A hierarchy of gambling disorders in the community

Abstract

Aims To help refine the definition and diagnosis of gambling disorders, we investigated the distribution among US gamblers of the 10 DSM‐IV criteria for Pathological Gambling. Design We drew data from two stratified random surveys (n = 2417, n= 530) of gambling behavior and consequences among community‐based samples of US adults. A fully structured questionnaire, administered by trained lay interviewers, screened for the life‐time prevalence of problem and Pathological Gambling. Per DSM‐IV definitions, anyone meeting five or more of 10 itemized criteria was considered a pathological gambler. We analyzed these criteria among all gamblers who met one or more criteria (n = 399). Findings Most gamblers who met only one or two criteria reported ‘chasing their losses’. At subclinical levels (three to four criteria), gamblers also reported elevated rates of gambling‐related fantasy: lying, gambling to escape and preoccupation. Pathological gamblers with five to seven criteria reported marked elevations of loss of control, withdrawal symptoms and tolerance (internalizing dimensions of dependence); risking their social relationships and needing to be bailed out financially (externalizing dimensions). Most of the highest‐level pathological gamblers (eight to 10 criteria) reported committing illegal acts to support gambling. Conclusion Dependence in a biobehavioral sense appears to be a hallmark of Pathological Gambling, but it marks only one threshold in a qualitative hierarchy of disorders beginning with a common subclinical behavior, ‘chasing’. Epidemiological assessments and future DSM revisions might consider explicit recognition of a problem gambling disorder, identifying people presenting some cognitive symptoms of Pathological Gambling but not clear signs of dependence. Pathological gamblers in turn appear to have two distinct levels of severity.