Pathological Gambling Classification from the Perspective of Genesis to the Present
INTRODUCTION
Pathological gambling ("Pathological, Excessive, Addictive, Compulsive Gambling"; "Pathologisches Glücksspielsucht, Spielsucht") is, from the perspective of social work, included in the field of social pathology. According to the model of psychoactive substance addiction, the perception of pathological gambling is shifting and it is classified among so-called addictive behaviors as a form of modern non-substance addiction – addiction to processes, despite the fact that according to diagnostic criteria it is an "addictive and impulse disorder" (impulse control disorder). It is a chronic progressive inability to resist impulses to gamble, resulting in disruption of the bio-psycho-social-spiritual dimension of the personality as well as the social environment. Pathological gambling is also defined abroad as the so-called "Pathological Gambling Disorder" (PGD). In the case of gambling addiction, various types of gambling behavior ("Types of Gambling Behaviours") are cited in foreign professional literature. These include gambling, problem gambling, problem online gambling, compulsive gambling, and pathological gambling and online pathological gambling ("Pathological Gambling"; "Online Gambling Disorder"). The diagnosis, classification, as well as the etiopathogenesis of pathological gambling remain open, and many correlations have not been sufficiently methodologically verified. In this context, it is necessary to point out the lack of elaborated concepts of pathological gambling in our conditions, especially in the humanities and behavioral sciences. Most concepts have been developed within medicine – the field of psychiatry in our country and within the field of addictology in the Czech Republic.
Gambling operators can, due to the new trend of online betting and gambling, profit from gambling even without the need for operating costs for buildings and employees that serve as gaming rooms or casinos. This rising trend, which keeps pace with the times, is a major threat to future generations. The problem in the case of virtual gambling from the perspective of age appears to be the accessibility of virtual gaming portals without verification of actual age. Age is thus not important in "online" gambling, even though the domain of "online games" notes that participation in gambling is possible from the age of 18. However, some virtual gaming portals have introduced player identity verification, which seems in this case to be a prevention of early gambling episodes at a young age. At present, attention should be drawn to the fact that society's tolerance regarding gambling is rapidly increasing, and this trend is likely to continue given the aforementioned possibilities and variability of available gambling activities. Many authors, primarily foreign, point to the importance of preventing pathological gambling from the perspective of research findings, namely Tolchard, Thomas and Battersby (2007); Dickson-Gillespie et al. (2008); Abbott et al. (2016); Todirita, Lupu (2013); Hing et al. (2014, 2014a) and Westphal (2007).
PATHOLOGICAL GAMBLING AS AN IMPULSE CONTROL DISORDER OR A BEHAVIORAL ADDICTION?
In the diagnostic manual of the American Psychiatric Association (APA – DSM-III), pathological gambling (PG) has appeared as a diagnostic category since 1980.
In the International Classification of Diseases (MKCH-10), it has been included since January 1994. In MKCH-10, PG is classified as diagnosis F 63.0 and belongs to the group of "addictive and impulse disorders" (Benkovič, Martinove, 2011). "Although both major diagnostic psychiatric classification systems (MKCH-10, DSM-IV) define pathological gambling as an impulse control disorder, the diagnostic criteria and course characteristics are rather similar to psychoactive substance addictions" (Nábělek, Vongrej, 2010, p. 2). The authors further present pathological gambling as an "addiction disorder – without interfering variables present in the clinical picture of psychoactive substance addiction." According to Nábělek, Vongrej and Gromová (2004), both diagnostic systems classify pathological gambling among "impulse control disorders," but according to these authors as well, many features of this mental disorder show remarkable similarity to two other categories of mental illnesses. On one hand, with obsessive-compulsive disorder in the spectrum of mental disorders, and on the other hand, with addictions to alcohol and other psychoactive substances. The authors also propose the hypothesis that pathological gambling is a "non-substance addiction." The authors consider this theory to be verified given that pathological gambling undoubtedly has its analogous criteria among the diagnostic criteria for "substance addiction." This is also evidenced by research demonstrating a neurobiological affinity between pathological gambling and substance addictions, where in both cases there is a disorder of serotonergic, dopaminergic, and noradrenergic neurotransmission. The connection between pathological gambling and impulsivity is also pointed out by Patarák (2013, p. 9), who states that "classically, serotonergic dysregulation is associated with increased impulsivity and aggressivity."
