Pathological Gambling: Diagnosis & Treatment

Gamblers Anonymous and Gam-Anon
Gamblers Anonymous (GA), a 12-step program modeled after Alcoholic Anonymous, is probably the most popular intervention for pathological gambling. It emphasizes the need for public confession to a peer group, and offers financial, legal and employment assistance. However, its efficacy as a stand-alone treatment has not been clearly established. Some reports indicate that retention rates of GA attendees are 10 to 30%. In addition, of those who continue, only 8% remain abstinent for 1 year and 7%for 2 years or more. Two studies have looked at the outcome of patients whose significant other attended Gam-Anon, the spousal counterpart of GA. Both studies found that participation in Gam-Anon tended to improve outcome of the patients and reduce marital discord, but the differences were not statistically significant in either study.

There is some evidence, from retrospective studies, that combining GA with professional help may improve the outcome of pathological gambling. Lesieur and Blume described the outcome of patients treated for pathological gambling in an inpatient program. Of 124 patients admitted for treatment, 72 were contacted between 6 and 14 months after discharge (the remaining 52 patients could not be contacted or refused to be interviewed). Gambling behavior had decreased significantly, and 64% of patients reported abstinence. Blackman and co-workers studied the outcome of 88 patients treated in a clinic specializing in the treatment of pathological gambling, and found significant decreases in indebtedness and gambling behavior from pretreatment levels in patients who attended GA.

Two studies in veterans also support the notion that GA plus professional treatment may be an effective treatment for pathological gambling. Russo and colleagues surveyed 60 of 124 individuals treated in a inpatient program (the mailed survey was not returned by 64 individuals). Patients were treated with individual and group psychotherapy, as well as attendance of GA. Abstinence was 55% by self-report. In a study by the same group, Taber et al. conducted a 6-month follow-up of 57 of 66 patients (9 patients were not located) consecutively admitted to the hospital. The self-reported rate of abstinence was almost identical to the previous study (56%), and improvements in associated psychiatric symptoms and psychosocial functioning were also documented.

Psychodynamic Psychotherapy
Bergler was one of the first to report the successful treatment of pathological gambling, using an ego-psychology psychoanalytic approach. 14 of 60 patients improved with treatment, but little information is provided about the other 46 patients. Others have also reported success in a number of single case studies. However, inadequate use of outcome measures as well as limited follow-up data make it difficult to assess the efficacy of this approach.

Cognitive-Behavioral Therapy
Early behavioral approaches to the treatment of pathological gambling included aversive conditioning using electric shocks, cue exposure with response prevention, and imaginal sensitization. More recently, approaches emphasizing cognitive restructuring have become increasingly influential. Bujold and colleagues successfully used cognitive restructuring, problem solving, social skills training and relapse prevention to treat 3 individuals who had a diagnosis of pathological gambling. In a subsequent controlled trial by the same group, 29 patients were randomly assigned to a manualized treatment incorporating the 4 strategies used in the pilot work or a waiting list where patients were contacted monthly by a therapist. 12 of 14 patients who completed the treatment were considered responders, compared with 1 of 15 in the control group. At 12 months’ follow-up, 8 of the patients in the treatment group had maintained their gains.

Choice of Treatment
There is evidence suggesting that a number of approaches may have efficacy in the treatment of pathological gambling. Professionally delivered cognitive-behavioral therapy is the psychotherapy with best documented efficacy for pathological gambling, and will probably prove to be an essential part of any treatment for the disorder in the future. The manuals used in the studies of this treatment approach have not yet been published, limiting the applicability of this therapy in the case of most individuals. However, some simple behavioral interventions can be easily implemented, if agreeable to the patient.

Fluvoxamine is the only medication that has been systematically studied to date. Although results appear modest at present, its safety and tolerability make it a reasonable option for patients agreeable to a trial of pharmacological treatment. Use in combination with cognitive-behavioral therapy is likely to improve compliance, similar to what has been found in the treatment of drug abuse, thus potentially increasing its therapeutic effect. Other SSRIs may be acceptable alternatives, although data regarding their efficacy are lacking. Use of other medications together or concomitantly in the presence of comorbidity may be considered, but there are no empirical data to support their efficacy at present.

There are currently no prospective studies of combined treatment for pathological gambling. However, based on our clinical experience and on the preceding review of the literature, we believe that it is unlikely that monotherapy (medication or psychotherapy) will be successful in the treatment of most patients. For that reason, in clinical practice, a multimodal approach, addressing both the symptoms and the psychosocial dysfunction of pathological gambling, may prove more fruitful. Attendance of GA, where available, should be encouraged as a complement to the treatment provided by professionals. Similarly, involvement of the family through Gam-Anon or through multifamily groups may be beneficial to both the patients and their relatives, and should be recommended. Given the frequent economic and criminal complications of pathological gambling, financial and legal counseling should also be an integral part of treatment.

Personal Reflection Exercise #8
The preceding section contained information regarding treatment options for pathological gambling.  Write three case study examples regarding how you might use the content of this section in your practice.

Online Continuing Education QUESTION 15
What were four strategies used by Bujold and colleagues in a cognitive-behavioral treatment plan for pathological gambling? Record the letter of the correct answer the CEU Answer Booklet