• Subscribe
  • Register for free Content
  • Cart
  • Login
  • Browse by Topic
    • 13 Reasons Why
    • ABA
    • Abstinence
    • Acamprosate
    • Addiction
    • Addiction Treatment
    • Addyi
    • Adhansia
    • Adhansia XR
    • ADHD
    • ADHD Attention Deficit Hyperactivity Disorder
    • ADHD Rating Scale-5
    • ADHD-RS-5
    • Adherence
    • Adjunct treatment
    • adolescents
    • Aducanumab
    • Aduhelm
    • Adult ADHD
    • Adverse Childhood Experiences (ACES)
    • adverse events
    • affective disorders
    • Affordable Care Act (ACA)
    • aggression
    • Agitation
    • Aid to capacity evaluation (ACE)
    • AIMS test (Assessment of Involuntary Movement)
    • air pollution
    • Akathisia
    • Alcohol
    • alcohol abuse
    • alcohol dependence
    • Alcohol Poisoning
    • Alcohol related liver disease
    • Alcohol Use
    • Alcohol use disorder
    • Alcoholism
    • Alpha Agonists
    • Alternative treatments
    • Alzheimers
    • Amantadine
    • amino acids
    • amphetamine
    • Amphetamines
    • anabolic steroids
    • Andro
    • Androstenedione
    • Anorexia
    • Anorexia Nervosa
    • Anti-NMDA Receptor Encephalitis
    • Antibiotic
    • Anticholinergic burden scale
    • Anticholinergics
    • Antidepressant
    • Antidepressant Augmentation
    • Antidepressants
    • Antipsychotic
    • Antipsychotics
    • Anxiety
    • Anxiety Disorder
    • anxiety disorders
    • APA CE Post-Test
    • Applied Behavioral Analysis
    • Aptensio
    • Aripiprazole
    • ArModafinil
    • Asenapine
    • Assault
    • Assent
    • Assessment
    • asthma
    • atamoxetine
    • Athletic performance
    • Ativan Challenge Test
    • Atomoxetine
    • Atomoxetine (ATX)
    • Atropine
    • attention
    • Attention Deficit Hyperactivity Disorder
    • Atypical Antipsychotics
    • Austedo
    • Autism
    • Autism Spectrum Disorder
    • Autism Spectrum Disorder
    • Autism Spectrum Disorder autism spectrum disorder
    • Behavior therapy
    • Behavioral addiction
    • Behavioral therapy
    • Behavioral treatment
    • Belsomra
    • Benzodiazepine
    • Benzodiazepines
    • Benzphetamine
    • Beta-blockers
    • Billing
    • Bipolar Depression
    • Bipolar Disorder
    • Bipolar II
    • Black youth
    • Bleeding
    • Board Certification
    • Borderline Personality Disorder
    • Boredom
    • BPD
    • BPSD (behavioral and psychological symptoms of dementia)
    • Brain Devices
    • Breastfeeding
    • Brexpiprazole
    • Brief psychotherapy
    • brief pulse
    • Brief Strategic Family Therapy (BFST)
    • Bulimia Nervosa
    • Bullying
    • Bumetanide
    • Buprenorphine
    • Buprenorphine Induction
    • Bupropion
    • Bush-Francis Scale
    • Buspirone
    • C-Reactive Protein
    • Caffeine
    • CAM Treatments
    • Cancer
    • Cannabidiol
    • Cannabis
    • Capacity
    • Caplyta
    • Carbamazepine
    • Cardiovascular
    • Cariprazine
    • Catatonia
    • CATIE
    • CBT
    • CBTi
    • Central Alpha Agonists
    • CGI
    • Chantix
    • Child and adolescent
    • Child Psychiatry
    • Child Psychiatry
    • childcare
    • children
    • children and adolescents
    • Chlorpromazine
    • Chokroverty
    • Chromosomal Microarray
    • circadian system
    • Citalopram
    • Clinical Global Impressions
    • Clinical practice
    • Clinical Practice Guidelines
    • Clozapine
    • CME Post-Test
    • co-morbidities
    • Co-occurring disorders
    • Cocaine
    • Cognition
    • Cognitive Behavioral Therapy
    • Cognitive Behavioral Therapy for Insomnia
    • Cognitive Behavioral Therapy for Insomnia (CBTi)
    • Cognitive Decline
    • Cognitive functioning
    • cognitive impact
    • Cognitive impairment
    • Cognitive Rehabilitation Therapy (CRT)
    • Collaboration
    • Collaborative care
    • Collateral data
    • Combination treatment
    • Combined Pharmacotherapy
    • Commitment
    • community trauma
    • Comorbidity
    • complementary medicine
    • Complementary treatments
    • Complimentary Medicine
    • Complimentary treatments
    • compulsions
    • Computer addiction
    • Computers in Psychiatric Practice
    • Conduct Disorder
    • Confidentiality
    • Connect
    • Connection
    • Connections
    • Consensual
    • Consent
    • Contagion
    • Contempla
    • contingency management
    • contraceptive services
    • control group
    • Coronavirus
    • Cosmetic pharmacology
    • Countertransference
    • court hearings
    • COVID-19
    • COVID19
    • craving
    • creatine
    • creatine monohydrate
    • Creativity
    • Crime
    • Criminal behavior
    • Crisis intervention
    • Crocus Sativus
    • CRP
    • Cultural Competence
    • Culture
    • custody agreement
    • Cymbalta
    • CYP2C19
    • CYP2D6
    • DASH diet
    • Dayvigo
    • De-escalation
    • Debriefing
    • Decisional Capacity
    • Degarelix
    • Deliberate foreign body ingestion
    • Delirium
    • Delusional Disorder
    • Dementia
    • Deplin
    • Deprescribing
    • Depression
    • Depressive Disorder
    • designer drugs
    • Detoxification
    • Deutetrabenazine
    • Developmental Relationship Based Intervention
    • DFBI
    • Diabetes
    • diabetes insipidus
    • Diagnosis
    • Diagnostic Testing
    • diet
    • Dietary Approaches to Stop Hypertension (DASH)
    • Diethylpropion
    • Diphenhydramine
    • Disaster
    • Discrepancies
    • Disparities
    • Dispositional capacity
    • Disruptive Mood Dysregulation Disorder (DMDD)
    • Disulfiram
    • Divalproex
    • Diversity
    • Divorce
    • DMDD
    • Dopamine
    • Dosage Timing
    • Dose Response
    • Dosing
    • double blind
    • DRBI
    • Drooling
    • Droperidol
    • drug misuse
    • Drug-assisted psychotherapy
    • DSM
    • Dual diagnosis
    • Duloxetine
    • duty to protect
    • duty to warn
    • Dyanaval
    • Dyslexia
    • Dysregulation
    • E-Cigarettes
    • Eating Disorders
    • eating restriction
    • eCigarettes
    • ECT
    • effect size
    • Effexor
    • efficacy
    • EHR
    • Electroconvulsive therapy
    • Electronic Health Records
    • electronic use
    • Emergency
    • Emergency Department
