CATR: How do we define gambling versus impulsive buying?
Dr. Potenza: Gambling is defined as placing something of value at risk in the hopes of gaining something of greater value. Usually that something is money, but it need not be. Impulsive buying or impulsive shopping is purchasing something on the spur of the moment, often with little forethought and sometimes with limited insight.

CATR: How is gambling disorder defined by DSM?
Dr. Potenza: Gambling disorder (previously called pathological gambling) has been in the DSM since 1980, but the diagnostic criteria have changed somewhat over time. The core element is persistent or recurrent gambling that leads to interference in areas of life functioning. One needs to satisfy 4 of 9 inclusionary criteria to meet a diagnostic threshold. These criteria include aspects of tolerance, withdrawal, multiple failed attempts to cut back or quit, chasing of losses, and financial bailouts. The gambling typically should last a year for a diagnosis to be made, but if it’s particularly severe, a diagnosis can be made earlier.

CATR: Is impulsive buying included in the DSM-5 or ICD-11?
Dr. Potenza: There are no formal criteria for impulsive buying, impulsive shopping, or compulsive buying or shopping within the DSM-5 or the ICD-11. Currently in the ICD-11, gambling disorder and gaming disorder are classified as disorders due to addictive behaviors with specific criteria. We propose that the category “other disorders due to addictive behaviors” may be used to diagnose individuals with problematic engagement in other areas—for example, buying or shopping, as well as forms of internet engagement like social media or social network use (Brand M et al, J Behav Addict 2020 Jun 30).

CATR: How would you recommend clinicians take a history that pertains to gambling?
Dr. Potenza: Often, people who gamble do not see their behavior as problematic, so simply asking someone if they have a problem with gambling may not be the most sensitive way to identify individuals. There are screening instruments to help identify people with gambling problems; for example, the Lie/Bet Questionnaire consists of 2 questions: 1. Have you ever had to lie to people important to you about how much you gambled? 2. Have you ever felt the need to bet more and more money? (www.ncrg.org/sites/default/files/uploads/docs/monographs/liebet.pdf; Johnson EE et al, Psychol Reports 1997;80(1):83–88).

CATR: Regarding gambling, should we assess all populations in the same way?
Dr. Potenza: One should keep in mind that gambling affects people differently, and this is in part due to age or maybe gender-related differences. In adults, for example, the financial impact of gambling problems can be quite substantial. In clinical practice it is not unusual for me to see individuals who have experienced 6-figure gambling losses or debts, or even more. There is often relational discord as people with gambling problems frequently lie about the extent of their gambling or keep it to themselves. A spouse may awaken one day and find the bank account drained, and one can imagine that this can be very stressful, both for the person with the gambling problem as well as family members or other people affected.

CATR: How about the teen population?
Dr. Potenza: Adolescents have high rates of gambling problems. They tend to be 2 to 4 times higher than the prevalence estimates in the general adult population (Giralt S et al, J Behav Addict 2018;7(2):339–347). However, adolescents may not have as much money with which to gamble, and so they may experience problems such as poor grades in school or other signs or symptoms that may reflect spending too much time in a behavior and not on other areas of life functioning.

CATR: Do people with impulsive shopping also experience this level of financial trouble?
Dr. Potenza: People with shopping problems may also experience significant financial concerns. Often, people who buy compulsively have a large number of items that they do not use. So, for example, clothing may be purchased and still have the tags on for long periods of time—months or years—and people continue to buy more in the setting of perhaps not needing the items.

CATR: How should we approach treatment for these patients?
Dr. Potenza: The mainstay of treatment for these conditions is psychotherapy. There are data showing that, for example, cognitive behavioral therapy (CBT) tailored to the disorder is helpful for a good proportion of individuals who have either gambling disorder or problematic buying or shopping. That being said, not everyone responds to CBT, and it can be useful to explore other avenues, such as 12-step meetings.

CATR: How helpful have 12-step interventions been?
Dr. Potenza: People who receive CBT and who attend GA (Gamblers Anonymous) do better than people who receive CBT alone (Potenza MN et al, Nat Rev Dis Primers 2019;5(1):51).

CATR: I would imagine that co-occurring psychiatric disorders can also pose treatment challenges.
Dr. Potenza: Correct. Data from the National Comorbidity Survey Replication found that of individuals with gambling disorder, 96% had 1 or more co-occurring psychiatric disorders, and close to two-thirds had 3 or more (Kessler RC et al, Psychol Med 2008;38(9):1351–1360). As a psychiatrist within a problem gambling treatment clinic, I typically work closely with therapists and prescribe medications particularly for individuals with co-occurring disorders. And some of our data indicate that when you treat the co-occurring disorder, the gambling disorder improves.

CATR: How has the COVID-19 pandemic impacted the prevalence or severity of gambling and impulsive shopping?
Dr. Potenza: On the one hand, the pandemic has caused the closure or reduced operation of land-based casinos, and many sporting events have ceased temporarily—leading to less sports gambling. On the other hand, people have more time on their hands, and they also may be experiencing significant stressors, and stress has been linked to gambling problems. There have also been reports that online casino gambling has increased during the pandemic.

CATR: Are there any special populations we should be particularly concerned about? You mentioned adolescents earlier.
Dr. Potenza: I think that each development stage warrants consideration. Vulnerable groups do include adolescents, but also older adults, who are often in the position to be less likely to recoup money that has been lost through gambling or problematic shopping. People who are socially disadvantaged or who are living on limited incomes may also be vulnerable. There have been reports of high rates of gambling problems among homeless individuals. Gender-related differences are important, too. While more men than women have problems with gambling, the progression of gambling problems is often more rapid in women as compared with men. This phenomenon has been termed “telescoping.” It was first reported for alcohol use, then later for drug use, and later by our group, another in Minnesota, and another in Brazil for gambling (Potenza MN et al, Am J Psychiatry 2001;158(9):1500–1505; Tavares H et al, J Clin Psychiatry 2003;64(4):433–438).

CATR: Does this apply to shopping as well?
Dr. Potenza: With respect to problematic shopping, oftentimes women are considered more vulnerable to developing shopping problems; however, a considerable proportion of men also develop shopping problems but often purchase different items than women (www.doi.org/10.1176/ajp.2006.163.10.1806).

CATR: How is the landscape changing with the advent of new technology?
Dr. Potenza: In many social media platforms we’re seeing “loot crates” or “loot boxes,” which are virtual treasure chests. You buy them, but you don’t know in advance what they contain. Often they will contain “skins” that can be used to decorate in-game weaponry, and these may help gamers succeed in the game and help them win either virtual or real money. You can imagine how addictive these loot boxes can become.

CATR: Thank you for your time, Dr. Potenza.