A predefined set of basic diagnostic criteria was created and is still used today. In some cases, it is partially modified. According to the diagnostic psychiatric classification systems, it is a chronic and progressive inability to resist impulses to gamble and a disruption in the areas of personal, family, and work functioning. Even in this definition, a clear interconnection between the psychological dimension of human life and the social dimension is evident. The definitions further link these "uncontrolled" impulses with feelings of happiness, excitement, and even euphoria that accompany active participation in gambling. These feelings can also be associated with feelings of emotional release (venting to catharsis) and subsequent feelings of guilt, incapability, and hopelessness. Nábělek and Vongrej (2010) further state that "pathological gambling" is assigned in DSM-III to "impulse control disorders," which also include pyromania, kleptomania, and trichotillomania. In the previous version, the criteria for pathological gambling were more or less descriptive, or rather behavioral. The revised modified version of this manual also includes the subjective experience of the pathological gambler and the experiential aspect of this disorder. Compared to the past, the diagnostic criteria have shifted more toward the model of psychoactive substance addiction, thereby moving the perception of pathological gambling among "addictive behaviors." Currently, however, the term "behavioral addiction" is also described according to DSM-5, or also according to the forthcoming MKCH-11.
Griffiths (1996) identified 5 manifestations of behavioral addictions whose presence in the clinical picture is necessary for diagnosis. Sussman, S. and Sussman, A. N. (2011) identified 6 components of behavioral addictions; in MKN-10, three or more manifestations are listed; and in DSM-5, addictive behavior is graded according to the number of manifestations, such that two to three manifestations are indicative of mild addiction, four to five manifestations are indicative of moderate addiction, and six or more manifestations are indicative of severe addiction. According to Griffiths, the basic symptoms include: salience (the activity is regarded as the most important in the individual's life and dominates feelings, behavior, and thinking), mood modification resulting from the initiation of a certain activity, which primarily has the character of a coping strategy, tolerance, withdrawal symptoms, interpersonal or intrapersonal conflict, and relapse. In DSM-5, in the new category "substance use and addictive behaviors," substance addictions and pathological gambling are combined; however, further considerations are directed toward modification in the sense of including other behavioral addictions, such as internet addiction, sex addiction, exercise addiction, shopping addiction, and the like. However, modification is still in the development stage since the relatedness has not yet been unequivocally and exactly proven (APA, 2013; Vacek, Vondráčková 2015).
The efforts of experts have been focused on a more precise conceptualization and definition of the term "behavioral addiction." Initially, in MKN-10 and DSM-IV, addictions were associated only with disorders induced by the use of some psychoactive substance. Currently, the latest revision of the Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association (DSM-5) includes all types of addictions (drug use and behavioral addictive behavior) here. They are classified in category R37, which also includes pathological gambling ("Gambling Disorder"; "Internet Gambling Disorder"). The revision of the International Classification of Diseases (MKN-11) – working version, includes in the group of mental and behavioral disorders a separate category of behavioral addictions, which includes the disorder "pathological gambling" and as yet unspecified certain specified behavioral addictions ("Certain Specified Behavioral Addictions") (Vacek, Vondráčková, 2014). Changes in the understanding of pathological gambling within DSM-5 (2013) have contributed to significant changes. The term "pathological gambling" was replaced by the term "gambling disorder." Gambling disorder was also removed from the group of "impulse control disorders" and was placed in a common category with substance addictions, as we have already outlined above in the text. Another change is the reduction in the number of diagnostic criteria (DSM-5, 2013).
