Travis Johnson

PSY 451
Professor ODonohue
Pathological Gambling
Gambling is very common among adults, though for some it can be very problematic. In
2012, four-thousand adults were surveyed about their gambling behaviors. Over fifty-five
percent of those surveyed reported at least one form of gambling in the previous four weeks
which does not show significant difference from rates of previous years (Gambling Commission
2013). This level of use demonstrates how mainstream and built-in gambling is to our society.
Pathological Gambling is an impulse control disorder that can result from a biological
predisposition or learned from personal experiences (DellOsso, Allen & Hollander 2005).
Research in Italy gave a reliable estimate that one to two percent of the population deals with
pathological gambling (Barbaranelli, Vecchione, Fida, & Podio-Guidugli 2013). This population
of pathological gamblers typically suffer from loss of money, poor physical health, poor mental
health, poor relationship skills, and negative feelings about ones life (Lin et al,. 2010). A
combination of Cognitive and Behavioral psychotherapy with pharmaceuticals has the most
evidence of positive treatment outcomes for pathological gambling and the comorbid conditions
related to it.
Many factors have been shown to increase ones vulnerability to pathological gambling.
Pathological gambling is much more common in males and those who are over forty-five years
old (Gambling Commission). Other factors such as male sex, black race,
divorced/separated/widowed marital status, middle age, and living in the West and Midwest have

been associated with increased risk for pathological gambling (Petry, Stinson & Grant 2005).
Further research has shown that four percent of college age males were at-risk or met criteria for
pathological gambling, while only point three percent of females met the same conditions
(Shead, Derevensky & Paskus 2014). Remote Gambling using mobile devices or computers is
becoming an important topic for pathological gambling. Twelve-percent of adults in 2012
reported that they have used remote gambling in the past four weeksup from the ten percent
figure found in 2008, and the seven percent figure from 2006 (Gambling Commission). This is
important because online gambling is available to anyone with internet access and has different
effects on those prone to pathological gambling.
Online gambling is growing quickly and makes the problems associated with gambling
accessible from ones own home. This form of gambling can be equally as dangerous for those
with pathological gambling, and has created a need for further research. In a recent study, one
fourth of college students reported that they have gambled on the internet, and six percent
reported doing so weekly (Smith, Rousu & Dion 2012). Two-thirds of college students who
gambled online on a weekly basis met criteria for pathological gambling (Smith, Rousu & Dion
2012). This is a very significant percentage given that only one-third of infrequent gamblers and
five-percent of non-internet gamblers met the same criteria (Smith, Rousu & Dion 2012). With
such a prevalence in online gambling for college students, research on the negative effects is
important for future treatments. Recently, over two-thousand college-age students were selected
for a study on the negative effects of online gambling (Mihaylova, Kairouz & Nadeau 2013).
From this study, online poker was associated with problem gambling, over-spending and debt,
as well as problems with university studies, interpersonal relationships, and illicit drug use
(Mihaylova, Kairouz & Nadeau 2013). This research shows the dangers of college-age online-

gambling, but may not give an accurate representation for all age groups. One reason for this is
that older people have different motivations for playing online-poker than younger college-age
students. Older people typically play online-poker just for fun and relaxation; as opposed to
younger people usually play with the intention of making money (Smith, Rousu & Dion 2012).
The intention to make money leads to more hours played, which leads to disruption in everyday
life and relationships as a result (Smith, Rousu & Dion 2012). Even though the older population
is spending less time online, they still face issues when it comes to losing money and
pathological gambling. Since they are relaxed and not focused on gaining money, they may also
lose money more regularly. This is important because people with higher gambling loss
reported significantly poorer physical health, mental health, relationships, feelings about self,
quality of life, satisfaction with life, living standards, and study performance (Lin et al. 2010).
In summary, typically younger individuals will suffer from spending too much time on online
games, while older individuals instead suffer more from the money that is lost.
The rise of professional gambling as a media spectacle, such as the World Series of
Poker, may play a part in why so many younger people are focused on making money through
online poker. There are a portion of people who do have success through online gambling, and
are even called professional gamblers. These Professional Gamblers describe games like
poker as a profitable occupation or sport involving skill and control across a number of
domains (Radburn and Horsley 2011). Many of these professional gamblers justify their
actions by saying they are not actually gambling if they are always betting on the side likely to
win (Radburn and Horsley 2011). They also tend to categorize other online players as Grinders,
Gamblers, and Mavericks (Radburn and Horsley 2011). Grinders are very frequent long-term
poker players, the hardcore, that grind a profit by playing their statistical edge on a daily basis

