Pathologic gambling: a nonsubstance, substance-related disorder?

This paper focuses on clinical and basic research findings about similar behaviors and common characteristics of pathologic gambling (PG) and substance-related disorders (SRD). A brief summary of changes that have occurred in classification, criteria, and views of addictions from the 1952 DSM through the DSM-IV is provided. A description of clinical similarities and differences between PG and SRD with respect to their presentation, criteria, signs and symptoms, assessments, characteristics, development, and course is given. Past and present literature on gambling epidemiology is presented and demonstrates how differences in definitions and societal changes have affected prevalence estimates. Data on the co-occurrence of problem and pathologic gambling with substancerelated disorders are provided to include proportions of PG among SRD, SRD among PG, and also the extent of overlap in their comorbidities. Multiple lines of evidence, derived from brain imaging, genetics and neurotransmitter studies of PG, suggesting that PG shares many neurobiological features with substance-related disorders are described. Newer findings with respect to both behavioral and pharmacologic treatments of PG are discussed as well as similarities and differences in treatment principles for PG and SRD. Finally, implications of these findings for the conceptualization of the chemical and behavioral addictions and their relationships are considered. Although pathologic gambling (PG) is classified in the DSM-IV1 as an Impulse Control Disorder Not Elsewhere Classified (ICD), its criteria have been described as bearing little resemblance to those of the other conditions in this “grab-bag” category.2 On the other hand, the PG criteria, according to the chapter on ICD in the American Textbook of Psychiatry,3 “are similar to the criteria for psychoactive substance abuse disorders (p. 691). ” They also noted that Freud was one of the first to recognize this similarity and to group gambling with alcoholism and drug dependence. Many clinicians and researchers in the field now regard PG as “an addiction to an altered psychologic state,4 “a nonpharmacologic addiction,”5 or a “behavioral addiction. ”6 Revisions in the criteria and classification of drug use disorders have been made in the successive editions of the American Psychiatry Association Diagnostic Statistical Manuals of Mental Disorders in keeping with changes in the evolving field, with more recent changes relying more on research findings in addition to expert opinion. Currently, as the planning for DSM-V moves forward, there is increasing discussion regarding the appropriateness of our present criteria and designations and concern about what changes are being considered. The American Journal of Psychiatry, for example, recently published an editorial “What’s in a Word? Addiction Versus Dependence in DSM-V” and a sampling of related letters to the editor. The editorial, written by 3 prominent and respected researchers in the field and involved in the DSM-V planning process, suggests that the term “dependence” is confusing and misleading, a special problem for clinicians