Introduction to the Gambling Disorder Special Issue

My son tells me that every time he gets a paycheck, he goes to the casino and loses it all. And every time he does, he just wants to drive his pickup truck into a wall. (Personal communication to the author from a Wisconsin mother of young problem gambler during one of the Wisconsin Problem Gambling annual conferences).

I met this mother when I began attending the annual state conferences on Gambling Disorder (GD)/Problem Gambling in Minnesota and Wisconsin. I was not seeing any references to GD in healthcare conferences, the psychiatric nursing literature, or general nursing journals. This addiction is flying well below the radar, with articles generally found in addictions literature not being translated into a usable format for healthcare providers working with patients and families.

Although receiving almost no attention in the psychiatric nursing literature, GD can be a crippling disease with enormous biopsychosociospiritual implications for individuals, families, communities and workplaces. Blaszczynski and Nower (2002) suggest that the causes of problem gambling may include genetics, biology, personality, developmental and cognitive issues, learning theory and ecological determinants in a complex stew. The biopsychosocial consequences of pathological gambling are very well laid out by Fong (2005) and include altered neurobiological processes, general decline in health status, escalating debt, high blood pressure, heart disease, ulcers, chronic and acute stress, sleep deprivation, substance use disorders (e.g. alcohol, illegal drugs, nicotine), obesity, binge eating, anxiety, depression, financial devastation, increased crime, lost time at work, bankruptcy, great hardship for families, divorce, total loss of life savings, domestic violence, spousal/child abuse, lost productivity, lateness, absenteeism, stealing, prostitution, embezzlement, insurance fraud, dealing with loan sharks, and homelessness (Fong, 2005).

Although GD affects at least 2 million Americans (Stein & Stinchfield, 2020), and destroys lives, individuals, families, family finances and family futures, as well as impacting workplaces and the health status of all involved, there is a relative dearth of GD research in nursing journals.

Nurses provide a lot of patient/family care in very diverse settings: clinics, hospitals, emergency departments, home health, public health, hospice care, adult day care, prisons and jails, geriatrics and gerontology, the military, elementary, middle and high schools as well as colleges and universities, work sites, and with special populations such as Southeast Asians and in many other settings, with many other populations. Yet the issue of GD is not receiving the attention it deserves and I venture to guess that few nurses are being asked to provide a quick GD screening, subsequently referring patients for more in-depth screenings.

In 2019, I approached a number of top GD researchers in Minnesota to form a committee about putting together a special issue on GD for Issues in Mental Health Nursing. This committee included Randy Stinchfield, Ph.D., L.P., University of Minnesota; Ellina Xiong, Ed.S., doctoral candidate, University of Minnesota; Serena King, Ph.D., L.P., Hamline University; and Susan Sheridan Tucker, Executive Director, NorthStar Problem Gambling Alliance. Through their efforts, their hard work, their research, their academic papers, and their active solicitation of articles worldwide (Editor-in-chief, Dr. Sandra Thomas, also solicited submissions through her international efforts), we began to assemble this special issue. It was difficult to find GD research outside of addictions literature. There are many reasons for this: GD research is woefully underfunded at the local/county/state/regional and federal levels, garnering very little focus or attention compared to other addictions. Those with GD can suffer for years in relative anonymity (gambling secretively every day until a spouse suddenly discovers that the farm, the business, the ranch, the home, the cars, the bank accounts and savings/pensions/IRAs have all disappeared). Sometimes the first time a spouse even knows there is a gambling problem is when the sheriff shows up at the door with a notice of eviction (see more about this “hidden addiction” in Stein & Stinchfield, 2020). And, because funding streams and research are so siloed in U.S. healthcare, it can be rare to find researchers and practitioners from different silos working together to treat patients, even when comorbidities exist and patients/families would be much better served by a more comprehensive, all-encompassing global approach.

