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Pathological Gambling Changes in the DSM-5

by Responsible Gambling Council | Jun 01, 2012 03:49 PM

Newscan (Vol. 14, Iss 21)

What is pathological gambling (PG)? How do you know that someone’s gambling problem is, medically speaking, a gambling disorder? The answer, for many in the mental health profession, can be found in the Diagnostic and Statistical Manual of Mental Disorders (DSM).

After more than 10 years of research, analysis and consultation, the publisher of the DSM, the American Psychiatric Association (APA), is in the final stages of developing a new edition, the DSM-5.

Below, Nigel Turner—a research scientist at the Centre for Addiction and Mental Health and the Department of Public Health Sciences at the University of Toronto—offers his insight and analysis into three significant changes to the criteria for diagnosing pathological gambling. Each change has important implications for research, treatment and prevention.

Please note that the changes identified here do not represent the final version of DSM-5, which was still under review at the time of the interview.

1) The reclassification of pathological gambling alongside other addictive behaviours

In the current edition (DSM-IV), gambling disorder is classified as part of “Impulse-Control Disorders Not Elsewhere Classified,” which also includes disorders like kleptomania. In the new edition, gambling disorder will join substance-related addictions in a renamed group called “Addiction and Related Disorders.”

Reasons and Implications

According to Nigel, "Impulse Control Disorder" is not a very useful label because it has never been clearly defined, and it is often used as a place to dump conditions that defy normal classification. What’s more, all psychiatric problems are essentially issues of impulse control, so this classification does little to clarify the nature of the disorder.

More significantly, classifying gambling disorder separately from other addictions drives an artificial wedge between substance addictions and behavioral addictions, even though there are many commonalities between them and they are treated using similar methods. In general, then, classifying problem gambling with other addictions is more informative.

Finally, another implication of this change is that it de-emphasizes the substance per se and focuses more on the experience of the person. It also works towards an understanding of factors that make some people more vulnerable not just to a specific drug, but to any addictive behaviour.

2) The lowering of the pathological gambling threshold to 4 symptoms

To be diagnosed with a gambling disorder, a certain set of behaviours must be present over a 12-month period—such as needing to bet with increased amounts of money, being preoccupied with gambling, or tending to chase losses. Currently, gamblers need to exhibit 5 of these behaviours to be diagnosed with a gambling disorder. In the DSM-5, the threshold will be lowered to 4.

Reasons and Implications

According to Nigel, this change is perhaps more controversial. His research shows that a cut off of 5 does result in substantially lower rates of problem gambling compared to other measures. Other researchers have argued that the cut off point of 5 may be too high for problem gambling.

This change does not address the important issue of subclinical forms of the disorder. Many gamblers who score below the threshold—meaning they only exhibit 2 or 3 behaviours on the list—do suffer some gambling-related problems. But, according to the DSM-5, they do not have a gambling disorder. Understanding this, researchers and prevention experts use terms like “at-risk gambling” or “moderate problems” to identify this group—creating inconsistency in terminology and definitions. Most importantly, recognizing the existence of gambling problems that do not meet the official criteria promotes early intervention, which is an important part of any effort to reduce the incidence of problem gambling.

3) The removal of the ‘‘illegal acts’’ criterion for the disorder

Another change is that, where in the DSM-IV there are 10 behaviours listed, in the DSM-5 there will only be 9. Whether or not a gambler has committed an illegal act (like theft or fraud) to finance gambling will no longer be considered a sign of pathological gambling.

Reasons and Implications

This behaviour was, in fact, the least frequently found symptom on the DSM-IV, which may be part of the reason it was removed. However, including a symptom that is rare does help identify those people with the most severe problems. In addition, a discussion of criminal activity between the client and therapist is clinically important.

Though committing illegal acts is not widely reported in treatment settings, it is (not surprisingly) more common amongst people in correctional facilities. Currently, few jurisdictions screen for problem gambling amongst offenders or offer treatment services to this population. Given that the research community is just beginning to understand the relationship between criminal activity and pathological gambling, Nigel believes it is premature to remove this item from the scale.

When did these changes take effect?

The DSM-5 was released in May 2013.

Reference

Ferentzy, P., & Turner, N.E., (2013). A History of Problem Gambling: Temperance, Substance Abuse, Medicine, and Metaphors. Springer.


Interested in hearing from more leading experts? Join RGC at Discovery 2017 in Toronto, April 18-20.