Author Archives: Judith Gordon Drake

Gambling addiction

When gambling stops being a game…

The term addiction describes a specific type of relationship between a person and a behaviour that generates a particular sensory reward. It is a relationship qualified by a state of being out-of-control. It is easy to identify the problem in the case of alcohol or drug dependence where the sensory reward is the intoxicating effect of the use of mood-altering substances. However, in the case of gambling, the addictive relationship lies with a particular behaviour, namely the experience of risk derived from playing a game of chance that produces a sensory response – a heightened sense of arousal or mood.

Several explanations (or models) have been presented to explain addiction. These divide, more or less, into the models which stress biological or genetic causes – and those which stress social or purely psychological causes. Of course there are also many models which attempt to see addiction as both a physiological and a psychosocial phenomenon. The model used most frequently by addiction treatment professionals (including gambling addiction counsellors) is the disease model; addiction is a “disease of the brain”. The premise of the disease model of addiction is that addiction is a disease, coming about as a result of either the impairment of neurochemical or behavioural processes, or of some combination of the two (Meyer, 2001).

Addiction can be described as a complex “brain disease” (Leshner, as cited in van Wormer & Davis, 2008, p. 38). Many factors are thought to contribute to the development of this condition, including genetic, physiological, socio-environmental, psychosocial and nutritional. Weich (2006, p. 436) refers to addiction as an “irreversible, chronic, relapsing brain disease”. It is characterised by a loss of control – or powerlessness over the drug or alcohol being used, despite the negative effects and consequences it causes (Hutton, 2011). Addiction almost always features a level of psychological dependence, and often, physical dependence.

Ultimately, addiction is an addictive behaviour – one over which an individual has impaired control (powerlessness). The addictive behaviour creates harmful consequences (unmanageability).

Although it is effectively related to a quantity, both in time and amount, it is not the quantity in its own right that is exclusively the problem. In the end, whether it is substance abuse or gambling, the hallmark of the addict is determined not by ‘how much’ but by ‘how’ he does the activity, that is, the manner in which he engages in the addictive behaviour. Equally, loss of control is very often reflected in the consequences of the behaviour and not in the behaviour itself. The assessment of the consequences of the behaviour remains highly subjective and individualised.

In the light of this, the diagnosis of addictive gambling, along with most other addictive disorders, remains a particularly daunting challenge, requiring a frame of reference gleaned only through experience (Meyer, 2001).

What is gambling? Gambling is placing a bet on anything that has an unknown outcome.

Types of gambling

    Types of gambling include:

  • Casino gambling – slots and tables
  • Lottery tickets
  • Scratch cards
  • Internet gambling
  • Sports betting
  • Betting in the Tab
  • Horse racing
  • Stock exchange.

Types of gamblers

There are four types of gamblers – social gamblers, who can happily put R100 into a slot machine and walk away if they lose; problem gamblers, who will immediately play another R100 to try and make up for the R100 they have just lost (“chasing”); and pathological gamblers, who are obsessed with gambling and constantly thinking of how to find more money with which to bet. The fourth type is professional gamblers who are generally not addicted and gamble for a living.

Social gambling

Casual, social gamblers gamble for recreation, sociability and entertainment and gambling typically occurs with friends or family. These people gamble for fun rather than for the ‘certainty’ of winning, recognise that they are likely to lose, and don’t bet more than they can afford to lose. Thus, the gambling is controlled, lasts for a limited period of time and the losses are predetermined and reasonable. Gambling does not interfere with family, social or vocational obligations.

Problem gambling

This describes an involvement in risky gambling behaviour that adversely affects the individual’s well being. This may include issues of relationships, family, financial standings, social matters and vocational pursuits (Arizona Council on Compulsive Gambling, Inc., 1995). The problem gambler experiences a preoccupation with gambling with impaired to poor, to periodic loss of control. There is a narrowing of interests and gambling continues despite adverse consequences. There are also failed attempts to cut down. Problem gamblers very often find themselves in in the losing phase (‘the chase’). Problem gambling is used to refer to the wider group of people who show some, but not all signs of developing a pathological gambling condition” (Bulwer, 2003).