    • emergent suicidality
    • emotion dysregulation
    • Emotional dysregulation
    • Encephalitis
    • End of Life Care
    • Engagement
    • Equine Assisted Psychotherapy
    • Equine therapy
    • Escitalopram
    • Esketamine
    • Estrogen
    • Eszopiclone
    • eTNS
    • Evekeo
    • excessive exercise
    • Exercise
    • Existing marijuana
    • expressed emotion
    • extended dosing
    • extended-release
    • Falls
    • Family Separation
    • Fast-acting
    • FDA
    • FDA Warnings
    • Female hypoactive sexual desire disorder
    • Female Issues in Psychiatry
    • fentanyl
    • fetal effects
    • First Generation Antipsychotics (FGAs)
    • fluid restriction
    • Fluoxetine
    • Folate
    • Folic Acid
    • Fragile X
    • Free Articles
    • gabapentin
    • GAD
    • GAMC
    • Gastroenterology
    • GDD
    • Gender
    • Gender & Sexuality
    • Gender Affirming Medical Care
    • Gender Diverse
    • Gender Dysphoria
    • Gender Dysphoric Disorder
    • Gender Identity
    • Generalized Anxiety Disorder
    • Generics
    • GeneSight
    • Genetic Testing
    • Genetics and Psychiatry
    • Geriatric
    • Geriatric Psychiatry
    • Geriatrics
    • Ginkgo
    • Good Psychiatric Management
    • Guanfacine
    • Hair loss
    • Haloperidol
    • Harm reduction
    • Head Trauma
    • Health Apps
    • Healthy aging
    • Hearing loss
    • Heart health
    • Heart rate
    • Hemorrhagic
    • Hepatitis
    • Heroin
    • Higher-calorie refeeding
    • HIPAA
    • Histamine
    • HIV
    • Hormone Replacement Therapy
    • Hospital policy
    • HRT
    • huffing
    • hydroxymethyl butyrate (HMB)
    • Hydroxyzine
    • hypersalivation
    • hypersexual behaviors
    • Hypnotics
    • Hypomania
    • Hyponatremia
    • IDEA
    • Incarceration
    • Inclusion
    • Inclusion strategies
    • Independent Educational Plan (IEP)
    • induction
    • infant
    • Inflammation
    • Ingrezza
    • Inhalants
    • Innovations
    • Inpatient Psychiatry
    • inquiry
    • Insomnia
    • Insulin resistance
    • Insurance
    • intermittent fasting
    • Internet
    • interpersonal stressors
    • Interpreter
    • Intervention
    • Intra-cerebral hemorrhage
    • Intra-nasal
    • involuntary civil commitment
    • Irritability
    • IV immunoglobulin therapy (IVIG)
    • Jornay PM
    • Keppra
    • Ketamine
    • l-methylfolate
    • Laboratory Testing in Psychiatry
    • lactation
    • Lamictal
    • Lamotrigine
    • Language
    • Lavender
    • Learning & Developmental Disabilities
    • Least Restrictive Environment
    • Legal issues
    • Lemborexant
    • Levetiracetam
    • Lewy Body Dementia
    • LGBT
    • LGBTQ+
    • Life coaching
    • Life expectancy
    • Light and Dark Therapy
    • Light therapy
    • Lightbox
    • Liraglutide
    • Literacy
    • Lithium
    • Longevity
    • lorazepam taper
    • Low calorie refeeding
    • Low libido
    • low sodium
    • Lumateperone
    • Lurasidone
    • Lyrica
    • maintenance ECT
    • Malingering
    • Malnourishment
    • Management
    • Mania
    • Mania on Antidepressants
    • MAOIs
    • Marijuana
    • MDMA
    • Media
    • Medical Comorbidities
    • Medical incapacity hold
    • Medication
    • Medication adherence
    • medication capacity hold
    • Medication for Opioid Use Disorder
    • Medication for Opioid Use Disorder (MOUD)
    • medication of opioid use disorder (MOUD)
    • medications
    • Melatonin
    • Memantine
    • memory loss
    • Mental Health
    • Meta-analysis
    • Metabolic syndrome
    • Metformin
    • Methadone
    • Methamphetamines
    • methylfolate
    • methylphenidate
    • Micronutrients
    • Mind-Gut Connection
    • Mindfulness
    • Minocycline
    • Minority
    • Mirtazapine
    • Mixed Features
    • Modafinil
    • Mood
    • mood disorders
    • Mood stabilizer
    • Mood Stabilizers
    • Mortality
    • Motivational Interviewing
    • MTA
    • MTHFR
    • muscle dysmorphia
    • Mydayis
    • Naloxone
    • Naltrexone
    • Narcolepsy
    • Natural Medications
    • natural treatments
    • Naturalistic Developmental-Behavioral Intervention
    • NDBI
    • Negative Symptoms
    • Negative symptoms of schizophrenia
    • Netflix
    • neuroleptic malignant syndrome
    • Neurology
    • Neuroscience in Psychiatry
    • Neurotoxicity
    • New York
    • newborn
    • News of Note
    • nicotine
    • Nightmares
    • NMDA
    • NNH
    • NNT
    • Nomogram
    • Non-pharmacologic
    • Non-suicidal self-injury
    • Norepinephrine
    • Nortriptyline
    • Novel drug
    • Novel Medications
    • Nuedexta
    • null hypothesis
    • number needed to harm
    • number needed to treat
    • Nuplazid
    • Nurses
    • Nutrition
    • Nuvigil
    • Obesity
    • observational study
    • obsessions
    • Obsessive Compulsive Disorder
    • Obsessive compulsive disorder/OCD
    • OCD
    • olanzapine
    • Omega-3
    • Online Learning
    • online therapy
    • Open Label
    • Opioid antagonist
    • Opioid epidemic
    • Opioid Use Disorder
    • Opioids
    • oppositional behavior
    • Oral Contraceptives
    • Orexin
    • Orthostasis
    • Osmolality
    • Osteporosis
    • Outcome tracking
    • Outcomes
    • Outpatient
    • Over the counter
    • Over the counter medication
    • Overdiagnosis
    • Overdose
    • Oxcarbazepine
    • p-value
    • Pain
    • pandemic
    • Panic Disorder
    • Parent Training
    • Parenting Strategies
    • Parents
    • Parkinson’s
    • Parkinson’s Disease
    • Paroxetine
    • Particulate matter
    • Patch
    • Patient relationship
    • pediatric
    • Pediatric Acute Onset Neuropsychiatric Syndrome (PANS)
    • Pediatric Autoimmune Neurologic Disorder Associated with Streptococcus (PANDAS)
    • Pedophilic Disorder
    • Performance Enhancing Substances
    • Perseveration
    • Perseverative Behavior
    • Personality Disorders
    • Pharmaceutical Industry
    • Pharmacogenomics
    • Pharmacology
    • Pharmacology Tips
    • Pharmacotherapy
    • Pharmacy
    • Phendimetrazine
    • Phentermine
    • phonemic awareness
    • Phonics
    • Physician assisted suicide