(Radburn and Horsley 2011). This type of play-style focused on slowly making money may line
up with the typical play-style of younger adults trying to earn money. Gamblers are said to be
lacking in skill and control and play poker primarily for recreation, rather than to win
(Radburn and Horsley 2011). These players are where professional players claim to make the
majority of their money since the gamblers would be willing to bet on situations they are likely
to lose. Mavericks are described as often thoughtlessly extravagant, grandiose, and out of
control (Radburn and Horsley 2011).

By distancing themselves from these groups with ideas

of occupational, cognitive, and emotional control, professional gamblers can justify their
profession. Frequent gamblers will sometimes be in denial and use these ideologies to justify
their actions as well (Radburn and Horsley 2011). As a result, professional poker players are in
an interesting position in terms of their identity; on the one hand, they are frequent gamblers,
while on the other, they are professional poker players and may be objects of esteem (Radburn
and Horsley). The ability for players to differentiate themselves from these two groups may be
related to how many will seek help.
Pathological Gambling is a difficult problem to understand for those who do not suffer
from it personally. As a result, people are often lead to believe stereotypes. A recent study on
college age students gave an idea of the general publics view on pathological gambling. In the
study, college students related problem gambling to being compulsive, impulsive, desperate,
irresponsible, risk-taking, depressed, greedy, irrational, antisocial, and aggressive (Horch and
Hodgins 2013). Before the DSM-III included pathological gambling, it was largely understood
to result from some failing in a persons character, or as a form of sin (Radburn and Horsley
2011). Gambling has even been linked with criminality and organized crime (Radburn and
Horsley 2011). These stereotypes may be alienating those with pathological gambling. It could

be a part of why so few pathological gamblers seek help. Research on adults has found that only
seven to twelve percent of those suffering from pathological gambling will seek formal treatment
or help groups (Slutske 2006). Luckily there has been a more recent shift in the perception of
pathological gambling. Those who were seen as immoral and criminal are instead being
seen as ill and a public health issue (Radburn and Horsley 2011). Looking at pathological
gambling as a public health issue takes blame and shame away from the addict and shifts
attention to how our environment and society plays a part in creating these problems.
A big part in removing the stigma behind Pathological Gambling is discovering the
underlying biology behind it. In the recent years our knowledge has grown very quickly, and it
appears that there are several biological factors that influence Pathological Gambling. Early
research found that the DRD2 gene plays a role in pathological gambling and that variants
of this gene are a risk factor for impulsive and addictive behaviors (Comings et al., 1996). This
study was very exciting and gave hope to researchers and those with Pathological Gambling that
improved treatment or medication could be right around the corner. Comings used his findings
to plan an even bigger study on thirty-one different genes (Comings et al., 1996). These genes
were related to regulation of dopamine, serotonin, norepinephrine, GABA and neurotransmitters
(Comings et al., 2001). Out of the thirty-one genes, the DRD2, DRD4, DAT1, TPH, ADRA2C,
NMDA1, and PS1 genes were found to be the most significant (Comings et al., 2001). Comings
noted that dopamine, serotonin, and norepinephrine genes contributed approximately equally to
the risk for pathological gambling (Comings et al., 2001). This gave many avenues for future
research and testing with medication since some of the biological factors were beginning to be
understood. Research on different mental systems as a whole was done as well. How the reward
system interacts with drug dependence is well understood, and influenced researchers to test