Pathological gambling

Pathological (or compulsive) gambling is classified as an impulse control disorder and is recognised as a medical disorder by the American Psychiatric Association. It has the elements of addiction similar to alcohol and drug addiction. According to Sadock & Sadock, “Pathological gambling is characterised by persistent and recurrent maladaptive gambling that causes economic problems and significant disturbances in personal, social, or occupational functioning. Aspects of the maladaptive behaviour include:

  • A preoccupation with gambling
  • The need to gamble with increasing amounts of money to achieve the desired excitement
  • Repeated unsuccessful efforts to control, cut back, or stop gambling
  • Gambling as a way to escape from problems
  • Gambling to recoup losses
  • Lying to conceal the extent of the involvement with gambling
  • The commission of illegal acts to finance gambling
  • Jeopardising or losing personal and vocational relationships because of gambling
  • A reliance on others for money to pay off debts” (2007)

Professional gambling

Professional gamblers consider themselves skilled in the games they play and believe that they are able to control both the amount of time they spend gambling and the amount of money they spend on gambling. Generally, professional gamblers are not addicted to gambling. They are disciplined and they limit the risk by patiently waiting for the best bet, in order to win as much money as possible. They can be considered to be practicing a profession, rather than gambling.
Researchers from University Hospital of Bellvitge and the Autonomous University of Barcelona(Responsible Gambling Digest, 2010) identified subtypes of pathological gamblers:

  • Type I (disorganised and emotionally unstable) is characterised by schizotypal personality traits, high degrees of impulsiveness, substance and alcohol abuse, psychopathological alterations and early onset age
  • Type II (schizoid) exhibits high levels of harm avoidance, social aloofness, and alcohol abuse
  • Type III (reward-sensitive) is characterised by high levels of sensation-seeking and impulsiveness, but without psychopathological alterations
  • Type IV (high functioning) is a globally-adapted personality type, without any disorders relating to substance abuse, and no associated psychopathological alterations.
    Clinical implication of this research is that pathological gambling is a highly heterogeneous disorder that may require different therapeutic approaches according to its specific characteristics.

Reflecting on how perspectives have changed in the field of research on gambling disorders, Black (cited in Black, Goodie, Wynne & Goudriaan, 2010) suggested that the most significant change was that pathological gambling was included in the Diagnostic and Statistical Manual of Mental Disorders, 3rd ed. in 1980. “This set off a paradigm shift away from disordered gambling being considered strictly a social and behavioural phenomenon, to that of it being a neuropsychiatric disorder” (Black, 2010, p. 1).

A May 2011 report states that pathological gambling “will be reclassified from a behavioural disorder to an addiction, as of 2013. For more than 30 years, doctors have considered pathological gambling a behavioral disorder, not an addiction. But that’s about to change. In 2013, the psychiatric community will officially classify uncontrolled gamblers as addicts — the first-ever ‘behavioral addiction’. Pathological gambling will no longer be an impulse-control problem” – like pyromania, kleptomania or trichotillomania (Mangels, 2011). This reclassification of pathological gambling with Substance-related disorders – including substance dependence and substance-induced disorders will be contained in the next edition of the American Psychiatric Association’s Diagnostic and Statistical Manual, the textbook that guides diagnosis and treatment.

A “psycho-bio-social” perspective on gambling research was presented by Wynne (2010) – in order to best understand the behaviour associated with problem gambling. He considers the “social milieu” in which the problem gambler exists, that is, the peer group, the family, the work environment, the cultural group and the community to be significant. As gambling is a social activity, research attention needs to be paid to the external factors which influence the gambler’s behaviour.

Epidemiology

    Various factors play a role in causing pathological gambling:

  • Biological
  • Psychological
  • Social
    Comorbidity is common and is being researched in South Africa, notably:

  • Other addictions
  • Depression and Anxiety disorders
  • Post traumatic stress disorder.
    Males are more likely to be pathological gamblers than females:

  • Male predictors are anxiety (hyper-arousal) and dissociation
  • Female predictors are depressed mood, dissociation and use of stimulants
    The majority of females began pathological gambling later in life:

  • Gravitated towards one object of addiction
  • Progressed more rapidly to dependency
  • Quicker to seek treatment

The proportion of pathological gamblers among adolescents is higher than in adults. The younger the gambling starts – the more likely it is to develop into pathological gambling.