According to Tucker:

Gambling Disorder needs high-level, federal recognition and focus before healthcare and mental health providers fully embrace problem gambling for the serious, destructive addiction it is. We are in a catch-22: we need recognition to collect data but we need data to gain recognition. In addition, we believe that many more individuals are now choosing to gamble online due to COVID-19, which is making it even more challenging to gather data and information. (Susan Sheridan Tucker, personal communication, 2020)

How is Gambling Disorder different from other addictions nurses may encounter? Because the gambler is not ingesting a substance, it is often more difficult to detect than alcohol/substance abuse. Gambling addiction may progress very rapidly after a “big win”. Also, problem gamblers often feel significantly more shame, guilt and/or depression, and are much more likely to attempt suicide than those with other addictions (NorthStar Problem Gambling Alliance, 2018). In addition, once a person with GD is in recovery, he/she is left with a huge mountain of debt that must be paid off, unlike those recovering from other addictions; this, then, is a constant reminder of the disorder which has affected her/his life.

The DSM-5 defines problem gambling as “persistent and recurrent problematic gambling behavior leading to clinically significant impairment or distress” (APA, 2013, p. 585; Rodda et al., 2016; Stein & Stinchfield, 2020). Gambling Disorder seems to be little understood, either by those working in healthcare or the general public. Those who have a little-understood gambling problem are stigmatized, and this stigma may cause gamblers to delay or avoid altogether getting the help they need.

Simple screening tools

Nurses can use this easy two-question screen to determine if someone may need to be referred for more in-depth assessment and possible treatment; there is also a 20-question screen suggested by Gamblers Anonymous:

1. Have you ever had to lie to people important to you about how much you gamble? (yes, no);

2. Have you ever felt the need to bet more and more money? (yes, no).

Gamblers Anonymous: Are you a compulsive gambler?

If you answer “yes” to 7 or more of these 20 questions, then you may be a compulsive gambler.

• Does gambling cause you to lose time from school/work?

• Does gambling cause unhappiness for your home/personal life?

• Has gambling affected your reputation?

• Have you felt guilty after gambling?

• Have you gambled to pay debts or solve money problems?

• Does gambling decrease your ambition for school/work?

• If you lose in gambling, do you try to win it back?

• If you win in gambling, do you wish to keep playing?

• Have you gambled until all your money was gone?

• Have you borrowed money to gamble?

• Have you sold anything and used the money for gambling?

• Have you used money intended for another purpose for gambling?

• Has gambling made you careless about yourself and others?

• Did you ever gamble longer than you had planned?

• Have you gambled to escape worry, trouble, loneliness, boredom?

• Have you committed/considered committing illegal acts to gamble?

• Has gambling caused you to lose sleep?

• Do disappointments/frustrations cause an urge for you to gamble?

• Do you have an urge to celebrate good fortune by gambling?

• Have you considered self-destruction/suicide due to your gambling?

Comorbidities and Gambling Disorder

Nurses and healthcare personnel working in any setting should be aware of the comorbidities that may accompany a patient’s problem gambling: alcohol/substance abuse (Black & Shaw, 2008; Lorains et al., 2011; Rash et al., 2016; Rodda et al., 2012, 2016; Streich et al., 2020; Wareham & Potenza, 2010); anxiety (Black & Shaw, 2008; Lorains et al., 2011; Rodda et al., 2012); ADHD (Black & Shaw, 2008); depression (Black & Shaw, 2008; Lorains et al., 2011; Quigley et al., 2015; Rodda et al., 2012); panic attacks (Lorains et al., 2011); severe legal and financial issues, such as job loss, lost time and lost productivity, theft, fraud and embezzlement, bankruptcy, divorce, healthcare problems due to high stress, prison time and homelessness (National Endowment for Financial Education & National Council on Problem Gambling, 2000); suicidal ideation/attempts (Goldman, 2013; Hills, 2010; NorthStar Problem Gambling Alliance, 2013; Russel, 2014); obesity (Streich et al., 2020); nicotine dependence (Lorains et al., 2011; Rodda et al., 2012; Streich et al., 2020); binge eating disorder (Yip et al., 2011); ACES or adverse childhood experiences (Sharma & Sacco, 2015); manic depressive disorder (Black & Shaw, 2008); homelessness (Stein & Stinchfield, 2020), using or taking dopamine for Parkinson’s Disease which may increase the incidence of GD (Stein & Stinchfield, 2020); domestic violence (NorthStar Problem Gambling Alliance, n.d.) and PTSD (Najavits et al., 2011).

