Clinical Characteristics

Gambling usually begins in adolescence, although women may begin gambling later in life. Pathological gambling often develops in three phases, originally described by Custer (1985): (1) the winning phase; (2) the losing phase; and (3) the desperation phase. Female pathological gamblers tend to have a later onset of the illness than males, and may never experience a winning phase.

The Winning Phase. Pathological gamblers often start as winners. Also, in a minority of cases, a significant upsurge in gambling activity begins with a ''big win''—a sum equal to half a year's income or more. With or without the big win, individuals developing a dependence on gambling often begin with some success. In this context, they develop an intense interest in gambling and derive an increasing proportion of their self-esteem from feeling smart or lucky. The high derived from being in action becomes a major source of pleasure, a solution to life problems, a remedy for boredom, anger, anxiety, depression, and other uncomfortable feeling states. Bets must be gradually increased in size, in frequency, and sometimes in riskiness to produce the desired psychological effects. This phenomenon parallels the development of tolerance in the substance-dependent patient who must continue to increase the alcohol or drug dosage to reach the preferred feeling state. At this stage of the illness, the gambler devotes a great deal of time and effort to handicapping, studying the sports page, selecting a lottery number, or following the stock market, as well as to the gambling itself. As one gambler put it, ''When I'm not occupied with gambling I'm preoccupied with it.'' Even if the gambler is winning more often than losing, time and emotional investment are withdrawn from friends, family, work, and other interests. The gambler's spouse often senses that something is wrong, but may not identify gambling as the problem. Marital counseling is sometimes sought.

An unreasonable attitude of optimism is also common during the early phase of pathological gambling, sustained by concentrating on wins and making excuses for (or even denying) losses. Because of this denial, the gambler often cannot account for money claimed to have been won. Pathological gamblers who begin with a winning phase are often those who state they gamble for excitement or stimulation.

The Losing Phase. All gamblers know that when on a losing streak it is wise to stop wagering, at least temporarily. For the compulsive gambler, however, losses are experienced as a severe injury to self-esteem. This produces an intense drive to continue gambling in an effort to recoup the money that has been lost, called chasing losses. Chasing losses is an important characteristic of this disease and an example of the pathological gambler's impaired control of gambling behavior. Chasing losses accelerates the gambler's losing and initiates a downward spiral. As the gambling debts mount, the pathological gambler will use any and all money available—take out loans, sell property, and gamble with money meant for family necessities. When these sources are exhausted, extended family members or friends may be approached for a ''bailout,'' in the form of a loan or gift to relieve immediate financial pressure. In return, the pathological gambler often promises to give up gambling. However, part of the bailout money is usually gambled in the hope of another big win, and the downward spiral resumes. Although there are both wins and losses during the losing phase, the overall result is mounting emotional and financial distress as well as interference with social, vocational, and family functioning. Serious depression and a variety of stress-related somatic disorders are often experienced. Pathological gamblers report insomnia, gastrointestinal symptoms, dizziness, headache, hypertension, palpitations, chest pains, and breathing problems. Medical help may be sought, but again the connection to gambling behavior is seldom recognized. Family problems become more intense and divorce often results. Alcohol and other drug abuse may accompany gambling and/or function as a substitute when gambling is temporarily interrupted.

Pathological gamblers also describe a WITHDRAWAL syndrome when they are prevented from gambling. Symptoms include craving, restlessness, irritability, insomnia, headache, weakness, gastrointestinal symptoms, shakiness, and muscle aches.

Those pathological gamblers who do not experience a winning phase often describe themselves as gambling for ''escape'' (from life problems that seem insoluble). However, by the time the disease is well-developed, most pathological gamblers report gambling for both escape and excitement.

The Desperation Phase. The desperation phase often begins when all legitimate sources of funds are exhausted. The gambling now takes on a desperate quality. The gambler's behavior during this phase may be characterized by activities inconsistent with the individual's previous moral standards, such as lying, embezzling, larceny, and forgery. These activities are justified as temporary expedients until the next big win. Pathological gamblers are often imprisoned both for white-collar crime and for illegal gambling activities such as bookmaking. Violent crime is less common. Studies of prison populations have found gambling problems in 15 to 30 percent of inmates.

An irrational belief in the inevitability of a big win sustains hope to some degree during this phase. Family problems become more intense and mood swings are common. Severe anxiety, major depression, and suicidal behavior are increasingly noted during the late stages of the disease. Manic or hypo-manic states are also seen in some cases. Most pathological gamblers who enter treatment or Gamblers Anonymous do so in the desperation phase. Surveys of Gamblers Anonymous have reported suicide attempts by 17 to 24 percent of members.

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