by: Christine Reilly and Institute Staff | Apr 4, 2010
The American Psychiatric Association currently is in the process of updating the Diagnostic and Statistical Manual of Mental Disorders to its fifth edition (DSM-V). The DSM is the handbook of mental disorders in the United States, used daily by health care providers, researchers, insurance companies and government agencies. The DSM-V Work Group that reviewed the diagnosis for pathological gambling has proposed several changes to the diagnostic definition of the disorder. Revisions in diagnostic codes are typically driven by evolving research that transforms our understanding of a disorder, and so this month’s Issues & Insights summarizes several studies that question the current definition of pathological gambling and, in some cases, might inform the final recommendations for the DSM-V.
From Impulse-Control Disorder to Addiction
Pathological gambling was added to the DSM in 1980. In the current edition of the DSM (DSM-IV), pathological gambling is classified under “Impulse-Control Disorders Not Elsewhere Classified,” along with compulsive stealing (kleptomania), fire starting (pyromania) and hair pulling (trichotillomania) (American Psychiatric Association, 2000). The DSM-V Work Group has proposed renaming pathological gambling “disordered gambling” and moving it under a new classification titled “Addiction and Related Disorders” (American Psychiatric Association, 2010). This category will replace the current Substance-Related Disorders classification and will include disorders related to alcohol and substance abuse. Disordered gambling will be the sole “behavioral addiction” in this group (Holden, 2010).
The rationale for this change is that the growing body of scientific literature, especially research on the brain’s reward center, has revealed many commonalities between pathological gambling and substance-use disorders, including cravings and highs in response to the gambling, alcohol or drug; the hereditary nature of all of these disorders; and evidence that the same forms of treatment (e.g., 12-step programs, cognitive behavioral therapy) seem to be effective for both gambling and substance-use disorders.
For example, the DSM-V Work Group cited studies showing a high rate of co-occurring substance use disorders with pathological gambling. One of the most definitive is the analysis of the gambling data in the National Comorbidity Survey Replication (NSC-R), a nationally representative sample of 9,282 English-speaking adults. The authors found that almost all participants who had pathological gambling during the course of their lifetime also had another lifetime psychiatric disorder (96.3 percent), and 64.3 percent suffered from three or more disorders. Substance-use disorders were significantly elevated among participants with pathological gambling (Kessler, Hwang, LaBrie, Petukhova, et al., 2008).
The Criterion of “Illegal Acts”
According to DSM-IV, to be diagnosed with pathological gambling, a person needs to have five or more out of 10 possible symptoms, such as a preoccupation with gambling; “chasing” one’s losses; lying to loved ones about gambling; and committing “illegal acts, such as forgery, fraud, theft or embezzlement to finance gambling.” The DSM-V Work Group has proposed eliminating the “illegal acts” criterion because it does not appear to be a decisive symptom for most people with gambling problems (American Psychiatric Association, 2010).
One of the studies cited by the DSM-V Work Group, “Evaluation of the continuum of gambling problems using the DSM-IV,” examined the gambling data from the National Epidemiologic Survey on Alcohol and Related Conditions (commonly known as NESARC) (Strong, & Kahler, 2007). The authors found that the symptom, “Is preoccupied with gambling,” is most useful for identifying individuals with the lowest levels of gambling problem severity, while the illegal acts symptom is most helpful only for identifying those with the highest levels of gambling problem severity. Individuals who commit illegal acts as a result of their gambling already reach the threshold of five or more symptoms and, therefore, this symptom does not improve the precision of the diagnostic code for identifying most individuals with pathological gambling.
Is Pathological Gambling “Persistent and Recurrent”?
The DSM-IV describes pathological gambling as a “persistent and recurrent disorder,” a description that has been challenged by several studies. For example, a review of five studies that followed 1,689 gamblers over the course of two to seven years found that while healthy gambling and non-gambling behavior appears to be relatively stable over time, individuals with gambling problems experience considerable movement in and out of more severe and less severe levels of gambling disorders (LaPlante, Nelson, LaBrie, & Shaffer, 2008). Moreover, the authors observed that rates of recovery from pathological gambling, the most severe level of the disorder, appeared higher than anticipated. Consequently, the authors found no evidence to support the assumptions (1) that individuals cannot recover from disordered gambling, (2) that individuals who have more severe gambling problems are less likely to improve than individuals who have less severe gambling problems, and (3) that individuals who have some gambling problems are more likely to get progressively worse than individuals who do not have gambling problems.
Although the DSM-V Work Group has not proposed altering the “persistent and recurrent” language, ample opportunities remain for consideration of such ideas as the DSM-V Development project moves toward publication in 2013. For a complete discussion of the proposed changes and registration for submitting public comments, visit www.dsm5.org. The deadline for public comment is April 20, 2010.
Christine Reilly is the executive director of the Institute for Research on Gambling Disorders.
American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text revision ed.). Washington, DC: American Psychiatric Association.
American Psychiatric Association. (2010). DSM-V: The Future of Psychiatric Diagnosis. Retrieved March 31, 2010 from www.dsm5.org.
Holden, C. (2010). Behavioral Addictions Debut in Proposed DSM-V. Science, 327(5968), 935.
Kessler, R. C., Hwang, I., LaBrie, R., Petukhova, M., Sampson, N. A., Winters, K. C., et al. (2008). DSM-IV pathological gambling in the National Comorbidity Survey Replication. Psychological Medicine, 38(9), 1351-1360.
LaPlante, D. A., Nelson, S. E., LaBrie, R. A., & Shaffer, H. J. (2008). Stability and progression of disordered gambling: Lessons from longitudinal studies. Canadian Journal of Psychiatry, 53(1), 52-60.
Strong, D. R., & Kahler, C. W. (2007). Evaluation of the continuum of gambling problems using the DSM-IV. Addiction, 102(5), 713-721.