    • Pica
    • PICOT
    • Pimozide
    • Pitolisant
    • Podcast
    • polypharmacy
    • post traumatic stress disorder
    • post-exposure prophylaxis
    • Post-hoc Analysis ADHD Rating Scale-5
    • Post-menopausal
    • Post-stroke depression
    • Posterior Probability
    • Postpartum Depression
    • Potency
    • Practice management
    • Practice Tools and Tips
    • Practice Tools and Tips
    • Pramipexole
    • Prazosin
    • Pregabalin
    • Pregnancy
    • pregnancy testing
    • Prepubescent children
    • prescribing patterns
    • Prescription costs
    • prevalence
    • Prevention
    • Primary care
    • primary outcome
    • Prison
    • Privacy
    • Prodrome
    • Prolactin
    • Prolonged exposure
    • Promethazine
    • Promotoras
    • Pronouns
    • Provigil
    • Prozac
    • pseudobulbar affect
    • Psilocybin
    • Psychedelics
    • Psychiatric interviewing
    • Psychoanalysis
    • Psychodynamic therapy
    • Psychological First Aide
    • Psychopharm Myths
    • Psychopharmacology
    • Psychopharmacology Tips
    • Psychosis
    • Psychotherapy
    • Psychotherapy
    • Psychotic Agitation
    • Psychotic Depression
    • psychotic disorders
    • Psychotropic medication
    • PTSD
    • Public health
    • Qelbree
    • Quality of care
    • quality of life
    • Quetiapine
    • Quillivant
    • Race
    • Raloxifene
    • Randomized controlled trial
    • randomized discontinuation design
    • rapid naming
    • Rapid-acting
    • RCT
    • Reading
    • Reading disorder
    • Reading Disorders
    • Reading remediation
    • recovery time
    • Red Cross
    • Refeeding syndrome
    • Registered Articles
    • Relationships
    • Remediation
    • Repetitive Behavior
    • Repetitive behaviors
    • replication
    • reporting requirements
    • Research
    • Research Update
    • Research Updates
    • Respectful Care
    • restrictive dieting
    • retarded vs excited catatonia
    • retention
    • Retirement
    • retrograde amnesia
    • Riluzole
    • Risk
    • Risk Management
    • Risk of Addiction
    • Risperidione
    • Risperidone
    • Ritalin
    • rTMS
    • safety
    • Safety Planning
    • Saffron
    • SAMe
    • Samidorphan
    • Saphris
    • Schizoaffective disorder
    • Schizophrenia
    • School Phobia
    • School Refusal
    • ScreeninGeg
    • Seasonal Affective Disorder
    • Second Generation Antipsychotics (SGAs)
    • secondary outcome
    • Secuado
    • Self-injury
    • Self-Regulation
    • Semaglutide
    • Separation
    • Separation Anxiety
    • SERM (Selective Estrogen Receptor Modulator)
    • Serotonin
    • Serotonin Norepinephine Reuptake Inhibitors
    • Serotonin Specific Reuptake Inhibitors
    • Serotonin Specific Reuptake Inhibitors (SSRIs)
    • Sertraline
    • Sex offenders
    • Sex Therapy
    • Sexual Abuse
    • Sexual Dysfunction
    • sexual intercourse
    • Sexual Side Effects
    • SIADH
    • Side Effects
    • Silexan
    • Skype
    • Sleep
    • Sleep Apnea
    • Sleep Disorders
    • Sleep Onset Insomnia
    • Smoking Cessation
    • Smoking Cessation Agents
    • smoking cessations
    • SNRIs
    • Social Anxiety
    • Social Anxiety Disorder
    • social cohesion
    • sodium supplementation
    • Somnambulism
    • Special populations
    • Specific Phobia
    • SSRIs
    • statistical significance
    • Statutes
    • Stereotypical Behavior
    • steroids
    • STI screening
    • Stigma
    • stimulant
    • Stimulant Medications
    • Stimulant treatment
    • Stimulant use disorder
    • Stimulants
    • Stroke
    • structured literacy
    • Suboxone
    • Substance Abuse
    • Substance Abuse
    • Substance Use
    • Substance Use Disorder
    • Substance use disorders
    • Suicidality
    • Suicide
    • Sundowning
    • Supplements
    • Surrogate decision-maker
    • Suvorexant
    • Swallowing
    • Symptom Assessment
    • Symptom Management
    • Systematic review
    • Tags
    • Tantrums
    • Tarasoff
    • Tardive dyskinesia
    • Technology
    • Teen
    • teens
    • Telehealth
    • Telemed
    • Telemedicine
    • Telepsychiatry
    • test cme quiz
    • testifying
    • Tetrabenazine
    • TFCBT
    • TGD
    • Therapy during medication appointment
    • Therapy with Med Management
    • tics
    • TMS
    • Tobacco
    • tobacco research
    • Tobacco use disorder
    • Top 10 Podcasts of 2021
    • Topiramate
    • Toxic Stress
    • Transcranial Magnetic Stimulation
    • Transdermal
    • Transgender
    • Translator
    • Trauma
    • Trauma Informed Care
    • Traumatic Brain Injury (TBI)
    • Trazodone
    • treatment
    • treatment efficacy
    • treatment pediatric
    • Treatment planning
    • Treatment-Resistant Depression
    • Trigeminal Nerve Stimulation
    • Trintellix
    • unblinded
    • Understanding Psychiatric Research
    • unilateral vs bilateral
    • urinary difficulties
    • Valbenazine
    • Valproate
    • Vaping
    • Varenicline
    • Venlafaxine
    • verbal de-escalation
    • videogaming addiction
    • Viloxazine
    • Violence
    • Vitamin B6
    • Vitamin D
    • Vitamin E
    • VMAT2 Inhibitors
    • Vortioxetine
    • Vyleesi
    • Waist circumference
    • Wakix
    • water intoxication
    • water restriction
    • Weed
    • Weight gain
    • Weight Loss Medications
    • Weiss Functional Impairment Rating Scale-Parent (WFIRS-P)
    • Wellbutrin
    • whey protein powders
    • Whole Genome Sequencing
    • Wilderness Therapy Programs
    • Withdrawal
    • Women's Issues in Psychiatry
    • Women’s Issues in Psychiatry
    • Working With Families
    • workplace
    • Xenazine
    • Youth
    • Zenzedi and ProCentra
    • Ziprasidone
  • HOME
  • STORE
  • CME CENTER
  • Blog
  • Podcast
  • NEWSLETTERS
    • The Carlat Psychiatry Report
    • The Carlat Child Psychiatry Report
    • The Carlat Addiction Treatment Report
    • The Carlat Hospital Psychiatry Report
    • The Carlat Geriatric Psychiatry Report
  • Archive
  • Archive
  • Archive
  • Archive
  • Archive
  • The Carlat Addiction Treatment Report
  • Behavioral Addictions (December)
  • How to Diagnose and Treat Gambling Disorder