Genetics definitely play a role in gambling disorder, with some twins studies elucidating exactly how genetics and GD relate. Studies show that there is considerable evidence for the influence of genetic factors on GD, along with complex interactions with both environmental factors as well as other psychiatric disorders. Lobo and Kennedy (2009) argue for the further study of genetic and biological factors and their impact on GD in order to develop more specific and finely targeted prevention and treatment strategies.

Is there a relationship between Gambling Disorder and Internet Gaming Disorder?

It is only fairly recently that Internet Gaming Disorder or IGD (Choi et al., 2014; King et al., 2020) has been shown to be comorbid with Gambling Disorder. Internet Gaming Disorder may lead to GD or GD may lead to IGD. Internet Gaming Disorder is now being considered for inclusion in the DSM with such serious sequelae as school failure, divorce, job loss, loss of productivity and more. These two addictions, both of which can be accessed at home on the computer or any Internet-ready device, can feed each other in those already at risk for addictive behaviors. King et al. (2020) have shown in their article in this issue that IGD and GD may be linked in emerging adults (those 18–25 years of age), and that risk-taking behaviors are intensified through the use of video game microtransactions such as loot boxes. King and colleagues (2020) also find that emerging adults with IGD and/or GD share many risk factors and may well warrant broader treatment approaches rather than symptom-specific treatments. According to King et al. (2020), gambling and gaming disorder may co-occur and may have some commonalities, while Flaskerud (2020a) in this issue points out the distinctions between Gambling Disorder and Gaming Disorder.

The DSM-5 (APA, 2013) states that gaming must cause “significant impairment or distress” in several aspects of one’s life (e.g. preoccupation with gaming; withdrawal symptoms such as irritability, sadness or anxiety if gaming cannot be accessed; tolerance or the need for more and more gaming to satisfy the urge to play; the player cannot reduce playing or quit playing; the player gives up other activities and loses interests in hobbies and activities once enjoyed; continues to game despite serious problems; the player deceives family and friends about the amount of time/money spent on gaming; uses gaming to relieve negative emotions such as guilt or hopelessness; and, the player risks losing a relationship or job due to gaming).

Petry et al. (2015) look at the reasons for a potential new diagnosis of IGD. They lay out the controversy and debate about including IGD in that it is a non-substance addiction. This major paper spells out the international research and recommends future research needed regarding IGD related to “prevalence rates, demographic, psychiatric, and neurobiological risk factors, the natural course of the condition, and promising treatment approaches.”

In her two-part paper in this special issue, Flaskerud (2020a, 2020b) goes into great detail on the history and evolution of Gaming Disorder (also called Gaming, or Internet Gaming Disorder) as it is included in The World Health Organization (WHO) 11^th Edition of the International Statistical Classification of Diseases and Related Health Problems (ICD-11). She points out that Gaming Disorder involves impaired control over gaming, increasing priority of gaming over other activities in one’s life, and continuation/escalation of gaming with increasingly negative consequences. It affects “personal, family, social, educational, occupational or other important areas of functioning and would normally have been evident for at least 12 months” (WHO, 2018). She cites evidence and research into gaming disorder from Great Britain, Northern Ireland, Japan, South Korea, China, Spain, France, Hong Kong, India, the US, Canada, and Italy. At the same time, Flaskerud (2020a) lays out the arguments against rushing to include Gaming Disorder in the DSM or ICD-11. Some researchers feel that this move is premature, may lead to overdiagnosis, and may be fed by what she terms moral panic over online gaming and the stigmatization of gamers.

Kraus et al. (2020) have provided us with an excellent pilot study of screening for Gambling Disorder in VA Primary Behavioral Health. In this case, researchers assessed the incidence of GD using the BBGS or Brief Biosocial Gambling Screen for military veterans who were accessing mental health services at a VA hospital in the Northeast. Kraus, et al. suggest the urgent need for large and robust studies to look at the value of using the BBGS for finding gambling problems in the military; they also point out that a good way to increase veterans’ participation rates in treatment programs aimed at GD will involve outreach/education efforts by VA staff as well as self-disclosure of problem gambling among the veterans themselves.

