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PathologicalGambling:ComorbidPsychiatricDiagnoses inPatientsand their Families

Pinhas N. Dannon, MD, Katherine Lowengrub, MD, Anat Aizer,MD, and Moshe Kotler, MD

Rehovot Community Health Care & Rehabilitation Center, affiliated with the Tel Aviv University, Sackler School of

Medicine, Rehovot, Israel.

Abstract: Objectives: Pathological gambling is a highly prevalent anddisabling impulse control disorder. Recent studieshave consistently demonstrated that pathological gamblers respond well to treatment with selective serotoninreuptake inhibitors, mood stabilizers and opioid antagonists. These findings have supported the observation thatpathological gambling is associated with anxiety and mood spectrum disorders as well as addictive disorders.Methods: Fifty-two male pathological gamblers and their first-degree relatives (n=93) completed a semi-structuredDSM-IV-based diagnostic interview as well as a series of data collection instruments including the South Oaks Gam-bling Scale, the Hamilton Rating Scale for Depression, the Hamilton Rating Scale for Anxiety, the Yale-Brown Obses-sive-Compulsive Scale, and the Young Mania Rating Scale. The study subjects and their first-degree relative werecompared to demographically matched normal controls (n=96).ResultsWe found higher prevalence of alcohol, sub-stance abuse, problematic gambling, depression, and anxiety disorders in the pathological gamblers and their first-de-gree relatives than in the control group. In particular, the scores on the Hamilton Rating Scale for Depression, theHamilton Rating Scale for Anxiety, and the Yale-Brown Obsessive-Compulsive Scale were higher in the study groupthan in the control group. Conclusions:Our finding of a high prevalence of psychiatric comorbidity in pathologicalgamblers and their families raises the question of the proper classification of pathological gambling in the DSM-IV.Furthermore, the pattern of psychiatric disorders seen in the first-degree relatives can lead to new insights about theetiopathology of pathological gambling.

Introduction

Pathological gambling (PG) is classified in the DSM-

IV of the American Psychiatric Association as a dis-

order of impulse control not otherwise specified (1).

In the International Classification of Diseases of the

World Health Organization (2), PG is coded under

the heading of Habit and Impulse Disorders together

with kleptomania, pyromania and trichotillomania.

Impulse control disorders are characterized by an

overwhelming urge to perform a harmful act. The

patient usually feels a sense of tension before com-

mitting the act and then experiences pleasure or re-

lief during the act. PG is a chronic, progressive,male-dominated disorder, which has a prevalence of

1.0% to 3.4% among U.S. adults (3). PGs engage in

persistent and recurrent maladaptive patterns of

gambling behavior. The enormous personal and so-

cial consequences of this disorder include a high rate

of suicide attempts, jobloss, marital andfamily prob-

lems, legal problems and criminal behavior caused

by gambling behavior all over the world (4, 5).PG appears to be associated with other psychiat-ric comorbidities, most notably mood disorders,anxiety disorders, attention deficit disorder, eatingdisorders, alcohol abuse and other disorders of psy-choactive substance abuse (5, 6). Indeed, most PGpatients are referred for psychiatric treatment due toa comorbid psychiatric or somatic disorder. Hol-lander et al. (7) describe a connection between theclinical features of PG and bipolar disorder. They de-scribe characteristics common to both disorderssuch as impulsive risk taking behavior, mood swings,poor judgement and grandiose thinking. According

to McElroy et al. (8), 30% of patients with bipolardisorder have had a diagnosis of comorbid PG. Hol-lander and Wong (9) suggested that impulsive disor-ders such as PG are associated with strongcompulsive and impulsive features, and hence, PGcan be viewed as an impulsive subtype of the ob-sessive-compulsive (OC) spectrum disorders. Ac-

Isr J Psychiatry Relat Sci Vol 43 No. 2 (2006) 8892

Address for Correspondence: Pinhas N. Dannon, Rehovot Community Health Care & Rehabilitation Center, 80 RemezSt., Rehovot 76449, Israel. E-mail: pinhasd@post.tau.ac.il

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cording to this theory, a common unifiying themeamong the OC spectrum disorders is their selectiveresponsiveness to treatment with selective serotoninreuptake inhibitors (SSRIs). Multiple open-label anddouble-blind studies have shown SSRIs to be benefi-cial in reducing gambling urges and behavior (10) al-though a recent controlled study yielded negativeresults (11).

Recently, investigators have looked at the role ofaddictive behavior in PG (12). Kim et al. (13) con-ducted a double-blind, placebo-controlled trial(N=83) and demonstrated that the opioid receptorantagonist naltrexone significantly reduced the aver-

age intensity of gambling urges, gambling thoughtsand gambling behavior. Our group also demon-strated the effectiveness of topiramate andfluvoxamine (14) in the treatment of PG, andbuproprion SR has been shown to be beneficial inpreliminary studies of male pathological gamblers(15, 16).

We believe that PG shares characteristics of bothaddictive behavior and anxiety spectrum disorders.The aim of this article is to present our findings re-garding the comorbid psychiatric diagnoses seen inour cohort of PGs and their first-degree relatives.

