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Screening: There are a number of instruments that can beused as screening tools for pathological gambling.The most common instrument for assessing gamblingproblems is probably the self-administeredSouth Oaks Gambling Screen (SOGS). Individualsendorsing 5 or more items are classified asprobable pathological gamblers. The instrument is based on DSM criteria and has good reliabilityand validity in clinical samples. The maindisadvantage of the SOGS is its length; a clinicianis unlikely to ask a patient 20 questions as a routinescreening for a disorder.The recently developed Lie/Bet screen is a verypromising alternative. In consists of 2 questions:‘Have you ever felt the need to bet more and moremoney?’ and ‘Have you ever had to lie to peopleimportant to you about how much you gamble?’.Answering ‘yes’ to either of these questions yieldsa 0.99 sensitivity and 0.91 specificity in the identificationof pathological gamblers using a checklistof DSM criteria as the gold standard.
Diagnosis: Once a diagnosis of pathological gambling issuspected on the basis of the screening questionsor other clinical indications, it is necessary to confirmthe diagnosis. There is at present no standardizedway of doing this. Most clinicians appear torely on clinical interview using DSM-IV (or ICD-10) criteria. An alternative is the use of the DiagnosticInterview Schedule (DIS) adapted for pathological gambling. New semistructured clinical interviews based on DSM-IV criteria are currently under development. Finally, it is important to note that the presence of a manic episode is the only exclusionary criterion in DSM-IV for the diagnosis of pathological gambling.
Severity: One of the difficulties in the assessment of pathologicalgambling is that, in contrast with theassessment of substance abusers where urine drugscreens can provide an objective estimate of recentuse, the main source of information for gamblingbehavior is self-report. Although collateral informationfrom friends or relatives is frequently available,and should always be sought with the patient’spermission, pathological gamblers have anuncanny ability to deceive relatives and clinicians, atleast in the short term. Therefore, patient-derivedinformation may not always be accurate, but providesa lower bound for the magnitude of the problem.An instrument that can be used to assess theseverity of gambling is the Gambling Severity Index (GSI). This is a modified version of the Addiction Severity Index that adds items such as embezzlement, fraud and gambling offenses to the list of possible legal problems, and a set of questions regarding participation in gambling which focuses on frequency, financial problems related to gambling and other gambling-related problems. However, the GSI has been rarely used in clinical studies. Based on their conceptualization of gambling as an obsessive-compulsive spectrum disorder, DeCaria et al. developed a modification of the Yale-Brown Obsessive-Compulsive Scale (YBOCS). This is a 10-question scale that assesses the interference withthe individual’s life and distress caused by actual gambling behavior or thoughts related to it. Preliminary data suggest that it has good reliability and validity, but further research is needed to confirm these initial results. Severity has frequently been assessed by the number of SOGS criteria met by the patient. Alternatives measures include time spent or money lost gambling (in absolute terms, or relative to the individual’s income). The relative merits of these methods have never been assessed and this assessment remains one of the most important challenges for the field as outcome evaluation and comparison of treatments become progressively important.
Comorbidity: An essential part of the assessment of pathologicalgambling should be the ascertainment ofpossible comorbid disorders that may influencethe course and severity of the disorder. Severalstudies have shown pathological gambling to behighly comorbid with other psychiatric disorders,especially substance abuse disorders, affective disordersand attention deficit hyperactivity disorder (ADHD). Epidemiological studies suggest that the lifetime prevalence of alcohol abuse/dependence in pathological gamblers is in the range of 40 to 60%, with studies of clinical samples reporting similar estimates. Use of illicit drugs is also common, with estimates of lifetime prevalence ranging from 10 to30%, whereas the prevalence of comorbid nicotine dependence may be as high as 85%. There are some indications that substance abuse may precede the onset of pathological gambling. Comorbidity with affective disorders is also high. Studies of inpatients have estimated that 75% of pathological gamblers have comorbid depression. However, a follow-up study of patients showed that only 18%of the gamblers remained depressed after abstinence. Community samples have yielded lifetime prevalence estimates of comorbid major depression of 10 to 20%. It is unclear at present whether mood disorders are the cause or consequence of gambling, with data supporting both hypotheses (Ibáñez A, unpublished data). Based on the frequent association of pathological gambling with criminal behavior, a number of studies have looked at antisocial features in pathological gamblers, and found positive results. Epidemiological studies suggest that almost 40% of pathological gamblers may have comorbid antisocial personality disorders. However, there are no studies that have looked at the stability of this diagnosis in gamblers who have achieved abstinence. There are also some suggestions that pathological gambling is associated with high rates of ADHD; a recent study found that 20% of an outpatient sampleof individuals who were pathological gamblers met criteria for ADHD. It is estimated that 3 to 5% of school-age children have ADHD, while data on the prevalence of ADHD in the adult population are limited. At present, there are no studies of the prevalence of pathological gambling among patients with ADHD. Each of these comorbidities appears to occur with higher prevalence in pathological gamblers than in the general population, suggesting a relationship between the disorders. However, the directionality of this relationship remains unexplored. Studies that examine the temporal sequence of the disorders, or possible common etiological mechanisms, may help clarify this relationship.
- Blanco, C.; Ibáñez, A.; Sáiz-Ruiz, J.; Blanco-Jerez, C.; Nunes, E.V.; Epidemiology, Pathophysiology and Treatment of Pathological Gambling. CNS Drugs, 2000, Vol. 13 Issue 6, p397-407
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