pathological gamblers for a similar result using functional magnetic resonance imaging (Reuter
et al., 2005). The results displayed a reduction of ventral striatal and ventromedial prefrontal
activation in the pathological gamblers that was negatively correlated with gambling severity,
which linked hypo-activation to disease severity (Reuter et al., 2005). It was becoming very
clear that there are many implicating biological factors for pathological gambling. Jung became
interested in the Default Mode Network and whether or not functional connectivity is altered for
pathological gamblers (Jung et al., 2014). Thirty subjects were observed using functional
magnetic resonance imaging while at a resting state (Jung et al., 2014). The results showed
decreased default mode connectivity in the left superior frontal gyrus, right middle temporal
gyrus, and precuneus compared with healthy controls (Jung et al., 2014). It was reported that
the severity of PG symptoms was negatively associated with connectivity between the
posterior cingulate cortex seed region and the precuneus (Jung et al., 2014). Jungs research was
important because it made it clear that Pathological Gambling may share similar
neurobiological abnormalities with other addictive disorders and that Pathological Gambling
symptoms are correlated with decreased connectivity in the precuneus (Jung et al., 2014). This
research has helped greatly with our understanding of where Pathological Gambling roots from.
Around the same time that research was done on biology, researchers began to notice that
not all pathological gamblers are alike. They began to formulate ideas for different types or
subgroups of pathological gambling. Blaszczynski and Nower were two of the first to create
three different subgroups for pathological gambling (Blaszczynski & Nower 2001). These
subgroups together make the pathways model and integrate the complex array of biological,
personality, developmental, cognitive, learning theory, and ecological determinants of problem
and pathological gambling (Blaszczynski & Nower 2001). The first group is considered to be

the most normal and attributes their gambling problems to conditioning and distorted
cognitions surrounding probability of winning (Blaszczynski & Nower 2001). This subgroup
typically requires minimal interventions for recovery and can even remit spontaneously
(Blaszczynski & Nower 2001). This subgroup appears to be the easiest to treat since emotions
and other comorbid problems seem less common. However, type two is the complete opposite.
Type two pathological gamblers are centered around emotion and are typically characterized
by disturbed family and personal histories, poor coping and problem-solving skills, affective
instability due to both biological and psychosocial deficits and later onset of gambling
(Blaszczynski & Nower 2001). Type two gamblers are often suffering from comorbid depression
or anxiety that may result from neurotransmitter or genetic deficits, result from experienced
trauma or loss, or be reactive to current stressor (Blaszczynski & Nower 2001). As a result of
all of their difficulties regulating emotion, they turn repetitive gambling as a means of
emotional escape through dissociation aimed at regulating negative mood states or
physiological states of hyper- or hypo- arousal (Blaszczynski & Nower 2001). Blaszczynski
speculated that group two would show positive reactions to SSRI or mood stabilizing
medications as a well as treatment for comorbid mental conditions (Blaszczynski & Nower
2001). Type three gamblers are most similar to type two, but differentiate in their reason for
gambling, when they start gambling, and their comorbid conditions. Type three gamblers are
characterized by a biological vulnerability towards impulsivity, early onset, attentional deficits,
antisocial traits and poor response to treatment and usually have an antisocial impulsivist
personality (Blaszczynski & Nower 2001). This means that they are born with the biological
vulnerabilities to pathological gambling and typically have much earlier onset of symptoms than
type two gamblers who begin to gamble due to their upbringing and specific life events. Having

an antisocial impulsivist personality complicates treatment and assessment. As a result of this