Methods

Fifty-two outpatients with a diagnosis of PG accord-ing to DSM-IV criteria were included in this study,and 93 first-degree relatives of this patient groupagreed to participate in the study. First-degree rela-tives included both parents and siblings. We notethat the patients children were not included in thestudy due to patient preference. Ninety-six demo-graphically matched normal controls were includedin this study.

The study was conducted at the Rehovot Com-

munity Mental Health & Rehabilitation Center, anambulatory care psychiatric clinic run by the IsraeliMinistry of Health. The participants were referred tothe walk-in clinic either by their family, medical phy-sician or social workers. All study subjects com-pleted a semi-structured psychiatric diagnosticinterview (using the SCID format) performed by asenior psychiatrist (PND, KL). The South OaksGambling Scale (SOGS) (17) was also administeredto all patients and to the cohort of first-degree rela-

tives at the screening interview. Diagnosis of patho-logical gambling in the study subjects and their first-degree relatives was made according to DSM-IV cri-teria and the South Oaks Gambling Scale. The par-ticipants gave their written informed consent forparticipating in the study, and the study was ap-proved by the hospitals Helsinki Committee (ChaimSheba Medical Center).

Instruments

A masked rater who was blind to the group alloca-tion delivered several data collection instruments

rating anxiety, depression and functioning. The in-struments were administered once at baseline to allstudy subjects, the cohort of first-degree relativesand to the control group. The normal controls werealsointerviewed at the ambulatory psychiatric clinic.We administered the Hamilton RatingScale for Anx-iety (HRSA) (18), the Hamilton Rating DepressionScale (HRDS) (19), the Yale-Brown Obsessive Com-pulsive Scale (Y-BOCS) (20), and the Young ManiaRating Scale (YMRS) (21).

Analysis

Statistical analysis was performed with t-test analy-sis, chi squares and ANOVA with repeated measures.Levels of significance were set at 0.05 (Bonferronicorrection), unless otherwise stated.

Results

The patient sample was composed of 52 male patho-logical gamblers.

Their age ranged from 21 to 67 years (38.716.4);65% of the sample was married and 27% was di-vorced or separated (n=14). An analysis of social sta-

tus demonstrated that 19% of the patients had auniversity degree; 62% of the patients had a highschool diploma, and 19% of the patients did notcomplete high school; 76% of the patients were em-ployed and only 10% were unemployed. Demo-graphic findings of the patients and families aresummarized in Table I.

The age at onset (meanSD) of gambling behav-ior was (19.711.4) years, ranging from 13 to 45, andthe majority of the sample reported a sudden onset

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of the course of disorder. The majority of the patientshad more than one comorbid psychiatric disorder,and most of them were referred to the clinic becauseof the comorbid diagnosis rather than gambling(Table II).

The group of 93 first-degree relatives was com-prised of 37 parents and 56 siblings. Twenty-seven ofthe parents were females and 10 were males.

Their ages ranged from 56 to 82 years (68.414.9); 47% of them were married, 22% of them di-vorced and 31% of them were widowed. An analysisof socioeconomic status showed a preeminentlymiddle-class background. Fifty-six siblings, 24 sis-ters and 32 brothers, ranged in age from 23 to 64years (32.617.9). Some of the first-degree relativeshave been diagnosed and treated before.

Table I.Demographic Findings

Pathological Gamblers Families

Parents Siblings

Number 52 37 56Age 36.711.4 68.414.9 32.617.9

Gender Female (%) 0% 73% 43%

Male (%) 100% 27% 57%

Race Sepharadi 65% 69% 64%

Ashkenazi 35% 31% 36%

Education (%) 12th grade 19% 50% 12%

High School diploma 62% 38% 66%

University 19% 12% 22%

Employment Unemployed/Pension 10% 38% 18%

Student/Homemaker 14% 54% 22%

Full Time 76% 8% 60%

Marital Status Married 65.4% 47% 59.3%

Divorced/Separated 27.1% 22% 24.7%

Widowed/Never Married 7.5% 31% 16.0%

Table II.Psychiatric Diagnoses in Patients and their First-Degree Relatives

Patients (N=52) Family Members (N=93)

Number Male (52) Number Male (42) Female (51)

Mood Disorders Unipolar Depression 7 7 12 5 7

Bipolar I 1 1 1 0 1

Bipolar II 1 1 4 1 3

Anxiety Disorders PTSD 2 2 2 1 1

OCD 2 2 4 2 2

Panic Disorder 2 2 5 2 3

GAD 1 1 2 0 2

Drug Abuse 4 4 3 3 0

Alcohol Abuse 10 10 15 11 4

Problematic-pathologic gambling 52 52 9 3 6

Attention Deficit Disorder 3 3 1 1 0

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Table III.Results of Rating Scales for Patients, First-Degree Relatives, and Controls

Pathological gamblers Relatives p Controls t p

HRSD 13.910.2 10.79.4 ns

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