How to Diagnose and Treat Gambling Disorder

The Carlat Addiction Treatment Report, Volume 2, Number 8, December 2014
https://www.thecarlatreport.com/newsletter-issue/catrv2n8/

From The Carlat Addiction Treatment Report, December 2014, Behavioral Addictions

Issue Links: Learning Objectives | Editorial Information | PDF of Issue

Topics: Addiction | Free Articles

Print Friendly, PDF & Email

Daniel Carlat, MD

Your typical patient with a gambling disorder may not fit yesterday’s stereotype.

Consider this case study:

A 42-year-old woman presented for relationship issues and problems with gambling. She had begun gambling by buying scratch tickets when she was in her early 30s. At times, she would spend up to $300 per day on these lottery tickets. She had tried to solve the problem by avoiding convenience stores where the tickets were sold but had found it difficult because they are so ubiquitous. She had often lied to her husband about her problem. She was preoccupied most of the day with thoughts about going to the store to buy more tickets. She began going to Gamblers Anonymous meetings, a twelve-step program for people with gambling problems, with some success. At the same time her relationship with her husband was deteriorating and she was reporting symptoms of depression robust enough to meet criteria for major depressive disorder. A trial of fluvoxamine at a dose of 100 mg/day was successful for mitigating her depressive symptoms and also helped her to maintain her attendance at all Gamblers Anonymous meetings and to stop her gambling.

Gambling has changed over the years. For one, there’s a whole lot more of it going on. About 75% of Americans above the age of 12 report having gambled in the past year, according to the National Council on Problem Gambling. Gambling is widespread, with some form of legalized gambling available in 48 states and the District of Columbia—only Utah and Hawaii have resisted the trend.

And there are more ways to gamble. Internet gambling is a new concern, along with the burgeoning phenomenon of social casino gaming—gambling games played on Facebook and other social networks. These games are the fastest growing segment of the gambling industry, with an estimated 170 million monthly average users and revenues of $2 billion last year.

While gamblers tend not to seek out treatment (fewer than 10%), chances are you have seen patients with gambling issues, and you’ll see more of them over the next few years. In this article we give you a primer on diagnosis and treatment of gambling disorder.

Diagnosing the Disorder

The basic DSM-5 definition of gambling disorder is quite helpful: “the failure to resist gambling impulses despite severe personal, family, or occupational consequences.” If you were to use this as your guide, chances are that you would accurately diagnose most cases of this disorder.

The name of the problem has changed over the years. DSM-III called it “compulsive gambling.” In DSM-IV, it was renamed “pathological gambling” and the latest edition, DSM-5, calls it “gambling disorder,” and has recategorized it as a type of addiction—you’ll find it in the “Substance-Related and Addictive Disorders” section of the manual. Much ink has been spilt parsing out whether gambling disorder is more appropriately considered an impulse disorder (such as ADHD), a conduct disorder, an obsessive compulsive problem, or an addiction problem. Depending on the patient, there may be elements of all four. Keeping this in mind might give you better insight into your particular patient’s motivations, and will help you better tailor your treatment.