personality type, type three gamblers are more likely to have other types of dysfunctional
behavior including substance abuse, criminal offences and social instability (Blaszczynski &
Nower 2001). This type of behavior leads to more severe gambling related problems, general
pathology, and salient features of attention deficit hyperactivity disorder (Blaszczynski &
Nower 2001). As a result, comorbid conditions must be carefully assessed and targeted for type
three gamblers similar to type two gamblers. The biological basis for type three gamblers also
makes them potential candidates for medications such as SSRIs or mood stabilizers. Recent
research by Lobo et al. challenges the three subtypes put forward by Blaszczynski and Nower.
Four-hundred ninety-two subjects with pathological gambling had their personality assessed on
four temperamentsNovelty-Seeking, Harm Avoidance, Reward Dependence, and persistence
and three character scales Self-Directedness, Cooperativeness, and Self-Transcendence
(Lobo et al., 2014). Contrary to Blaszczynski & Nower, only two subgroups were developed
from the results. The first subgroup of gamblers identified were those who are behaviorally
conditioned, the second subgroup was those who are emotionally vulnerable, and no evidence
was found for a third subgroup based on antisocial impulsiveness (Lobo et al., 2014).
However, a portion of the subjects were considered to have sub-clinical pathological gambling
which caused no subgroups to be identified when removed from the study (Lobo et al., 2014).
This is a problem that can be solved by replicating the study with larger sample sizes and
additional clinical and community settings. However, this problem also indicates that
Pathological Gambling severity, rather than community or clinical setting, may have an effect on
Pathological Gambling subtypes (Lobo et al., 2014). Overall, these subgroups should be used
during assessment to develop a treatment plan to better suit the individual and any of their

comorbid conditions. The third subtype of antisocial impulsiveness may or may not actually
exist, though it is important to consider for assessment.
There is a high probability that those with Pathological Gambling problems will also
suffer from comorbid problems such as substance abuse, mood disorders, anxiety disorders,
personality disorders, depression, and suicide (Lorains, Cowlishaw & Thomas 2011). The most
common comorbid problems are substance abuse related (Lorains, Cowlishaw & Thomas 2011).
A meta-analysis of eleven different studies on comorbid disorders showed that over sixty-percent
had comorbid nicotine dependence, and over fifty-seven percent had a substance use disorder
(Lorains, Cowlishaw & Thomas 2011). In one study, seventy-two pathological gamblers with
comorbid substance abuse were selected to be treated for both of their conditions simultaneously
(Lesieur & Blume 2006). It was shown that patients reduced their intake of alcohol, other drugs
and their gambling as well as improved in legal, family/social, and psychological functioning
(Lesieur & Blume 2006). This gives reason to careful assess pathological gamblers for comorbid
substance abuse that can be treated simultaneously. Comorbid mood disorders were found in
thirty-eight percent of pathological gamblers, and anxiety disorders were found thirty-seven
percent of the time (Lorains, Cowlishaw & Thomas 2011). These disorders will play a large
part in designing treatment specific for the individual and need to be carefully assessed.
Problem gamblers were more likely to experience one symptom of depression when compared
with non-gamblers or those not at risk (Momper et al., 2010). Momper also reported a doseresponse association between the degree of gambling problem and the likelihood of having
experienced two depressive symptoms (Momper et al., 2010). It is not well known whether
these depressive symptoms are problems created by gambling, such as financial loss and family
problems, or problems that lead to gambling as a coping method for emotions (Momper et al.,

2010). Depression needs to be taken into careful consideration since in the worst cases it may
lead to suicide. Patients with pathological gambling were questioned on the topic of suicide and
over thirty-nine percent reported at least one suicide attempt throughout their life (Otto 2003).
Out of those who had attempted suicide, sixty-four percent claimed their most recent attempt was
gambling related (Otto 2003). Otto also noted that the most common method of suicide for the
group was overdose (Otto 2003). This shows the importance of screening of suicidal tendencies
and depression. Providing treatment for comorbid conditions at the same time as pathological
gambling is usually beneficial. Medications should also be careful assessed for suicide potential
for those with suicidal tendencies. Researchers in recent years have noticed an interesting
relationship between Parkinsons disease and pathological gambling as well. Gambling behavior
for those with Parkinsons appears more often in the on periods of motor fluctuations
(Molina et al., 2001). It was also noted that the patients pathological gambling became
prevalent after the onset of Parkinsons disease for most, and got worse while taking levodopa
(Molina et al., 2001). As a result, those who are developing Parkinsons disease should be
carefully watched for signs of pathological gamblingespecially those with the medication
levodopa.
When it comes to assessing pathological gambling, there is a wide variety of assessment
tools that have been created. The DSM has nine criteria for pathological gambling of which five
must be met for the diagnosis of pathological gambling (Stinchfield 2003). Research on the
DSM criteria has found it to be both reliable and valid (Stinchfield 2003). However,
Stinchfield also claimed in that requiring only four criteria, rather than five, for diagnosis would
make small improvements in classification accuracy and a reduced rate of false negatives
(Stinchfield 2003). The South Oaks Gambling Screen (SOGS) is a twenty-item questionnaire