Petry (2010), as well as George, Ijeoma and Bowden-Jones (2013), also emphasize that the conceptual and nosological ambiguity in the diagnostic criteria of pathological gambling has been a part of all previous diagnostic systems. Currently, however, according to the authors, it is correctly and clearly defined within the diagnostic criteria in the section on addictive disorders in DSM-5. Current classification systems and definitions regard "pathological (addictive) gambling" as an "egosyntonic activity," which distinguishes it from obsessive-compulsive disorder. In connection with this disorder, egodystonic activities are associated with experiencing significant discomfort. Pathological gambling and its definitions thus begin to approach again the original classifications and definitions that assigned it more to psychoactive substance addictions. This is also followed by the emphasis on accompanying phenomena of gambling addiction, such as loss of control during the development of addiction, withdrawal symptoms in the form of increased nervousness, tachycardia, restlessness, hyperhidrosis, anxiety, as well as "gambling in thoughts and fantasies" (Nábělek, Vongrej, 2010).
CONCLUSION
As we have stated above in the text, pathological gambling is classified in the International Classification of Diseases among the so-called "addictive and impulse disorders" along with kleptomania, pyromania, and trichotillomania (TTM). Other disorders such as oniomania, dromomania, and shopoholism could also be assigned to these addictive and impulse disorders ("Impulse Control Disorders – ICD"). In the American classification, these disorders are assigned to "impulse control disorders – not elsewhere classified," which also includes "intermittent explosive disorder."
Despite the currently valid classification, pathological gambling undoubtedly exhibits the presence of substantially more complex psychopathological symptomatology compared to "other" impulse control disorders. Alongside phenomenological analysis, other factors (prevalence, course, comorbidity, neurobiological and genetic connections, suicidality, criminal offenses) also point to the indisputable relatedness of pathological gambling and psychoactive substance addictions.
The assertion that pathological gambling represents a mental disorder comparable to alcoholism and other addictions (Nábělek, 2013; Frouzová, 2008) brings significant theoretical and practical implications.
In conclusion of the paper, we consider it important to again point out the constantly increasing prevalence of pathological gambling in the general population. The prevalence, or rather the exact "percentage" of occurrence of this phenomenon in the population in Europe and the world is not entirely clear; however, it is evident that due to the availability and popularity of various gambling activities, it is constantly increasing, which is becoming a problem of the present time.
Author: PhDr. Michaela Dávidová, PhD.
LIST OF ABBREVIATIONS AND SYMBOLS
APA – ("American Psychiatric Association"); American Psychiatric Association; DSM-III-R – ("Diagnostic and Statistical Manual of Mental Disorders III Revised"); Third revised edition of the Diagnostic and Statistical Manual of Mental Disorders; DSM-IV-MR – ("Diagnostic and Statistical Manual of Mental Disorders IV Multiple Response"); Ten-item questionnaire designed to measure diagnostic criteria of adult pathological gamblers; DSM-5 – ("Diagnostic and Statistical Manual of Mental Disorders 5"); Fifth edition of the Diagnostic and Statistical Manual of Mental Disorders; MKCH-10 – International Classification of Diseases – 10th revision; MKCH-11 – International Classification of Diseases – forthcoming 11th revision.
GLOSSARY OF TERMS
Addictology – an interdisciplinary field focusing on prevention, treatment, or minimization of disorders and diseases related to the use of addictive substances and disorders arising in connection with various forms of addictive behavior. It is a field integrating several scientific disciplines, coordinated by experts from multiple areas (physicians and "non-physicians" – addictologists, nurses, clinical psychologists, social workers, special pedagogues) (Sklenář, 2013). Analogous – similar; accompanying. Anxiety – a feeling of worry; Anxious – worried. Dopaminergic neurotransmission – the neurotransmitter of this system is dopamine and its transmission. Dopaminergic – dopamine systems and their structures. Dysregulation – disorder of regulation; disturbance in the control of the body's system. Egodystonic (Ego-dystonic) – thoughts, feelings, impulses, and wishes that are unacceptable or contradictory to one's own "Self." They manifest as a personality difference that is problematic for the individual and their surroundings. The consequence of this difference is a discrepancy between the individual's own "Self" and the role they occupy. Examples include obsessive