Risk factors

    There is a higher risk of developing problem gambling if people are using gambling:

  • In the hope of solving money problems
  • As a means of escaping painful realities such as relationship problems, divorce, job loss, retirement or death of a loved one
  • In order to cope with a health concern and/or physical pain
  • As an antidote to loneliness
  • As an antidote to boredom
  • To anaesthetise themselves against negative feelings or events, such as depression and anxiety and situations which provoke them
  • As a reaction to a history of abuse or trauma
  • As one amongst a cluster of problem behaviours such as excessive use of alcohol or other drugs or overspending
    In gambling addiction there is also:

  • Genetic component
  • Environmental factors
  • Gambling related superstitions and false beliefs – which means people gamble more than can afford to lose

Process of gambling addiction

    The process of gambling addiction can be described as:

  • Winning stage – Impaired control – Comfortable passing of time; recreational activity; excitement and entertainment; initial period of winning; increased self esteem
  • Losing stage – Poor control – Increased tolerance with more time spent gambling; higher stakes and bigger losses; gambling with borrowed money; secret gambling; promises to stop
  • Critical stage – Loss of control “chasing” – Onset of “consequences”; problems with finances, relationships and work; failed attempts at control; rationalisation of behaviour
  • Desperate stage – Absence of control – Gambling is a full-time occupation with loss of
    social supports and work; criminal offences; social misfit; depression and suicidal behavior

REFERENCES

Black, D. W., Goodie, A.S., Wynne, H. & Goudriaan, A. (2010). Looking back: Perspectives on changes in the field of research on gambling disorders. Issues & insights, 1-2.

Bulwer, M. (2003). Treating gambling addiction: A psychological study in the South African context (Masters thesis). University of South Africa, Pretoria.

Hutton, B. (Ed). (2011). Recovery RSA: A resource book for those affected by addiction. Johannesburg, South Africa: Stonebridge Books.

Mangels, J. (2011). Psychiatric community decides to classify uncontrolled gamblers as addicts, which could change how society views them. Retrieved from www.responsiblegambling.org/articles/Psychiatric_community.pdf

Meyer, R. (2001). National Responsible Gambling Programme: Treatment protocol for the gambling addiction network counsellors. Cape Town.

National Responsible Gambling Programme. (2010). Scientists identify four types of compulsive gamblers. Responsible Gambling Digest, 10/10, 19-20.

Sadock, B. J., & Sadock, V. A. (2007). Kaplan & Sadock’s synopsis of psychiatry: Behavioural sciences/clinical psychiatry (10th ed.). Philadelphia: Lippincott Williams & Wilkins.

Van Wormer, K., & Davis, D. R. (2008). Addiction treatment: A strengths perspective (2nd ed.). Belmont, CA, USA: Thomson Brooks/Cole.

Weich, E. M. (2006). Substance use disorders. CME (Continuing medical education): The SA journal of CPF, 24:8, pp. 436-440.

Co-morbidity – Alcoholism / addiction with psychiatric illness

Introduction

It is an age-old riddle that has perplexed us for generations; which came first, the chicken or the egg? (There is definitive scientific evidence that it’s actually the chicken – but that is not important.) In this article I focus on co-morbidity, which is the presence of two conditions which exist in a person simultaneously. My focus is the co-existence of addiction/alcoholism and a psychiatric illness, but there is also the co-existence of addiction/alcoholism and a medical illness. Both psychiatric and medical illnesses can be caused by the addiction – or they can be present coincidentally, that is, together with/alongside the addiction.

    The Addiction disease concept construct – from the The Jellinek Curve, modified by Max Glatt, a professor at Yale University in 1961 is:

  • Drug use (apparent control)
  • Drug misuse (poor control)
  • Drug addiction (loss of control)
  • Drug dependence (no control)
  • “Rock bottom” (no purpose/no pleasure)
    Physical illness differs from mental illness in that symptoms can often be related to a cause and a standard treatment can be prescribed. Teggin (as cited in Hutton, 2011) describes medical illness co-morbidity, specifically alcoholics risk contracting the following medical illnesses:

  • Cirrhosis of the liver
  • Gastro-intestinal haemorrhaging and gastritis
  • Alcohol-related dementia
  • Pancreatitis
  • Wernicke-Korsakoff syndrome (“wet brain” or impairment of recent memory)
    Drug addicts, specifically risk contracting the following medical illnesses:

  • Hepatitis C
  • HIV and AIDS
  • Infection of the heart valves
  • Other infections, including abscesses
    Owing to the debilitating effects of alcohol and drug addiction, addicts may contract other medical illnesses such as:

  • Nutritional disorders
  • Tuberculosis (TB)
  • Pneumonia
  • Other infections and malignancies

In my clinical social work practice, specialising in addiction, I frequently come across psychiatric illness co-morbidity – or “dual diagnosis”, as it is also called.