developed in 1987 based on DSM-III criteria and is still often used to screen for pathological
gambling (Lesieur & Blume 1987). SOGS has also received a fair bit of criticism. One study
argued that some items in the SOGS were not fully understood by the subject and led to
inaccurate scores and reported that clarification of items would decrease the number of
participants identified as problem gamblers (Ladouceur et al., 2000). While these measures
show some validity, they are not considered to be completely accurate. As a result, many
alterations, revisions, and new diagnostic tools have been developed. A newer screen called the
Massachusetts Gambling Screen (MAGS) was compared to SOGS for convergent validity,
discriminant validity, and predictive validity (Weinstock, Whelan, Meyers & McCausland 2007).
MAGS was shown to share convergent and predictive validity with SOGS (Weinstock, Whelan,
Meyers & McCausland 2007). However, age was related to SOGS scores and not MAGS scores
(Weinstock, Whelan, Meyers & McCausland 2007). As a result, MAGS may be better at
accurately assessing pathological gambling across diverse age groups. A more recent study in
2008 compared the validity between SOGS, Gamblers Anonymous twenty questions (GA-20),
DSM-IV, and the Canadian Problem Gambling Index (CPGI) (Arthur et al., 2008). The results
showed that CPGI was the most reliable and valid in terms of construct validity (Arthur et al.,
2008). However, it was also reported that CPGI is a lengthy instrument that could be made
more effective by using fewer items and more appropriate terminology (Arthur et al., 2008).
The Diagnostic Interview for Gambling Severity (DIGS) is a structured interview designed to
make an accurate and reliable DSM-IV diagnosis of pathological gambling (Winters, Specker,
& Stinchfield 2002). DIGS is also used to assess relevant information such as demographics,
treatment history, mental health status and other impulse-related problems (Winters, Specker &
Stinchfield 2002). DIGS has been found to have both convergent and discriminant validity as

well as Internal consistency for the twenty items addressing the ten DSM-IV criteria (Winters,
Specker & Stinchfield 2002). An acceptable amount of validity has been found for many
diagnostic tools for pathological gambling, it will be up to researchers to develop and decide
upon a common tool. Currently, many different tools are used for assessment in research which
may cause some inconsistency of results. It is important to remember that these tools are also
very specific to pathological gambling, careful consideration and assessment of comorbid
conditions must be done as well for effective treatment planning.
Effective treatment for pathological gambling is typically a combination of different
forms of behavioral and cognitive therapies and medication. While treatment shows promising
results, a small percentage of those suffering will actually seek help (Slutske 2006). Two large
national U.S. surveys reported that thirty-six to thirty-nine percent those with pathological
gambling history did not experience any gambling-related problems in the past year, while only
seven to twelve percent had formal treatment (Slutske 2006). As a result, thirty-three to thirtysix percent of the individuals with pathological gambling disorder were characterized by natural
recovery (Slutske 2006). This gives some hope for those who do not seek help, though
treatment would typically be a more effective and long-term answer. Some treatments for
pathological gambling require complete abstinence from gambling, while others tend to make
goals for gambling less or quitting specific types of gambling (Stud 2014). Research has shown
that those with abstinence-based goals gambled significantly fewer days than those with
moderation-based goals (Stud 2014). However, it was also found that goal selection over time
was not related to dollars gambled, dollars per day gambled, or perceived goal achievement
(Stud 2014). So while abstinence based treatments typically have less instances of gambling,
they still tend to spend the same amount of money as goal-based treatments.