In order to formally diagnose gambling disorder, you have to establish that your patient has had at least four of a list of nine potential symptoms (“criteria”) in a 12-month period, and that the gambling problem isn’t caused by a manic episode. These core symptoms include factors such as wanting to gamble badly, always thinking about gambling, having a hard time resisting the urge to gamble, etc.

One way to remember the basic criteria is with the following mnemonic, Tempted With Casinos:

  • Tolerance (a need to gamble with more and more money to achieve the gambling high)
  • Withdrawal syndrome (feeling restless when forced to give up gambling)
  • Loss of Control (not being able to stop your gambling even after multiple negative consequences)

A validated rapid screen for gambling problems is the CLiP questionnaire (similar to the CAGE questionnaire for substance abuse), which evaluates loss of control, lying, and preoccupation.

  1. (Control) Have you ever tried to stop, cut down, or control your gambling?
  2. (Lying) Have you ever lied to family members, friends, or others about how much you gamble or how much money you lost on gambling?
  3. (Preoccupation) Have there ever been periods lasting two weeks or longer when you spent a lot of time thinking about your gambling experiences or planning out future gambling ventures or bets?

A positive answer to one of these questions indicates a high likelihood of problem gambling (Toce-Gerstein M et al, J Gambl Stud 2009;25(4):541–555).

Prevalence

The well-known US National Comorbidity Survey Replication (which is somewhat outdated, since it is based on interviews conducted from 2001–2003) estimated that 78% of all Americans have gambled at least once in their lives, but only 0.6% have had pathological gambling, while 2.3% have had “problem gambling” (defined as meeting at least one symptom of DSM-5’s criterion A).

The average age of onset of pathological gambling was about 17, the problem persisted an average of nine years, and the largest gambling loss in a single year averaged $4,800. The average gambler partakes in a range of gambling activities. The most common types of gambling are lottos/scratch tickets (86% of pathological gamblers), slot machines or bingo (77%), and casinos (78%)(Kessler RC et al, Psychol Med 2008;38(9):1351–1360).

Patients with gambling disorder are at high risk for other psychiatric problems. In the Kessler study, 46% of pathological gamblers were alcohol or drug abusers, 60% had an anxiety disorder, 38% had depression, and 17% had bipolar disorder.

Etiology

While nobody knows what causes gambling addiction in a biological sense, experts note that many of the same brain regions light up among problem gamblers as among drug addicts—such as the ventral striatum and the orbitofrontal cortex (Bullock SA and Potenza MN, Curr Psychopharmacol 2012;1(1)). None of the neurobiological studies have produced successful treatment yet.

Treatment
Psychosocial

This section is based mainly on a recent review of psychological treatments for gambling disorder (Rash CJ and Petry NM, Psychol Res Behav Manag 2014;7:285–295).

To begin with, it’s probably helpful to know that gambling disorder is often transient, episodic, and self-resolving. Studies have shown that over the course of a given year about 33% of problem gamblers will recover on their own. In-depth interviews of people who have recovered on their own show that they use practical means to do so, including avoiding going to places that remind them of gambling, and involving themselves in time-consuming activities that take their minds off gambling.

As a clinician, you’re more likely to see the more seriously affected patients who need treatment—either because they want it or because they are forced into it by spouses or the legal system. Studies of psychotherapy for gambling show that all techniques work better than no treatment at all, and no one technique is superior to others.

An easy intervention for a busy psychiatrist is to recommend that your patients attend Gamblers Anonymous (GA) meetings, which are increasingly widely available, especially during the current national binge to approve new casinos. As you can imagine, there are no good, randomized double-blind studies on GA (would such a study even be possible?), but various retrospective and open studies have implied a benefit of GA, at least for those who keep going to meetings. Thus, you can accurately tell patients that GA meetings are effective—but only if they attend regularly.

In terms of more formal interventions, behavior therapy, cognitive therapy, and motivational interviewing all appear to work, at least better than no therapy at all. In behavior therapy you help your patients avoid high-risk situations and desensitize them to these environments when they can’t avoid them. One strategy, for example, is to have patients gradually spend more and more time close to, and then inside of, casinos, and provide them with coping skills needed to avoid partaking of the gambling activities.

In cognitive therapy, you identify distorted cognitions associated with gambling, such as: overestimating the probability of winning; having an illusion of control over the outcome of the gambling; or the belief that a win is due after a series of losses (the so-called “gambler’s fallacy”). It’s likely that the most effective treatments combine cognitive and behavioral approaches.

A different approach is motivational interviewing. This is a technique often used in addictions in which you address your patient’s ambivalence about whether they really want to stop the behavior and allow them to come up with their own reasons for doing so. Though studied less, motivational interviewing appears to work as well as other approaches.

Medications

Various medications have shown promise in helping patients with gambling disorder (you can find individual references in a recent review paper, Pirritano D et al, Biomed Res Int 2014:728038; while the paper focuses on the disorder in Parkinson’s disease, it has a good general review of gambling treatment). Possibly the most robust data is on naltrexone, the opioid antagonist, which has shown benefit in both controlled and open trials, often at high doses up to 250 mg/day.

On the theory that gambling disorder shares certain features with OCD, SSRIs have been tested, but the results are mixed. For example, both fluvoxamine and paroxetine have been tested in small, randomized, controlled trials. In each case, one trial showed a benefit over placebo while the other did not. For the positive trials, the mean dose of fluvoxamine was 195 mg/day, and the mean dose of paroxetine was 51.7 mg/day. The best way to think about SSRIs is that they might be effective for some people with gambling disorder, and are particularly worth trying if your patient has a comorbid condition responsive to SSRIs (as was true for my patient described in the vignette at the beginning of this article).

