programs: (1) gambling programs that focus only on gambling and mental health problems, and (2) alcohol/drug/gambling programs that focus on all three types of addictions (Jamieson et al., 2011). Problem gambling initiatives tend to have more success when they employ a more holistic approach that targets both gambling disorders and the psychiatric disorders that are commonly associated with gambling disorders (Hartmann & Blaszczynski, 2016). All treatment programs should include screening for substance use disorders, gambling disorder, and mental health disorders because it may help in reduce future problems and assist in relapse and recovery rates.

Approximately 10% of problem gamblers seek treatment for their problem but about 50% report they rely on help from their partner, children, family members, and friends (Hing et al., 2013). Programs that involve the family in the problem gamblers treatment process addresses the needs of the individual as well as the family which can ultimately decrease the overall burden of the gambling problem (Ingle et al., 2008). The family of the problem gambler can be maintained as a key component of support throughout treatment and recovery when they are actively involved. Ingle et al. (2008) showed that problem gamblers who have a significant other involved in their treatment participate 30% longer than those without significant others involved. This indicates that the added positive support and encouragement is a motivational factor for the individual to successfully complete treatment. Problem gamblers often report that their treatment seeking was prompted by their significant others, demonstrating that having a supportive significant other may be the needed encouragement to start or remain in treatment.

Although there is evidence supporting family involvement in the problem gamblers treatment, there may be circumstances when it harms rather than benefits the individual. Familial dysfunction (Ingle et al., 2008) and the complexity of intimate relationships (Hing et al., 2013) may complicate help for the problem gambler due to inconsistency or negative consequences which may interfere with treatment. Partners of problem gamblers often find themselves engaged in processes of denying, monitoring, and controlling or facilitating the partners gambling while also attempting to improve both their partner’s behaviors and their own life (Hing et al., 2013). Family members often add more stress to themselves by taking on the role of trouble-shooter, confidant, advisor, mediator, and spokesperson (Hing et al., 2013) for the problem gambler.

As important as having the family involved in the problem gamblers treatment it is equally important that the family is involved in their own treatment. Treatments for the family should involve impacts related to emotional distress, finances, social life, and interpersonal relationships (Dowling et al., 2014). Concerned significant others comprise approximately one-third of the clients that access face-to-face treatment, helplines, and web-based services for their loved ones gambling disorder however there are few treatment specifically designed for this population (Dowling et al., 2014; Dowling et al., 2016). Telephone and web-based services tend to be more appealing to significant others due to discreteness, anonymity, and ease of access with the majority of treatment seeking significant others being females aged 30 to 65 years (Dowling et al., 2014). Interventions for family members of problem gamblers has been slow to evolve however two interventions have been evaluated: a self-help workbook based on community reinforcement and family therapy (CRAFT) model and face-to-face coping skills interventions (Dowling et al., 2016). CRAFT teaches family and friends effective ways of helping their loved one by changing the way they interact with the problem gambler while also improving their life (“Center for Motivation & Change,” 2014). The program was developed to teach families how to have an impact on their loved one while also avoiding detachment and confrontation. The skills that are taught to families include: understanding triggers, positive communication, positive reinforcement, problem-solving, self-care, precautions for domestic violence, and helping the problem gambler accept help (“Center for Motivation & Change,” 2014). Coping Skills Training (CST) is an intervention for the family aimed to increase awareness about the role of gambling for the individual and helps to change coping mechanisms through skills learning to ultimately decrease the gambling behaviors (Williams, 2016). Further research on family impact and interventions need to be conducted in order to understand what treatments are most effective for the families of problem gamblers.

Medication treatment for many ailments and disorders has been on the rise and its use for gambling disorder is no exception. Although there have been no approved U.S. Food and Drug Administration pharmacotherapies for the treatment of problem gambling many classes of medications have been evaluated: serotonin reuptake inhibitors, opioid antagonists, mood stabilizers, bupropion, and N-acetyl-cysteine (Wareham & Potenza, 2010; Hodgins, Stea, & Grant, 2011). Research to date on pharmacological treatment for gambling disorders has been promising, particularly with opioid antagonists (Hodgins et al., 2011). Two opioid antagonists, naltrexone and nalmefene, have shown positive effects in substance use disorders as well as gambling disorder (Petry, 2009; Chamberlain et al., 2016). These medications have shown to decrease gambling symptoms and urges in studies when compared to placebo groups (Grant et al., 2006; Grant & Chamberlain, 2015). This finding suggests that mu-opioid receptors may play a similar role in behavioral addictions as they do in substance use (Grant et al., 2010).  Medications that modify glutamatergic effects in behavioral addictions include glutamate and memantine (Chamberlain et al., 2016; Hodgins et al., 2011; Grant & Chamberlain, 2015). These have shown to play an important role in impulsivity, cravings, attentional bias, relapse, and stealing.