Pharmacological treatment for pathological gambling has shown promising results and is
typically based on the comorbid conditions present. Medications such as Serotonin Reuptake
Inhibitors (SRIs), mood stabilizers, opioid antagonists, and antidepressants have all been
researched as potential pathological gambling treatments. Medications such as naltrexone,
paroxetine, topiramate, fluvoxamine, and n-acetyl-cysteine have all received some scientific
support (Potenza 2014). The medication paroxetine is believed to reduce unwanted behaviors
when greater attention is focused on them, and might also increase motivation (DellOsso, Allen
& Hollander 2005). The serotonin agent demonstrated an advantage over placebo, but not at a
significant level (Grant et al. 2003). This gives hope that future research will reaffirm paroxetine
as a beneficial drug for pathological gambling in the future. Topiramate and fluvoxamine are
two different pharmaceutical options intended to help with impulse control (Dannon et al. 2005).
A comparison study between topiramate and fluvoxamine gave promising results (Dannon et al.
2005). Both of the drugs said to be effective for treating pathological gambling, but topiramate
showed a higher rate of treatment completion and better rates of remission (Dannon et al. 2005).
Topiramate seems promising for those with gambling problems centered around impulse control,
though it will need further testing to confirm the result. Naltrexone is currently the only opioid
antagonist to be found effective for pathological gambling (DellOsso, Allen & Hollander 2005).
Naltrexone blocks the effect of endogenous endorphins on central opiate receptors and also
inhibits dopamine released in the nuclease accumbens, acting on pathways involved in reward,
pleasure, and urge (DellOsso, Allen & Hollander 2005). A study in 2000 found that seventyfive percent of subjects taking naltrexone showed positive results, as opposed to only twentyfour percent from those taking a placebo (Kim, Grant, Adson & Shin). Another study in 2001
found similar results and also noted that the naltrexone works equally for both sexes typically

within a four week period (Kim & Grant 2001). Both of these studies show a very impressive
effect from naltrexone which is promising for treatment. N-acetyl-cysteine was tested in
combination with behavioral therapy during the past year (Grant et al. 2014). The results
showed that n-acetyl-cysteine facilitated long-term application of behavioral therapy techniques
once patients are in the community after therapy has been completed (Grant et al. 2014). This is
important because this drug is able to benefit methods of cognitive behavioral therapy. A formal
drug for pathological gamblers has yet to be decided upon, though all of these show promise for
the near future.
Cognitive Behavioral treatment for pathological gambling has had promising and reliable
results across many studies. Behavioral therapies such as imaginal desensitization, motivational
interviewing and brief interventions have been given support by recent research (Potenza 2014).
Imaginal desensitization specifically has been shown to have a greater positive effect than other
similar behavioral treatments (McConaghy, Blaszczynski & Frankova 1991). Another study
tested cognitive behavioral therapy that was based on four components; cognitive correction of
erroneous perceptions about gambling, problem-solving training, social skills training, and
relapse prevention (Sylvain, Ladouceur & Boisvert 1997). The results were highly positive on
all outcome measures and retained validity for six and twelve month follow-ups (Sylvain
Ladouceur & Boisvert 1997). These components will play a part in effective cognitive
behavioral therapy. The high level of research for cognitive behavioral therapies in recent years
has allowed meta-analysis to be possible. A meta-analysis in 2005 analyzed the results of
twenty-two different studies with nearly fifteen-hundred subjects that had received psychological
interventions (Pallesen et al., 2005). The results of the meta-analysis showed that psychological
treatments were more effective than no treatment and their effectiveness held up over time