Another logical treatment approach is to use mood stabilizers, since one of the symptoms of mania is irresponsible spending, of which gambling is an example. One small study suggested that sustained release lithium (mean dose, 1150 mg once a day) might be effective (Hollander E et al, Am J Psychiatry, 2005;162(1):137–145).

One interesting aspect of the psychopharmacology of gambling is that when patients with Parkinson’s disease are given dopamine agonist medications (which are the most effect treatments for the disorder), their risk of developing gambling disorder increases by 50%. The implication for non-Parkinson’s patients is, theoretically, that gambling disorder is caused by too much dopamine, and that dopamine blockers (ie, antipsychotics) should be effective. But they are not. Three studies of olanzapine have been negative, and small studies of aripiprazole have indicated that it might actually worsen gambling behavior.

Dr. Carlat’s Verdict: Gambling disorder is treatable—refer patients to GA, use cognitive behavioral therapy, and try naltrexone for core symptoms, and SSRIs when there are comorbidities.

Daniel Carlat, MD

Editor-in-Chief, Publisher, The Carlat Report. 

Dr. Carlat has disclosed that he has no relevant relationships or financial interests in any commercial company pertaining to this educational activity.

Share this page!
Subscribe
Register for free content

Register For Free Articles

Register to receive free email newsletters with concise, practical advice for busy clinicians. You will also have access to select article content on the website and you will receive notifications of new books and special discount offers.




Courses and Book CME
Medication Fact Book for Psychiatric Practice, Sixth Edition (2022)
2022 Carlat Psychiatry Report Self-Assessment Course
Prescribing Psychotropics: From Drug Interactions to Genetics
The Child Medication Fact Book for Psychiatric Practice (2018)
Issues Archives

2022

  • Alcohol Use Disorder (March/April)
  • Smoking Cessation (January/February)

2021

  • Opioid Epidemic Update (November/December)
  • Designer Drugs (September/October)
  • Addiction in Pregnancy (July/August)
  • Stimulant Use Disorder (May/June)
  • Integrating Pharmacotherapy and Psychotherapy (March/April)
  • Pain and Addiction (January/February)

2020

  • Esketamine (January)
  • Telepsychiatry (May)
  • Mind-Gut Connection (January)
  • Practical Psychotherapy (November/December)
  • Mood and Menopause (October)
  • When to Use Lithium (September)
  • Traumatic Brain Injury (August)
  • Borderline Personality Disorder (June/July)
  • Psychopharmacology Algorithms (April)
  • Bipolar II (March)
  • Inflammation and Depression (February)

2020

  • Mood Disorders in Children and Adolescents (Oct/Nov/Dec)
  • Identity & Culture in Children and Adolescents (July/August/September)
  • Psychosis in Children and Adolescents (April/May/June)
  • ADHD in Children and Adolescents (Jan/Feb/Mar)

2020

  • Harm Reduction (January/February)
  • Substance Use in Health Professionals (March/April)
  • Alternative Treatment in Addiction (November/December)
  • Social Aspects of Addiction (September/October)
  • Opioid Use Disorder Treatment (July/August)
  • Emerging Risks for Old Medications (May/June)

2019

  • Depression (May)
  • Adult ADHD (November/December)
  • Mental Health Apps (October)
  • How to Talk about Medication (September)
  • Side Effects Part II (August)
  • Side Effects Part I (June/July)
  • Sleep (April)
  • Parenting, Pregnancy, and Prevention (March)
  • Dark and Light Therapy (February)
  • Deprescribing (January)

2018

  • Drug Metabolism (November/December)
  • Working With Transgender Patients (October)
  • Emergency Psychiatry (September)
  • Treatment-Resistant Depression (July/August)
  • Neurobiology (June)
  • Anxiety (May)
  • Neurofeedback (April)
  • Antipsychotics Update (March)
  • Working With Families (February)
  • Bipolar Disorder (January)

2017

  • PTSD (December)
  • Retirement (November)
  • Intellectual Disability (September/October)
  • Antidepressants (July/August)
  • Personality Disorders (June)
  • Dementia (May)
  • Cognitive Behavior Therapy Techniques (April)
  • Pharmacogenetics (March)
  • Treating Psychosis (February)
  • Adult ADHD (January)

2016

  • Complementary and Alternative Medicine in Psychiatry (November/December)
  • Side Effects (October)
  • Pain Management (September)
  • Medication in Pregnancy (July/August)
  • Psychoanalysis in Modern Psychiatry (June)
  • Correctional Psychiatry (May)
  • Antidepressant Roundup (April)
  • Burnout (March)
  • Private Practice (February)
  • Bipolar Disorder (January)

2015

  • Psychiatry and General Medicine (November/December)
  • Biomarkers in Psychiatry (May)
  • Telepsychiatry (October)
  • Sleep Disorders (September)
  • Interventional Psychiatry (July/August)
  • Eating Disorders (June)
  • Psychotherapy Updates (April)
  • Topics in Geriatric Psychiatry (March)
  • Antipsychotics Update (February)
  • Risk Management (January)

2014

  • Bipolar Disorder (November/December)
  • Pharmacogenetics (October)
  • Keeping up in Psychiatry (September)
  • Research in Psychiatry (July/August)
  • Marijuana (June)
  • Psychiatric Diagnosis (May)
  • Issues in Psychopharmacology (April)
  • Schizophrenia (March)
  • Women’s Psychiatry (February)
  • Ethics in Psychiatry (January)

2013

  • Military Psychiatry (December)
  • Depression (November)
  • Treatment of Dementia (October)
  • Anxiety Disorders (September)
  • Natural and Alternative Treatments in Psychiatry (July/August)
  • Autism Spectrum Disorder (June)
  • Practice Tips (May)
  • Substance Abuse (April)
  • Medicolegal Topics (March)
  • End of Life Care (February)
  • Antipsychotic Update (January)