thoughts and compulsive behavior (Hartl, Hartlová, 2010). Egosyntonic (Ego-syntonic) – thoughts, feelings, impulses, and wishes that are in harmony with one's own "Self." Egosyntonicity manifests as an inseparable peculiarity of the personality with which the individual is comfortable and which does not cause them problems, and they have no urge to get rid of this peculiarity. Examples may include delusions and illusions (Hartl, Hartlová, 2010). Etiopathogenesis – describes the origin of a disease including its causes (i.e., etiology), as well as other processes that accompany the origin and development of the given disease (signs; symptoms) (Orel et al., 2012). Phenomenology (phenomenological analysis) – a procedure in which experimental data are accepted without further analysis. It is also the initial collection of data. It is also a science of essences based on experience and lived experiences. According to phenomenology, psychic phenomena are not consciously created, or rather not immediately given. Phenomenology is also a medical field dealing with the causes of origin and patterns of spread of mass-occurrence diseases (Hartl, Hartlová, 2010). Hyperhidrosis – hyperhydration; excessive fluid intake into the body; excessive fluid content in the organism. Hypothesis – theory; assumption; assertion. Intermittent explosive disorder – interrupted, occasional, recurring emotionally unstable disorder. Catharsis – emotional release of tension, anxiety, feelings of guilt and remorse through disclosure, or also through re-experiencing unpleasant to traumatic past experiences. In psychoanalytic theory, catharsis is understood as liberation from internal conflicts, internal tension, stress states together with accumulated aggression (Hartl, Hartlová, 2010). Classification – sorting; assignment into groups according to given criteria; from the perspective of psychopathology, the classification of mental illnesses and disorders is important (Hartl, Hartlová, 2010). Kleptomania – morbid compulsive stealing of objects that are insignificant to the kleptomaniac (Hartl, Hartlová, 2010). Comorbidity – the simultaneous occurrence of two or more disorders in the same individual, each of which may require different treatment. For example, dissocial personality disorder and alcohol addiction (Hartl, Hartlová, 2010). Methodology – the science of methods of scientific research. It is a "system of views on the principles, ways, methods, and possibilities of knowing the subject of a selected scientific field and methods of research (sociological, psychological, medical). Methodology in the humanities is currently focused on two approaches, namely qualitative and quantitative methodological approach (Křivohlavý, 2006). Multidisciplinary approach – based on multiple scientific disciplines, or intertwining knowledge from several scientific fields. Addictive behavior – a synonymous term is dependent behavior, i.e., behavior leading to a certain type of addiction. Neurotransmission – transmission of excitation from nerve to muscle (Hartl, Hartlová, 2010). Obsessive-compulsive disorder – compulsive need to repeatedly engage in any, usually repulsive, unpleasant thoughts, ideas, images, impulses, often of a violent, obscene, or nonsensical nature, or activities associated with unpleasant feelings and resulting anxiety. The anxiety subsides only after performing a repeated ritual or act (Hartl, Hartlová, 2010). Obsessive-compulsive disorder (OCD - spectrum of mental disorders) – the basic characteristic is the inability to prevent or postpone the realization of inappropriate or even disadvantageous behavior, resulting in the repetition of undesirable behavioral patterns. The undesirable behavior can be directed either toward feelings of discomfort and anxiety, or conversely toward achieving a feeling of satisfaction (Nábělek, Vongrej, Gromová, 2004). Progressive – advancing; spreading; progressing. Psychopathology – a field dealing with morbid psychic phenomena, symptoms of mental disorders, and the classification of these disorders and borderline states (Hartl, Hartlová, 2010). Pyromania – pathological fire-setting. Relapse – return of symptomatology after achieving remission, but before achieving recovery. It is a re-eruption of a previously suppressed disease or behavior, such as a breach of abstinence in addiction treatment (Hartl, Hartlová, 2010). It is a complication of addiction treatment (Kalina et al., 2008). Serotonergic – serotonin systems and their structures. Suicidality – tendency toward suicide. Symptomatology – the science of individual symptoms, signs of diseases, and their classification (Hartl, Hartlová, 2010). Tachycardia – accelerated heart activity. Trichotillomania (trichokryptomania, trichoclasia, trichomania) – compulsive pulling out of one's own hair (Hartl, Hartlová, 2010). Verified – confirmed; valid.
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