Several antidepressants (Petry, 2009), anticonvulsants (Chamberlain et al., 2016), and mood stabilizers (Wareham & Potenza, 2010) have been explored and shown to be effective in many cases. A rigorous 9-week study using paroxetine in 45 gambling disorder patients’ reports 48% rated as very much improved compared to 5% of the placebo group (Kim, Grant, Adson, & Shin, 2002). Topiramate, gabapentin, and lamotrigine have shown to have channels that inhibit the release of neurotransmitters (Chamberlain et al., 2016) which may help in reducing reward seeking behaviors and impulsivity (Grant & Chamberlain, 2015). Lastly, the mood stabilizer lithium has been studied in individuals with pathological gambling and bipolar disorder symptoms (Petry, 2009; Wareham & Potenza, 2010). Lithium treatment with this group has shown a reduction in gambling symptoms, urges, and thoughts (Petry, 2009). Although there have been several studies to show different pharmacological treatments have positive outcomes, more research is needed.

Cognitive behavioral therapy (CBT) for problem gambling is a form of psychotherapy that focuses on changing behaviors and thoughts that are unhealthy by teaching how to combat urges, deal with uncomfortable situations, and solve financial, work, and relationship problems (Jazaeri & Habil, 2012). The goal of CBT with problem gamblers is to rewire the individual’s brain to think about gambling in a new way. Many exercises in CBT can be incorporated to assist with comorbid substance use disorders and/or mental health disorders (Petry, 2009) by helping to identify triggers and make an alternative plan. Although there are several types of CBT, it is important to focus on what they can do for the individual rather than what they are (Jazaeri & Habil, 2012). CBT is meant to be time-limited so an individual should get the most out of the treatment they can in a short amount of time. Two variations of CBT that have been developed and show promise for working with problems gamblers are Petry’s (2005) eight-session format and the four steps program (Padesky & Mooney, 2012). Petry (2005) developed an eight-session CBT format that includes topics on identifying and managing triggers, building interpersonal conflict skills, conducting functional analysis of gambling episodes, dealing with urges and cravings, increasing alternate activities, recognizing and correcting cognitive biases, and preventing relapse. The four steps program has a goal of changing the gamblers thoughts and beliefs about gambling through four steps: re-label, re-attribute, refocus, and revalue (Padesky & Mooney, 2012). Both models are strength based to help the individual build positive qualities and strengthen resilience. CBT may be beneficial for gamblers who may suffer from cognitive illusions such as superstitious behaviors, overestimating chances of winning, and feelings that future wins are dependent on past experiences (Petry, 2009). Incorporating CBT with other types of therapeutic interventions may give the problem gambler more chance of reducing gambling habits.

Motivational approaches such as motivational interviewing (Hodgins et al., 2011) and motivational enhancement therapy (MET) attempt to address the problem gamblers ambivalence to change by exploring the advantages and disadvantages of changing disruptive gambling behaviors (Rash & Petry, 2014). Motivational interviewing is a style of interaction with individuals which encourages them to focus on personal reasons to change their gambling behaviors and to voice factors that may be working against the change (Hodgins et al., 2011). The resolution to the natural ambivalence to change may motivate the individual to take action. Motivational enhancement therapy is based on the concept that behavioral changes happen through four stages: pre-contemplation, contemplation, action, and maintenance (Petry, 2009). Understanding of the consequences of an individual’s gambling behaviors may strengthen their commitment to change. Motivational approaches may also be valuable to engage problem or at-risk gamblers that may not meet the diagnostic criteria for problem gambling (Rash & Petry, 2014). Identifying these individuals can aid in an attempt to prevent increased problem gambling behaviors and their consequences. These approaches can be combined with other treatment options such as CBT and gamblers anonymous (GA) for an increased chance of change in behaviors (Rash & Petry, 2014).

Although some problem gamblers seek professional help, many prefer more self-help methods such as gamblers anonymous, Self-Management and Recovery Training (SMART Recovery), and CBT based workbooks. Gamblers anonymous (GA) was developed in 1957 in Los Angeles (Grant & Chamberlain, 2015) as a twelve-step program designed after alcoholics anonymous (Jazaeri & Habil, 2012; Petry, 2009) and is the most commonly used approach to treatment. The purpose of GA is to choose a sponsor who has time and experience gamble free (Jazaeri & Habil, 2012) who can help with acknowledgement over powerlessness of compulsive gambling and to remain gamble free themselves (Grant & Chamberlain, 2015; Hodgins et al., 2011). These groups help to promote a sense of common purpose and understanding as well as to reinforce abstinence from gambling (Hodgins et al., 2011; Grant & Chamberlain, 2015). SMART Recovery provides tools and support through on-line communities, recovery meetings, and a handbook (“SMART Recovery,” 2013). SMART Recovery’s 4-point program is an alternative to 12 step programs like GA and is designed to help the problem gambler by enhancing and maintaining motivation to quit, coping with urges, managing problems, and lifestyle balance. Members are able to work independently using the workbook but also have support through on-line and face-to-face meetings and forums which help aid in the recovery process (“SMART Recovery,” 2013).