“Mental illness” is most commonly defined by the criteria contained in the Diagnostic and Statistical Manual of Mental Disorders (4th Edition) (Text Revised) (DSM-IV-TR) (American Psychiatric Association, 2000).

Mental illness is however, difficult to define, and there are different ideas about its causes. One theory is that its roots are organic (that is, owing to abnormal functioning in the brain) and that chemical imbalances in the brain lead to mental disorders. Another theory is that it stems from a difficult social environment or from “faulty” learning experiences that have led to inappropriate or unusual behavior. Such behaviour may be viewed as a sign of mental illness. The two factors actually overlap and interact. Organically rooted mental illness may lead to inappropriate behaviour, and unusual behaviour may lead to changes in brain chemistry. Mental illness is therefore not fixed; rather, it encompasses a broad range of conditions, interpretations and behaviours.

These days, many mental health professionals regard mental illness as a result of both “nature” and “nurture”. A simple definition taken from an unreferenced LifeLine Johannesburg training handout is, “A person is considered to be suffering from a major mental illness if he has developed a lifestyle that seriously impeded his ability to function in his day-to-day activities. Mental health, as defined by the World Health Organisation (WHO) “refers to a broad array of activities directly or indirectly related to the mental well-being component included in the WHO’s definition of health: ‘A state of complete physical, mental and social well-being, and not merely the absence of disease’. It is related to the promotion of well-being, the prevention of mental disorders, and the treatment and rehabilitation of people affected by mental disorders” (World Health Organisation, 2011). The WHO has also issued a new report in which they describe mental health and development. In the report they refer to the target group of “people with mental health conditions” as “a vulnerable group” (World Health Organisation, 2011).

As Teggin (as cited in Hutton, 2011, p. 79) has indicated, “Psychiatric conditions tend to be more complex than medical illnesses because they can either be caused by the alcohol or drug addiction, or they can co-exist independently, with or without Personality Disorder”. The author (as cited in Hutton) concludes, “Research shows that a person may have a genetic predisposition to both addiction and psychiatric illness. In other words any psychiatric illness can co-exist in an addict or alcoholic” (2011, p. 81).

Van Wormer and Davis (2003, p. 247) begin their chapter: “Substance misuse with a co-existing disorder or disability” with a metaphoric quote by Stevie Smith:
“I was much too far out all my life
And not waving but drowning”
Mental illness can be frightening when it spirals out of control. When combined with the misery, shame, guilt and consequences of alcohol/addiction, the result can be an unmanageable life – that can be likened “drowning”.

With regard to prevalence, Ries et al., (as cited in Doweiko) suggested that overall “between 40% and 75% of people who struggle with mental illness have a separate substance-use disorder” (2006, p. 292); Patrick; RachBeisel et al., (as cited in Doweiko) stated “In the early 21st century, it has become generally accepted that about 50% of patients with a form of mental illness will have a concurrent substance-abuse problem (2006, p. 292); and “The National Co-morbidity Survey found that 51% of persons with a lifetime addictive disorder also have a lifetime mental disorder” (Kessler, Nelson, & McGonagle, as cited in Van Wormer & Davis, 2003, p. 249). In fact, “There is evidence that the more serious the individual’s psychiatric diagnosis, the more difficult it is for him or her to abstain from drugs of abuse” (Ritsher, Moos, & Finney, as cited in Doweiko, 2006, p. 292).

    Van Wormer and Davis’s research show that the following disorders and disabilities commonly co-exist with alcoholism/addiction:

  • Anxiety
  • Pathological (Compulsive) gambling
  • Eating disorders
  • Mood disorders
  • Personality disorders
  • Psychotic disorders

Doweiko (2006, p. 292) is more specific about the scope of the problem; in a Table showing “The overlap between substance use disorders and various psychiatric disorders”, they compare the “Lifetime prevalence of psychiatric diagnosis” with “Substance-use disorder”:

Depression 32%
Bipolar affective disorder (or manic depression) 64%
Anxiety disorder 36%
Antisocial personality disorder 84%
Attention deficit hyperactivity disorder (ADHD) 23%
Eating disorders 28%
Schizophrenia 50%
Somatoform disorders Unknown, but suspected to be related

Many people with mental illnesses use alcohol and substances to “self-medicate” emotional pain and to relieve depression symptoms. Research studies on co-morbidity have found that “the individual’s alcohol abuse frequently precedes clinical manifestations of the person’s psychiatric condition” (Doweiko, 2006, p. 293). Meuser, Drake, and Wallach (as cited in Van Wormer & Davis) disagree with Doweiko when they stated, “Persons with co-existing disorders appear to use alcohol and other drugs for the same reasons persons without co-existing disorders use substances, i.e., loneliness, anxiety, boredom, and insomnia” (2003, p. 250).