In their contribution to this issue, King and Whelan (2020) look at gambling and alcohol problems during the college years: personality, physical and emotional health, and gambling beliefs. They point out that alcohol problems and gambling often co-occur during young adulthood and that these co-occurring problems relate to personality factors, physical health, and mental health as well as gambling beliefs. They conclude that gambling, alcohol issues, emotional and health problems, and personality and belief systems may all be related to the co-occurring problems of gambling and alcohol use.

Contributing author Stinchfield (2020) is very well known in the field of GD and was the first to research gambling and youth. In his article in this issue, he looks at gambling participation and problem gambling rates in 2019 among Minnesota public school students, then compares 2019 gambling participation rates and problem gambling to those in 2016 to see what changes may have occurred (increased, decreased, stayed the same), and finally, looks at the behavioral, psychosocial and demographic factors associated with problem gambling in these adolescents. He concludes, among other things, that there is a relatively small number of adolescents gambling excessively and experiencing problems due to their gambling behavior.

Finally, Li et al. (2020) look at the phenomenon of FoMO or Fear of Missing Out and gaming disorder among Chinese university students, specifically examining impulsivity and game time as mediators. Those with high levels of FoMO are more likely to act impulsively and to spend longer amounts of time gaming, both associated with gaming disorder. These authors suggest that their findings mean that it is important to incorporate health prevention programs which help Chinese university students regulate emotion, control impulsivity and thus decrease gaming disorder.

Special populations and Gambling Disorder

With regard to Gambling Disorder, there are many special populations, and therefore different/variable onsets, trajectories, assessments, GA groups and tailored treatments. Among these special populations are women vs. men; Southeast Asians (such as Lao, Hmong, Cambodian); Latinos; Native Americans; active and retired military; seniors; prisoners and others.

Look at the website for the NorthStar Problem Gambling Alliance in Minnesota for excellent fact sheets on GD for some of these special populations And most importantly, nurses/healthcare personnel must never focus solely on the problem gambler and lose sight of the families and significant others whose lives are turned upside down and permanently impacted by those with Gambling Disorder.

Where can one go to learn more about Gambling Disorder?

To learn more about Gambling Disorder, refer to the website of the National Council on Problem Gambling (https://www.ncpgambling.org). This amazing site offers Counselor Search, FAQs, Help by State on a state-by-state basis, a 24-hour confidential National Helpline (1-800-522-4700), Helpline Chat, Screening Tools, and Treatment Facilities. This site lets you see instantly which states have an NCPG state affiliate; many of these affiliates have annual conferences and newsletters as well as other resources so nurses can get more information on GD. Also listed are websites for Advocacy, Programs, Webinar Series, Problem Gambling Awareness Month, the NCPG National Conference, Responsible Gambling, Sports Gambling, NASPL-NCPG Responsible Gambling Verification Program, Internet Compliance Assessment Program, Holiday Lottery Campaign, and other resources. In addition to the Help and Treatment resources, there are also Training and Certification programs. There are listings for outpatient treatment centers, for offices of problem gambling services, and even an International Center for Responsible Gambling as well as a plethora of international organizations and links, information on financial issues, and a whole section on the military and problem gambling.

In addition, there is a newly published research paper: “Gambling in Minnesota: A Study of Participation, Attitudes, and the Prevalence of Problem Gambling” by Francie Streich, Ph.D., Mark Anton, MS, Med, and Walter Bosch, MPP, prepared for the Minnesota Department of Human Services by Wilder Research in February, 2020.

What interventions might work to help those with Gambling Disorder?

Rodda et al. (2012) suggest that “Effective management involves a nonjudgemental and empathic approach, which may include referral to telephone or online services, face-to-face problem gambling programs, financial counselling, psychological and pharmacological interventions” (p. 2). Stein and Stinchfield (2020) note that treatment may be anything from one-on-one therapeutic counseling to intensive weeklong residential treatment, as well as online programs, public education, prevention programs, public policy initiatives, research, consumer protections, and assessment/treatment.

We hope this special issue on Gambling Disorder/Problem Gambling will alert nurses, physicians, and healthcare personnel in general to this important sleeper issue and cause them to observe and assess patients and clients in a new light. Should GD screening be part of routine healthcare assessments?