 Although there are many people who seek professional help for gambling disorder, there are many who are able to recover without formal treatment which is known as natural recovery (Slutske, 2006). Evidence of high recovery rates with low treatment-seeking rates suggests that natural recovery may be more common than previously realized (Slutske, 2006; Petry, 2009). The stigma of seeking professional treatment may be a reason many do not attend treatment but would rather use more self-help tools for their recovery (Hing, Nuske, Gainsbury, Russell, & Breen, 2016) because there are fewer barriers involved (Rash & Petry, 2014). Typically an individual reaches out for help when they hit a crisis point and only as a last resort which keeps rates of help-seeking low (Hing et al., 2016). Profession treatments appear to significantly improve outcomes because they tend to enhance skills of self-esteem and empowerment by addressing embarrassment, shame, and fears (Hing et al., 2016). Education on irrational beliefs about gambling and the availability of treatments is important in order to increase utilization of treatment programs by problem gamblers (Cunningham, Cordingley, Hodgins, & Toneatto, 2011).

Stigma

Stigma is often a major motive for individuals with problem gambling to not seek professional treatment (Horch & Hodgins, 2015; Hing, Nuske, Gainsbury, & Russell, 2016a). The term stigma has been defined as deeply discrediting attributes that reduces an individual from a whole and usual person to a tainted and discounted person (Hing et al., 2016a). Stigma can be divided into four components which correspond to cognition, perception, behavior, and affect: cues, stereotypes, prejudice, and discrimination (Horch & Hodgins, 2015). There are three types of stigma that affect the problem gambler from seeking the treatment they need: public stigma (Hing, Russell, Gainsbury, & Nuske, 2016c), perceived stigma (Hing et al., 2016a), and self-stigma (Hing et al., 2016b; Horch & Hodgins, 2015).

Public stigma is the negative reaction society has toward individuals with a stigmatizing condition (Hing et al., 2016c). This stigma strengthens division between individuals who are perceived as normal and those who are not which causes stereotyping and discrimination that may lead to mental health effects. Problem gamblers have been stereotyped as impulsive, desperate, compulsive, irresponsible, depressed, greedy, irrational, aggressive, and antisocial (Hing et al., 2016a). The degree of public stigma appears reliant on perceived dimensions of the condition or attribute. These may include: concealability, origin, course, disruptiveness, and aesthetics (Hing et al., 2016a). Perceived stigma is the awareness of public stigma or holding the belief that others pass judgement or stereotypes about problem gambling (Hing et al., 2016a). Public and perceived stigma are reinforced through external (accident, genetic causes) as well as internal (lack of self-control, poor decision-making) attributions directed toward the individual with a gambling disorder (Hing et al., 2016c) which may elicit anger, annoyance, and punishing behaviors.

Self-stigma is internalized beliefs by the individual about how they are viewed by others which further increases negative mental health outcomes (Horch & Hodgins, 2015). Some of the consequences that have been found due to self-stigmatizing behaviors include: unemployment, reduced housing opportunities, decreased quality of life, poor social adjustment, and decreased self-esteem and self-efficacy. Fear of being identified as a problem gambler is a major barrier in help-seeking by professionals (Hing et al., 2016b). Internalizing public stigmatizing beliefs affects the individual by decreasing their self-worth, withdrawal from social supports, and increased rejection of treatment which may further decrease mental health (Hing et al., 2016c). Shame and fear around the stigma of having, admitting, and receiving treatment for problem gambling delays and deters treatment-seeking for individuals with gambling problems.

Conclusion

Gambling problems tend to affect a small but clinically substantial proportion of the general population but can also occur at higher rates in some subgroups such as in those with mental health disorders and substance use (Petry, 2009). Links between gambling disorder and comorbid conditions such as mood and anxiety disorders and substance use appear to be bidirectional in adolescent and young adults with impulsivity as a strong predictor (Hartmann & Blaszczynski, 2016). Evidence for treatment programs support the use of some pharmacological approaches (Choi, Shin, Youn, Lim, & Ha, 2016), motivational therapies (Wareham & Potenza, 2010), and cognitive behavioral therapy (Rash & Petry, 2014) combined with self-help approaches such as gamblers anonymous (Jazaeri & Habil, 2012) and SMART Recovery (“SMART Recovery,” 2013). Having concerned significant others, family, and friends involved in the problem gamblers treatment as well as their own treatment, has been shown to have a significant impact on the recovery of the problem gambler (Ingle et al., 2008). Although there has been significant research recently on the affects and treatments of problem gambling, more research is needed in all areas of the disorder to gain a better understanding of the causes, outcomes, and treatments for the individual and their loved ones.

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