    There are several hypotheses, with some evidence for each as to why psychiatric illness and substance dependence may co-exist. These, according to GreenFacts (2006) are:

  • There may be a similar neurobiological basis to both
  • Substance use may help to alleviate some of the symptoms of the psychiatric illness or the side effects of medication
  • Substance use may precipitate psychiatric illnesses or lead to biological changes that have common elements with psychiatric illnesses

“It is interesting that the effects of many psychoactive substances can produce psychiatric-like syndromes. For example amphetamines and cocaine can induce psychotic-like symptoms. Hallucinogenic substances can produce hallucinations, which are an aspect of some psychoses. Furthermore, psychoactive substances regularly alter mood states, producing either euphoric and happy feelings, or inducing depressive symptoms, especially during substance withdrawal. Psychoactive substances can alter cognitive functioning, which is also a core feature of many mental illnesses. These factors all suggest common neurobiological substrates to both mental illnesses and substance dependence” (GreenFacts, 2006).

Treatment and recovery of co-morbidity: alcoholism/addiction with psychiatric illness

    Where co-morbidity – alcoholism/addiction with psychiatric illness exists, both conditions have to be treated simultaneously by appropriate professionals, utilising a multidisciplinary or integrated approach:

  • Alcoholism and drug addiction should be treated by an addiction counsellor (preferably in an addiction treatment setting)
  • Psychiatric illness should be treated by a psychiatrist
  • The addiction counsellor and psychiatrist should liaise and work together regarding appropriate in-patient or out-patient treatment for the client
  • The addiction counsellor and psychiatrist should refer where necessary to other professionals such as psychologists, social workers, dieticians, occupational therapists, general practitioners and biokineticists
  • Specific interventions should be instituted where necessary, for example, grief counselling, cognitive behavioural therapy (CBT), couple counselling, nutritional planning, social/lifestyle assistance and physical wellness programmes

A welcome trend is for psychiatric clinics to have Dual Diagnosis Units (DDU). One such clinic’s website explains that “The DDU, while holding onto the belief that addiction is a disease in and of itself, also understands that the abuse of substances is associated with psychiatric diagnoses such as depression, anxiety and bipolar disorder. Addiction can also be related to unresolved issues from the past, current social circumstances and personality” (Crescent Clinic: Private Psychiatric Clinic, 2011).

The ideological conflict of identifying a primary problem has, to some extent been relieved with the “integrated” approach – which provides simultaneous treatment for clients’ needs. Instead of an abstinence approach, which is often unrealistic, harm-reduction therapy and motivational interviewing (MI) have proved useful in addiction treatment. “Abstinence is now considered a more realistic long-term goal for many, instead of being a rigid requirement for receiving treatment” (Von Wormer & Davis, 2003, p. 248). Newer approaches emphasise clients’ strengths, self-determination and harm reduction.

However in conclusion on the topic: Co-morbidity – alcoholism/addiction with psychiatric illness, I agree with Teggin (as cited in Hutton, 2011, p. 87), “Psychiatric treatment is usually long-term, in some cases life-long. Sobriety (or being clean) is essential for satisfactory psychiatric outcome and long-tem support from Alcoholics Anonymous or similar support systems is required”.

Reference list

Crescent Clinic: Private Psychiatric Clinic. (2011). The Dual Diagnosis Unit (DDU). Retrieved September 30, 2011, from http://www.crescentclinic.co.za/The_Dual_Diagnosis_Program.html

Doweiko, H. E. (2006). Concepts of chemical dependency (6th ed.). Belmont, CA: Thomson Brooks/Cole.

GreenFacts. (2006). Why do drug addiction and mental illness often coexist? Retrieved October 27, 2011, from http://www.greenfacts.org/en/psychoactive-drugs/1-3/5-drugs-depression.htm

Hutton, B. (2011). Recovery RSA: A resource book for those affected by addiction. Johannesburg, South Africa: Stonebridge Books.

Van Wormer, K., & Davis, D.R. (2003). Addiction treatment: A strengths perspective. Pacific Grove, CA: Brooks/Cole – Thomson Learning.

World Health Organization. (2011). Mental health. Retrieved September 30, 2011, from http://www.who.int/topics/mental_health/en/