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--> 4 Research on the Origins of Pathological and Problem Gambling Etiology is the study of causal pathways. Because of the complex analyses and study designs that must be used, this type of research represents the crown jewel of health research. The outcomes of such research often lead to successful treatments and preventive interventions. The process of discovering causal associations and pathways to understand how different factors, exposures, or disease-causing situations relate to each other usually involves multidisciplinary teams of psychiatrists, psychologists, statisticians, sociologists, economists, and epidemiologists. This chapter begins by describing considerations for undertaking or evaluating etiological research on pathological gambling, as well as the current state of knowledge regarding the causal pathways of pathological gambling. Risk factors for and correlates of pathological gambling, including psychosocial, environmental, genetic, and biological ones, are discussed and evaluated in terms of commonly accepted criteria for determining the strength of an association. Cooccurring disorders and their similar risk factors are also discussed. Throughout the chapter, substantial deficiencies in current research on pathological gambling are noted.
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--> Etiological Considerations in Undertaking Research on Pathological Gambling Etiological research is complex, and a number of aspects are essential to consider in undertaking it. They include the accuracy of diagnostic labels, the associations and causal relationships among potential risk factors, the uniqueness of risk factors, and age and cohort effects. In order to review the available evidence, the committee developed criteria to determine a causal association between a given risk factor and pathological gambling. Diagnostic Labels Considerable discussion has already been devoted to the definition, measurement, and prevalence of pathological gambling. When discussing the etiology of an illness, it is useful to revisit its label, because a label, as suggested by Nathan (1967), reflects the state of knowledge about the illness at the time it is labeled. In addition, etiological explanations keen on identifying causal pathways necessarily take labels into consideration, because they often describe the clinical site and clinical picture of an illness. For example, lung cancer, myocardial infarction, and lymphatic leukemia are medical labels that describe both the clinical site and the clinical picture of those illnesses. Medical labels such as tuberculosis and human immunodeficiency virus (HIV) can also specify the diagnosis, cause, or etiology of a physical illness. Precise diagnostic labels are less common in psychiatry. However, with the American Psychiatric Association's introduction of the Diagnostic and Statistical Manual of Mental Disorders (DSM), research on the more common mental disorders has flourished and has led to a concomitant explosion in research on risk factors (Goodwin and Guze, 1974). Research on the diagnostic classification of pathological gambling has lagged behind, and it has been identified as an area in serious need of etiological research. Associations and Causal Relationships As with other areas of research, when designing, undertaking, or evaluating etiological research on pathological gambling,
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--> one must understand and distinguish between associations and causal relationships among many potential risk factors. A risk factor is something that has a possible role in the initiation of a disease, the progression of a disease to a further state, or in the waning of a disease (which is then a protective factor). Demographic, biological, personality, family, peer, and genetic factors, among other possible risk factors, may interact over time to influence the course of outcomes, symptoms, and behaviors. Risk factors are most useful for research when they refer to a specific phenomenon that provides a feasible point of intervention. Some factors may be related exclusively to initiation; others may be related only to subsequent progression into problem or pathological gambling. Although important, such etiological distinctions have been rarely made in the relatively recent and limited literature on pathological and problem gambling. The literature on posttraumatic stress disorder (PTSD) offers an analytic model for distinguishing risk factors. Breslau and Davis (1987) demonstrated that it was the original exposure to a precipitating event, and not reexposure, that led to symptoms of PTSD among Vietnam veterans. In another study, Breslau and colleagues (1991), in an examination of young urban adults, identified risk factors for exposure to traumatic events (i.e., low education levels, being male, early conduct problems, and extraversion) that were distinct from risk factors for the actual disorder once exposed (i.e., early separation from parents, neuroticism, preexisting anxiety or depression). Distinguishing risk factors is crucial in etiology research, as is identifying common risk factors for the progression of an illness. In the study just described, a family history of a psychiatric disorder or a substance abuse problem was identified as a common risk factor for exposure to traumatic events and acquiring PTSD. Unique Risk Factors Equally important to consider in etiological research on pathological and problem gambling is which factors for chronic, long-term gambling are unique to this disorder and not just predictors of excessive deviant behavior of all kinds. Again, the PTSD literature provides a template for research on pathological