2012

  • Screening Tools and Tips (December)
  • Medical Comorbidities (November)
  • Devices in Psychiatry (October)
  • Eating Disorders (September)
  • Bipolar Disorder (July/August)
  • Risk Management (June)
  • Antidepressant Roundup 2012 (May)
  • Gender and Sexuality (April)
  • Personality Disorders (March)
  • ADHD (February)
  • Natural Treatments in Psychiatry (January)

2011

  • Electronic Medical Records (December)
  • Insomnia (November)
  • Psychotherapy (October)
  • Alcoholism (September)
  • Anxiety Disorders (July/August)
  • Schizophrenia (June)
  • Managing Side Effects (May)
  • Antidepressant Roundup 2011 (April)
  • DSM-5 and Diagnostic Issues (March)
  • Drug-Drug Interactions (February)
  • Bipolar Disorder (January)

2010

  • Hospital Psychiatry (December)
  • Psychiatric Medication in Pregnancy (November)
  • Maintenance of Certification (October)
  • The Neuroscience of Psychotherapy (September)
  • Treatment of Depression (July/August)
  • Email and the Internet in Psychiatry (June)
  • Substance Abuse (May)
  • The Diagnosis and Treatment of Dementia (April)
  • Ethics in Psychiatry (March)
  • Natural Treatments in Psychiatry (February)
  • ADHD (January)

2009

  • Treating Schizophrenia (December)
  • Treatment for Anxiety Disorders (November)
  • The Latest on Antidepressants (October)
  • Topics in Neuropsychiatry (September)
  • The Interface of Medicine and Psychiatry (July/August)
  • Generic Medications in Psychiatry (June)
  • The Treatment of Eating Disorders (May)
  • Healthcare Policy and Psychiatry (April)
  • Antipsychotic Roundup 2009 (March)
  • Psychiatric Medication in Pregnancy and Lactation (February)
  • Transcranial Magnetic Stimulation (January)

2008

  • Treating Fibromyalgia and Pain in Psychiatry (December)
  • Issues in Child Psychiatry (November)
  • Improving Psychiatric Practice (October)
  • Treating Personality Disorders (September)
  • Bipolar Disorder (July/August)
  • Antipsychotic Roundup 2008 (June)
  • Atypical Antipsychotics in Clinical Practice (February)
  • Neuropsychological Testing (May)
  • Psychiatric Medications: Effects and Side Effects (April)
  • Update on Substance Abuse (March)
  • Anticonvulsants in Psychiatry (February)
  • Brain Devices in Psychiatry (January)

2007

  • The Treatment of Insomnia (December)
  • Avoiding Malpractice in Psychiatry (November)
  • Update on Eating Disorders (October)
  • Complex Psychopharmacology (September)
  • Laboratory Testing in Psychiatry (August)
  • Psychotherapy in Psychiatry (July)
  • Posttraumatic Stress Disorder (June)
  • Topics in Geriatric Psychiatry 2007 (May)
  • Pregnancy and Menopause in Psychiatry (Apil)
  • Antipsychotic Roundup 2007 (March)
  • Understanding Psychiatric Research (February)
  • Antidepressant Round-up 2007 (January)

2006

  • Technology and Psychiatric Practice (December)
  • The Use of MAOIs (November)
  • Medication Treatment of Depression (January)
  • Seasonal Affective Disorder (October)
  • Treatment of ADHD (September)
  • Topics in Bipolar Disorder (August)
  • Neurotransmitters in Psychiatry (July)
  • Treating Substance Abuse (June)
  • The STAR*D Antidepressant Trial (May)
  • Natural Treatments in Psychiatry (April)
  • Medication Treatment of Anxiety (March)
  • Panic Disorder: Making Treatment Work (March)
  • Antipsychotic Roundup 2006 (February)
  • Antidepressant Roundup 2006 (January)

2005

  • Self-Help Books and Psychiatry (December)
  • Genetics and Psychiatry (November)
  • Pregnancy and Psychiatric Treatment (October)
  • Benzodiazepines and Hypnotics in Psychiatry (September)
  • Geriatric Psychiatry Update (August)
  • Chart Documentation in Psychiatry (July)
  • The Treatment of Bipolar Disorder (June)
  • Weight Loss and Smoking Cessation in Psychiatry (May)
  • Treating ADHD (April)
  • Drug Industry Influence in Psychiatry (March)
  • Atypical Antipsychotics 2005 (February)
  • Antidepressant Roundup 2005 (January)

2004

  • Sexual Dysfunction (December)
  • Suicide Prevention (November)
  • To Sleep, To Awake (October)
  • Women’s Issues in Psychiatry (September)
  • OCD: An Update (August)
  • Chronic Pain and Psychiatry (July)
  • Neuroimaging in Psychiatry (June)
  • Natural Medications in Psychiatry (May)
  • Posttraumatic Stress Disorder (April)
  • Treatment of Alcoholism (March)
  • Battle of the Atypicals (February)
  • Antidepressant Roundup, 2004 (January)

2003

  • Research Methods in Psychiatry (December)
  • Antidepressants in Children (November)
  • The Treatment of Dementia (October)
  • Bipolar Disorder, Part II: The Novel Anticonvulsants (September)
  • Bipolar Disorder: The Basics (August)
  • Drug-Drug Interactions in Psychiatry (July)
  • Managing Antidepressant Side Effects (June)
  • Antidepressants in Pregnancy and Lactation (May)
  • ADHD: Medication Options (April)
  • Panic Disorder: Making Treatment Work (March)
  • Atypical Antipsychotics in Clinical Practice (February)
  • Medication Treatment of Depression (January)

2019

  • Autism in Children and Adolescents (November/December)
  • Depression in Children and Adolescents (May/June/July/August)
  • Substance Use in Children and Adolescents (September/October)
  • Trauma in Children and Adolescents (March/April)
  • Anxiety in Children and Adolescents (January/February)

2018

  • Psychotropic Risks in Children and Adolescents (May/June)
  • ADHD in Children and Adolescents (November/December)
  • Depression in Children and Adolescents (September/October)
  • Autism in Children and Adolescents (July/August)
  • Anxiety in Children and Adolescents (March/April)
  • Suicide in Children and Adolescents (January/February)