(Pallesen et al., 2005). This solidified the idea that psychological treatments were a valid option
for pathological gambling. A later meta-analysis using twenty-five studies tested whether or not
cognitive-behavioral treatment specifically was beneficial for those with pathological gambling
(Gooding & Tarrier 2009). The analysis found that CBT was effective in reducing gambling
behaviors within the first three months regardless of the type of gambling behavior practiced
(Gooding & Tarrier 2009). The analysis also compared group and individual CBT and found that
group therapy was equally effective at outcome but not equal after a six-month follow-up
(Gooding & Tarrier 2009). However, other research has argued for the effectiveness of group
cognitive behavioral therapy. In one study those involved in group therapy, subjects were found
to be four times as likely to no-longer meet DSM-IV criteria in group therapy compared to a
control (Ladouceur et al., 2003) . Meaning that group therapy may not be quite as effective as
individual therapy, though it still remains as a viable option for treatment when compared to no
treatment. Since pathological gambling is a widespread global problem, research was done to
test the effectiveness of cognitive behavioral therapy for low to middle-income countries (Pasche
et al., 2013). It was reported the urges and disability of symptoms related to pathological
gambling were significantly reduced as a result of treatment (Pasche et al., 2013). This gives
support to cognitive behavioral therapy for being an effective treatment across diverse
populations. This level of support from various studies and meta-analysis gives cognitive
behavioral therapy a lot of validity for treating pathological gambling.
Even though cognitive behavioral therapy is a supported form of treatment of
pathological gambling, there is reason to believe that additional techniques can be added or
supplemented to improve treatment outcomes. One factor that can hurt treatment outcomes is
the retention rate of patients. One study combined motivational enhancement with cognitive

behavioral therapy to test the effect on retention rates (Wulfert, Blanchard, Freidenberg &
Martell 2006). First the subjects were given a motivational intervention designed to decrease
client defensiveness, increase problem awareness, and strengthen commitment to change, then
they were given typical cognitive behavioral therapy, followed by two sessions of relapse
prevention (Wulfert, Blanchard, Freidenberg & Martell 2006). The results showed that all
participants in the treatment condition completed treatment, as opposed to only two-thirds of the
treatment-as-usual participants completing treatment (Wulfert, Blanchard, Freidenberg & Martell
2006). These results are very promising and give reason to believe that motivational aspects
should be included in cognitive behavioral therapy for pathological gamblers. The small sample
sizes require further research to confirm these results. Other research has given us factors that
play into retention and relapse rates. The main predictors of relapse were single marital status,
spending less than one-hundred euros/week on gambling, active gambling behavior at treatment
inclusion, and high scores on the TCI-R Harm Avoidance personality dimension (Aragay et al.,
2014). The predictors for dropouts were single marital status, young age, and high scores on the
TCI-R Novelty Seeking personality dimension (Aragay et al., 2014). This gives very clear
factors to be aware of during assessment to properly treat those prone to relapse or dropping out
of therapy. It also offered the TCI-R as a means of testing for these problems.
Emotional problems have also come into question, especially for subgroup two
gamblers. The correlation between anger and pathological gambling severity was found to be
strong (Aymami et al., 2014). One study used cognitive behavioral therapy combined with
anger management to treat pathological gamblers with comorbid anger issues (Korman et al.,
2008). As a result, participants in the integrated anger and addictions treatment reported
significantly less gambling .less trait anger and substance abuse (Korman et al., 2008).

These two studies confirmed that emotions such as anger can play a direct role in pathological
gambling. Screening and treatment for comorbid anger problems is useful for cognitive
behavioral therapy. Stress plays a major role at the onset and relapse of pathological gambling
and can also be the aftermath of gambling behavior, thus revealing a reciprocal relationship
(Linardatou et al., 2013). When cognitive behavioral therapy is combined with stress
management, statistically significant amelioration of stress, depression, anxiety symptoms and
an increase of life satisfaction and a better daily routine (Linardatou et al., 2013). So stress and
anger are both comorbid emotional problems to pathological gambling that have shown positive
results when treated simultaneously.
Even though effective treatments have been developed, their uptake is limited to 10% of
the target population (Carlbring & Smit 2008). Self-help options and support groups are
working to become more easily accessible to those who are suffering. A newer form of treatment
that is being examined is online self-help. An eight-week online cognitive behavioral therapy
program that requires less than four hours of professional time per patient has been created
(Carlbring & Smit 2008). This online program was tested on sixty-six individuals and was found
to have favorable changes in pathological gambling, anxiety, depression, and quality of life
that were sustained up to three years after treatment (Carlbring & Smit 2008). Self-help phone
lines are another way that psychologists are attempting to reach out to pathological gamblers.
Research on these self-help call lines revealed that they are more effective and satisfactory to
callers who are requesting a referral rather than direct information (Ferland et al., 2013). This
could be because referring people to effective care is quite easy, while giving in-depth analysis of
their condition is much more difficult (Ferland et al., 2013). These forms of therapy are very
promising since they are both time-efficient, and cheap compared to individual cognitive