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--> and problem gambling. For example, Breslau and Davis (1992) identified several unique risk factors for chronic compared with nonchronic PTSD. Age and Cohort Effects Etiological research must also consider how the effects of age and being in a cohort (a group of people born in the same year or decade) increase or decrease one's risk for initiating gambling or developing a gambling problem. Although these effects are infrequently considered in existing pathological and problem gambling research, Erikson's stages of development (Erickson, 1963, 1968, 1982) are one explanatory model that accounts for aging effects and could potentially be applied when investigating gambling behaviors. Specifically, the model hypothesizes that, as people age, they move through several developmental stages that correspond to certain stage-related tasks. When applied to gambling behavior, the implication is that, at certain developmental stages, the motivation for and expectations about gambling might change. A recent review demonstrated that gambling among young people occurs on a developmental continuum of gambling involvement ranging from no gambling experimentation to gambling with serious consequences (Stinchfield and Winters, 1998). These effects pertain to how risk factors and outcomes change with age and differ among groups of people (Mok and Hraba, 1991). Cohort effects pertain to specific events that affect groups of people born during the same time period (Mok and Hraba, 1991). When applied to gambling behavior, this means that increases in gambling opportunities during a certain period in history may affect a certain age group of people. For example, a cohort of same-age people who are passing through the age of risk for gambling problems when gambling opportunities are expanding may experience greater and increasing exposure to, involvement in, and social acceptance of gambling during their lifetimes than a cohort of same-age people at risk during periods of fewer gambling opportunities. In addition, circumstances can affect more than one cohort in the same way or in different ways. A classic example of an event that changed the trajectory of same-age
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--> people is the drug revolution of the late 1960s and early 1970s. During this period, expanded drug use affected both teens and young adults, marking this time period as a historical risk factor for drug abuse. As opportunities to gamble continue to increase throughout most of the United States, it is likely that certain birth cohorts will be affected differently, perhaps in unanticipated ways. For example, in a random telephone survey of 1,011 Iowa residents stratified into eight age cohorts (ranging from 18-24 through 85 and older), it was found, even after controlling for other variables, that older cohorts are less likely to gamble than younger cohorts (Mok and Hraba, 1991). Criteria to Determine the Strength of an Association Mindful of the considerations discussed above, and in order to evaluate the research evidence that various risk factors are associated with pathological gambling, the committee adopted a number of general criteria, which are commonly accepted by epidemiologists throughout the world (Hill et al., 1963), for determining the strength of an association: The event or exposure precedes the outcome of pathological gambling; Findings are consistent—that is, they have been replicated in other studies, with other samples, or in other cultures; There is a strong association between the risk factor and pathological gambling; The association between the risk factor and pathological gambling is biologically plausible based on scientific research findings in such areas as behavioral genetics or neurobiology; Findings remain consistent when different study methods and designs are used (e.g., case control and cohort epidemiological studies, experimental studies, biological studies); and Associations examined are specific to pathological gambling and are not generally found in other disorders as well. To suggest that a causal association might exist between risk factors, events, or situations and pathological gambling, it would
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--> be necessary for at least one of these criteria to be met. However, satisfying one or more of the criteria would not be sufficient to positively determine if there is a causal relationship between an exposure and pathological or problem gambling. In many gambling studies, the first criterion (that a risk factor necessarily precedes the outcome of pathological or problem gambling) is unknown. Without this principal evidence, an exposure, a situation, or an event is not proven to be causal. Furthermore, many studies reviewed by the committee collected data without exploring when and to what extent subjects were exposed to potential risk factors, or the age of onset of their pathological or problem gambling. Again from an etiological standpoint, these methodological limitations make it impossible to determine whether suspected risk factors might ''cause" pathological or problem gambling, or whether they are only correlated or associated with these behaviors. Thus, much of the evidence presented or implied in the literature as causal to pathological and problem gambling is, by commonly accepted etiological standards, better defined merely as evidence for an association. Still, despite the generally deficient state of etiological research on pathological and problem gambling, there does exist some tangible evidence to suggest certain risk factors and associations.1 Psychosocial and Environmental Risk Factors Determining psychosocial and environmental risk factors for pathological and problem gambling is guided by the following question: Is the risk for pathological or problem gambling associated with sociodemographic factors, such as age, gender, ethnicity, and family effects, or is it associated with the availability of gambling to the gambler? In this section, we pay special attention to studies having sufficient sample sizes to generalize findings to larger groups within the population and studies that examine: (1) sociodemographic, family, and peer influences that 1 Some demographic risk factors pertaining to pathological and problem gamblers in vulnerable populations were previously discussed in Chapter 3.