2017

  • Adolescents (November/December)
  • ADHD in Children and Adolescents (September/October)
  • Psychosis in Children and Adolescents (August)
  • PANDAS, PANS, and Related Disorders (June/July)
  • Marijuana in Children and Adolescents (May)
  • Tourette’s and Other Tic Disorders in Children and Adolescents (March/April)
  • Autism in Children and Adolescents (January/February)

2016

  • Gender Dysphoria in Children and Adolescents (November/December)
  • Technology Issues With Children and Adolescents (September/October)
  • Mood Dysregulation in Children and Adolescents (July/August)
  • Eating Disorders in Children and Adolescents (May/June)
  • Conduct Disorder in Children and Adolescents (April)
  • Sleep Disorders in Children and Adolescents (March)
  • ADHD in Children and Adolescents (January/February)

2015

  • Antidepressant Use in Children (November/December)
  • Foster Care and Child Psychiatry (September/October)
  • Autism (July/August)
  • Trauma (May/June)
  • Anxiety Disorders (April)
  • Schools and Psychiatry (March)
  • Emergency Psychiatry in Children (January/February)

2014

  • Antipsychotics in Children (December)
  • ADHD (November)
  • Gender and Sexuality (September/October)
  • Psychotic Symptoms (Summer)
  • Medication Side Effects (May)
  • Food and Mood (April)
  • Learning and Developmental Disabilities (February)

2013

  • Complex Practice Issues (December)
  • Diet and Nutrition (November)
  • Child Psychiatry in DSM-5 (August/September)
  • Medication Side Effects and Interactions (June/July)
  • Problematic Technology (March/April)
  • Autism Spectrum Disorders (January/February)

2012

  • Bipolar Disorder (December)
  • Substance Abuse (October/November)
  • Transitional Age Youth (July/August)
  • Rating Scales (May/June)
  • Eating Disorders (March/April)
  • Behavioral Disorders (February)

2011

  • Treatment of Anxiety Disorders (December)
  • Trauma (November)
  • Bullying and School Issues (October)
  • Hidden Medical Disorders (August)
  • OCD and Tic Disorders (June)
  • Suicide and Non-Suicidal Self Injury (April)
  • Sleep Disorders (March)
  • ADHD (January)

2010

  • Use of Antipsychotics in Children and Adolescents (December)
  • Learning and Developmental Disabilities (October)
  • Major Depression (September)
  • Treating Children and Families (July)
  • The Explosive Child (May)

2019

  • Dual Diagnosis in Addiction Medicine (May/June)
  • Medical Issues in Addiction Practice (November/December)
  • Alcohol Addiction (September/October)
  • Legal Issues in Addiction Medicine (July/August)
  • Traumatic Brain Injury and Addiction (March/April)
  • Board Certification in Addiction Medicine (January/February)

2018

  • Opioid Addiction (November/December)
  • Addiction in Older Adults (October)
  • Sleep Disorders and Addiction (September)
  • Adolescent Addiction (July/August)
  • Pain and Addiction (May/June)
  • Cannabis and Addiction (March/April)
  • Stigma and Addiction (January/February)

2017

  • Pregnancy and Addiction (November/December)
  • Detox (Sepember/October)
  • Dual Diagnosis (August)
  • Alternatives to 12-Step Programs (June/July)
  • Recovery (May)
  • Psychiatric Uses of Street Drugs (March/April)
  • Sex Addiction (January/February)

2016

  • Prescription Drug Monitoring Programs (PDMPs) (November/December)
  • Addiction in Health Care Professionals (September/October)
  • Dialectical Behavior Therapy in Addiction (August)
  • Motivational Interviewing (June/July)
  • Benzodiazepines (May)
  • Opioid Addiction (March/April)
  • Families and Substance Abuse (January/February)

2015

  • The Twelve Steps (November/December)
  • Designer Drugs (September/October)
  • Residential Treatment Programs Decoded (July/August)
  • Nicotine and E-Cigarettes (June)
  • Drug Screening (April/May)
  • Integrating Therapy and Medications for Alcoholism (March)
  • Detoxification Protocols (January/February)

2014

  • Behavioral Addictions (December)
  • Risk and Reimbursement (November)
  • Stimulant Abuse (September/October)
  • Self-Help Programs (June)
  • Opioid Addiction (May)
  • Coping with Bad Outcomes (March)
  • Change Management in Addiction Treatment (January/February)

2013

  • Cocaine Addiction (December)
  • Relapse Prevention (November)
  • Cannabis Addiction (August/September)
  • Addiction in DSM-5 (June/July)
Editor-in-Chief

Noah Capurso, MD, MHS

Dr. Capurso is an assistant professor of psychiatry at the Yale University School of Medicine and practices clinically at the West Haven Veterans Administration Hospital. He attended medical school at Yale, where he received his MD, and where he conducted research in the Department of Biomedical Engineering. He stayed at Yale for residency and addiction psychiatry fellowship training. As an educator, Dr. Capurso teaches medical students about addiction treatment and develops the psychiatric curriculum for residents. As a clinician, Dr. Capurso is the medical director of the VA’s Detoxification & Addiction Stabilization Service and the Psychosocial Residential Rehabilitation Program.

Full Editorial Information

About

  • About Us
  • CME Center
  • FAQ
  • Contact Us

Shop Online

  • Subscriptions
  • Books
  • Online Courses

Newsletters

  • The Carlat Psychiatry Report
  • The Carlat Addiction Treatment Report
  • The Carlat Child Psychiatry Report
  • The Carlat Hospital Psychiatry Report

Contact

  • info@thecarlatreport.com
  • 866-348-9279
  • PO Box 626, Newburyport MA 01950

Follow Us

© 2022 Carlat Publishing, LLC and Affiliates, All Rights Reserved.

Please see our Privacy Policy and the Hardware/Software Requirements to view our website.

×