behavioral therapy. Self-help options also make treatment much more accessible to those who
are nervous about seeing therapists one-on-one or who simply do not have time to. Comorbid
conditions may be more difficult to assess when the patient is not assessed in person which needs
to be researched further.
Gamblers Anonymous is an organization that was created based on the ideas of
Alcoholics Anonymous for those with pathological gamblingwith some alterations to better
suit gamblers (Richard, Blaszczynski & Nower 2013). Since Gamblers Anonymous is an
organization based on the idea of anonymity it is typically more difficult to find information
regarding outcome measures, though it has been noted as a provider of peer support that cannot
be replicated by professionals (Richard, Blaszczynski & Nower 2013). This peer support may be
able to help normalize the patients problems and remove guilt, while improving motivation.
Gamblers Anonymous is also free to attend, making it a cost-effective adjunct to formal
treatment as well as a convenient after-care option (Richard, Blaszczynski & Nower 2013). The
ability for anyone to attend Gamblers Anonymous free of charge may make it much more
accessible to those who are in poor financial situations due to their gambling. I personally took
advantage of the accessibility of gamblers anonymous to sit-in and observe a meeting held in
Reno, NV. The meeting was small in numbers and was set up in a circle so that people could
easily communicate with one another. The experiences that were told were very personal and
often emotional for the person speaking, though the general atmosphere was comforting at the
time. One aspect that may be aversive to certain individuals is the role of God in Gamblers
Anonymous. Throughout the meeting several people claimed to have received help from god,
and it was almost felt like a built in part of Gamblers Anonymous. Overall, I found the support
to be really satisfying despite not sharing in their condition. Gamblers Anonymous may be

beneficial in combination with individual cognitive behavioral therapy as a means of motivating

the patient and reducing drop-out rates. Cognitive Behavioral therapy while attending Gamblers
Anonymous has been under research as well. It has been found that Cognitive Behavioral
treatment reduced gambling behaviors at a greater level than Gamblers Anonymous alone,
however, attendance at gamblers anonymous was also linked to gambling abstinence (Petry et
al., 2006). While Gamblers Anonymous does not have nearly as much evidence behind it as
cognitive behavioral therapy, there is no reason to believe it should only exist independent of
cognitive behavioral therapy. Gamblers Anonymous can offer valuable peer support that is not
offered by cognitive behavioral therapy.
Overall evidence has pointed towards cognitive behavioral therapy as the core of
effective treatment for pathological gambling. As a result of the high prevalence of comorbid
disorders, assessment is both important and difficult. Comorbid disorders have a direct effect on
pathological gambling symptoms and must be treated simultaneously for the best results.
Individual cognitive behavioral therapy has shown more positive results than group-oriented
therapies. Group-oriented treatment such as gamblers anonymous can offer peer-support in
combination with cognitive behavioral therapy, and should be considered to increase retention
rates. Pharmaceuticals have shown a positive effect on pathological gamblingespecially in
those with comorbid personality and mood disorders. However more research is required before
any drug is labeled or sold for pathological gambling. Cognitive behavioral therapy was a huge
breakthrough for those suffering from pathological gambling. There is reason to believe that
future research will continue to improve outcomes for those who seek treatment.

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