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--> are associated with initiation into gambling, (2) the risk of progression from gambling without problems to problem or pathological gambling, (3) individual factors among multiple factors associated with pathological or problem gambling, and (4) factors that predict chronicity of symptoms of pathological gambling. Age In the United States and throughout much of the world, many people begin gambling as children. For example, in a small study of British adolescents ages 13 and 14, the mean age of initiation into gambling for social recreation or entertainment was found to be 8.3 years for boys and 8.9 years for girls (Ide-Smith and Lea, 1988). The literature has also weakly supported a young age of onset of pathological and problem gambling following initiation to gambling (Kallick et al., 1979; Lesieur and Klein, 1987). In a retrospective study, for example, it was found that adult pathological gamblers remembered their gambling addiction to have started when they were between ages 10 and 19 (Dell et al., 1981). In 1990, Griffiths found that adolescents addicted to slot machines began gambling significantly earlier (at 9.2 years of age) than nonaddicted adolescents (who began at 11.3 years of age) (Griffiths, 1990a). In 1997, Gupta and Derevensky (1998a) found that pathological gamblers started gambling, on average, at age 10.9 and nonpathological gamblers at age 11.5. Studies of teens indicate that young age of onset of gambling is more than an artifact of reporting bias. According to a summary of independent studies of high school students conducted between 1984 and 1988 (Jacobs, 1989b; Lesieur and Klein, 1985; Jacobs et al., 1989), 36 percent of teenage respondents reported gambling before age 11; 46 percent began gambling between ages 11 and 15; and 18 percent began after age 15. Between 6 and 25 percent of the teenagers in these studies reportedly wanted to stop gambling but could not. These findings are consistent with a study of 892 eleventh and twelfth graders at four high schools in New Jersey, in which 91 percent reported having gambled during their lifetime and 5.7 percent met criteria for pathological gambling as measured by
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--> the DSM-III (Lesieur and Klein, 1987). In a school newspaper survey of over 1,100 students at an inner-city, largely minority Atlantic City high school, 62 percent reported having gambled at area casinos, and 9 percent reported gambling at least once a week (Arcuri et al., 1985). In another study among students from six colleges and universities in New York, New Jersey, Oklahoma, Texas, and Nevada (Lesieur et al., 1991), using the South Oaks Gambling Screen (SOGS), the lifetime gambling rate was found to be 85 percent, the rate of problem gambling was 15 percent, and the rate of probable pathological gambling was 5.5 percent (Lesieur and Blume, 1987).2 Comparable lifetime gambling rates were found in a Minnesota study of 1,094 youths ages 15-18 (including 684 from a random telephone sample and 410 from a school sample) in which the rate of problem gambling was found to be 6.3 percent and the age of onset for over half the subjects was reported to be before or during the sixth grade (Winters et al., 1993a). Finally, in a recent review of 12 U.S. and 5 Canadian adolescent gambling studies, Jacobs found that in the past 10 years the number of teenagers ages 12 to 17 reporting serious gambling problems has increased from 50 to 66 percent. The age of onset for gambling has dropped so that now, throughout America, the majority of 12-year-olds have already gambled (Jacobs, in press). Studies of those who seek help for themselves or others indicate that gambling severity and frequency varies by age. A recent analysis of problem gambling help-line calls in Texas revealed that the frequency of calls increased with age, peaked at ages 35 to 44, and declined for callers age 45 and older (Cox, 1998). In fact, adults age 55 and older who called about their own gambling problems (14 percent of all callers) were comparable in frequency to those age 18 and younger who called about their own gambling problems (13 percent of all callers). The percentage of calls about a problem gambler from a friend, family member, or other concerned person followed a similar age pattern. Although interesting and clinically meaningful, these help-line data alone do 2 The SOGS covers betting for money on a wide variety of gambling activities, including cards, sports, dogs, dice games, bingo, and slot and other machines.
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--> not contradict the notion that younger and older people have gambling problems. Gender Etiological studies of pathological and problem gambling have generally focused on men from Gamblers Anonymous (GA) and men from the Veterans Administration hospital system (Mark and Lesieur, 1992). Consequently, men in the general population have been underrepresented in studies, and women are critically underrepresented as well. Many early studies that did include women were based on small numbers of women or relied on anecdotal reports of women in Gamblers Anonymous (Lesieur and Blume, 1991). Yet many studies inappropriately generalize findings about men to women (Mark and Lesieur, 1992). Although men typically begin gambling earlier than women, women appear to experience the onset of problem gambling earlier in the course of their gambling disorder than men (Mark and Lesieur, 1992), but controlled studies are rare (Custer, 1982; Livingston, 1974; Custer and Milt, 1985). The American Psychiatric Association reports in three editions of the Diagnostic and Statistical Manual of Mental Disorders (DSM) that the rate of pathological gambling is twice as high among men than among women (American Psychiatric Association, 1987, 1994, 1980). Although no epidemiological evidence substantiated this finding at the time the manuals were first published, some studies have found rates that high (e.g., Cunningham-Williams et al., 1998; Volberg and Abbott, 1997; Volberg, 1994), and other studies consistently show that men gamble more and have higher rates of pathological gambling than do women, even if not at twice the rate (e.g., Lesieur et al., 1991). Ethnicity and Socioeconomic Status Most studies of pathological and problem gambling have focused on white male gamblers. Consequently, there exists little population-based literature or data pertaining to women or nonwhite ethnic and cultural groups (Mark and Lesieur, 1992; Volberg, 1994). Specifically, studies among black, Hispanic, Asian,
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--> and American Indian gamblers have been lacking. The few studies that include diverse populations have in general failed to distinguish the specific racial or ethnic background of the minority group being included, thus limiting conclusions regarding specific subgroups. A few studies have specifically compared gambling among minority and majority populations (Volberg and Abbott, 1997; Zitzow, 1996; Cunningham-Williams et al., 1998). Since the passage of the Indian Gaming Regulatory Act of 1988, gambling among and sponsored by American Indians on reservations has increased substantially (Rose, 1992). In the Zitzow study, American Indian adolescents exhibited more serious problems from gambling, earlier onset of gambling problems, and greater frequency of gambling problems than their non-Indian peers. The Volberg study found that indigenous populations reported more gambling involvement, gambling expenditures, and gambling-related problems than white populations from the same areas. However, the sampling strategies and questionnaires of these two studies were not identical (Volberg and Abbott, 1997). Thus, the Cunningham-Williams et al. study, using a sample of the St. Louis general population, remains one of the few studies of race that controlled for race and other factors. The finding that problem gambling (but not pathological gambling) is more likely to affect whites than African Americans remains unchallenged. Among African Americans in this study, problem gambling was more common than gambling without problems or social and recreational gambling (Cunningham-Williams et al., 1998). Studies have also generally failed to disentangle race and ethnicity from issues of poverty and sociodemographic status. A series of analyses of Georgia residents identified 10 sociodemographic variables that correctly discriminated nearly 80 percent of nongamblers from (nonproblematic) social and recreational gamblers; 84 percent of the cases of nongamblers from problem gamblers; and 94 percent of gamblers without problems from pathological gamblers. When compared with nongamblers, problem gamblers tended to be nonwhite (race/ethnicity was not specified), male, and single, and to have low self-esteem (Volberg and Abbott, 1997). An earlier multistate analysis found that the only significant difference between probable pathological gamblers from different states is that those from the East Coast states
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--> and California are significantly more likely to be nonwhite than those from Iowa (Volberg, 1994). Family and Peer Influences on Children and Adolescents Family and peer influences on children and adolescents to gamble may also constitute a risk factor for pathological and problem gambling. Studies reveal that gamblers, especially pathological and problem gamblers who begin gambling as children or adolescents, are frequently introduced to gambling by family members or their peers (Jacobs, 1989b, 1989a; Jacobs et al., 1989). Often the first exposure to gambling for American youths is gambling in a relaxed family setting with cards, dice, and board games. Other forms of gambling exposure reported by adolescents include playing lotteries, playing games of skill such as bowling or billiards for money, sports betting, racetrack betting, and gambling in casinos (Lesieur and Klein, 1987; Kuley and Jacobs, 1988; Steinberg, 1989), which themselves may be potentially influenced by family members and friends. An association between personal gambling and peer gambling has been observed in several studies of adolescent gamblers (Derevensky and Gupta, 1996; Gupta and Derevensky, 1998a, 1998b; Jacobs, 1989a; Wynne et al., 1996; Stinchfield and Winters, 1998). These findings are consistent with theoretical and empirical literature substantiating that peers have a strong influence on other adolescent risky behaviors, such as substance use, driving without safety belts, and early sexual behavior (Jessor and Jessor, 1977; Billy and Udry, 1985; Newcomb and Bentler, 1989). Moreover, peer gambling may influence an individual's involvement in gambling in a direct way, through social factors that include peer pressure, or through indirect processes, in which an individual is attracted to a peer group for several reasons, including gambling behavior. But there is still some question as to whether peers have a strong influence on early gambling or other risky adolescent behaviors. At this point, all we can say for sure is that family and peer influences as psychosocial variables are correlates or predictors of gambling behavior.
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