Problem gambling

Problem gambling or ludomania is repetitive gambling behavior despite harm and negative consequences. Problem gambling may be diagnosed as a mental disorder according to DSM-5 if certain diagnostic criteria are met. Pathological gambling is a common disorder associated with social and family costs.

Problem gambling
Other names	Ludomania, degenerate gambling, gambling addiction, compulsive gambling, gambling disorder
Specialty	Psychiatry, clinical psychology
Symptoms	Spending a lot of money and time in casino/sports betting, Video game addiction^[1]

Addiction and dependence glossary^[2]^[3]^[4]
addiction – a biopsychosocial disorder characterized by persistent use of drugs (including alcohol) despite substantial harm and adverse consequences addictive drug – psychoactive substances that with repeated use are associated with significantly higher rates of substance use disorders, due in large part to the drug's effect on brain reward systems dependence – an adaptive state associated with a withdrawal syndrome upon cessation of repeated exposure to a stimulus (e.g., drug intake) drug sensitization or reverse tolerance – the escalating effect of a drug resulting from repeated administration at a given dose drug withdrawal – symptoms that occur upon cessation of repeated drug use physical dependence – dependence that involves persistent physical–somatic withdrawal symptoms (e.g., fatigue and delirium tremens) psychological dependence – dependence socially seen as being extremely mild compared to physical dependence (e.g., With enough willpower it could be overcome) reinforcing stimuli – stimuli that increase the probability of repeating behaviors paired with them rewarding stimuli – stimuli that the brain interprets as intrinsically positive and desirable or as something to approach sensitization – an amplified response to a stimulus resulting from repeated exposure to it substance use disorder – a condition in which the use of substances leads to clinically and functionally significant impairment or distress tolerance – the diminishing effect of a drug resulting from repeated administration at a given dose
v t e

The DSM-5 has re-classified the condition as an addictive disorder, with those affected exhibiting many similarities to those with substance addictions. The term gambling addiction has long been used in the recovery movement.^[5] Pathological gambling was long considered by the American Psychiatric Association to be an impulse-control disorder rather than an addiction.^[6] However, data suggest a closer relationship between pathological gambling and substance use disorders than exists between PG and obsessive–compulsive disorder, mainly because the behaviors in problem gambling and most primary substance use disorders (i.e., those not resulting from a desire to "self-medicate" for another condition such as depression) seek to activate the brain's reward mechanisms while the behaviors characterizing obsessive-compulsive disorder are prompted by overactive and misplaced signals from the brain's fear mechanisms.^[7]

Problem gambling is an addictive behavior with a high comorbidity with alcohol problems. A common tendency shared by people who have a gambling addiction is impulsivity.^{[citation needed]}

Signs and symptoms

Research by governments in Australia led to a universal definition for that country which appears to be the only research-based definition not to use diagnostic criteria: "Problem gambling is characterized by many difficulties in limiting money and/or time spent on gambling which leads to adverse consequences for the gambler, others, or for the community."^[8] The University of Maryland Medical Center defines pathological gambling as "being unable to resist impulses to gamble, which can lead to severe personal or social consequences".^[9]

Most other definitions of problem gambling can usually be simplified to any gambling that causes harm to the gambler or someone else in any way; however, these definitions are usually coupled with descriptions of the type of harm or the use of diagnostic criteria.^{[citation needed]} The DSM-V has since reclassified pathological gambling as gambling disorder and has listed the disorder under substance-related and addictive disorders rather than impulse-control disorders. This is due to the symptomatology of the disorder resembling an addiction not dissimilar to that of a substance use disorder.^[10] To be diagnosed, an individual must have at least four of the following symptoms in 12 months:^[11]

• Needs to gamble with increasing amounts of money to achieve the desired excitement
• Is restless or irritable when attempting to cut down or stop gambling
• Has made repeated unsuccessful efforts to control, cut back, or stop gambling
• Is often preoccupied with gambling (e.g., having persistent thoughts of reliving past gambling experiences, handicapping or planning the next venture, thinking of ways to get money with which to gamble)
• Often gambles when feeling distressed (e.g., helpless, guilty, anxious, depressed)
• After losing money gambling, often returns another day to get even ("chasing" one's losses)
• Lies to conceal the extent of involvement with gambling
• Has jeopardized or lost a significant relationship, job, education, or career opportunity because of gambling
• Relies on others to provide money to relieve desperate financial situations caused by gambling

Factors that lead to gambling addiction

Mayo Clinic specialists state that compulsive gambling may result from biological, genetic, and environmental factors, such as:^[12]

• mental health disorders (the presence of substance use disorders, personality disorders, emotional states)
• age and sex (usually found in youth or middle-aged people, and more common to men than women)
• impact of family or friends
• personality traits
• video games (including any factors that resemble gambling such as slot machines or loot boxes)^[13]
• drugs with rare side-effects (for example, antipsychotic medications or dopamine agonists).

Other studies add the following triggers to the mentioned above:^[14]

• traumatic conditions
• job-related stress
• solitude
• other addictions

If not treated, problem gambling may cause severe and lasting effects on an individual's life:^[15]

• relationship-related issues
• problems with money, bankruptcy
• legal problems, imprisonment
• health problems
• suicide, including suicidal thoughts and attempts

Suicide rates

A gambler who does not receive treatment for pathological gambling when in a desperation phase may contemplate suicide.^[16] Problem gambling is often associated with increased suicidal ideation and attempts compared to the general population.^[17][18]

Early onset of problem gambling may increase the lifetime risk of suicide.^[19] Both comorbid substance use^[20][21] and comorbid mental disorders increase the risk of suicide in people with problem gambling.^[22] A 2010 Australian hospital study found that 17% of suicidal patients admitted to the Alfred Hospital's emergency department were problem gamblers.^[23]

Mechanisms

Biology

According to the Illinois Institute for Addiction Recovery, evidence indicates that pathological gambling is an addiction similar to chemical addiction.^[24] It has been observed that some pathological gamblers have lower levels of norepinephrine than normal gamblers.^[25] According to a study conducted by Alec Roy, formerly at the National Institute on Alcohol Abuse and Alcoholism, norepinephrine is secreted under stress, arousal, or thrill, so pathological gamblers gamble to make up for their under-dosage.^[26]

Studies have compared pathological gamblers to substance addicts, concluding that addicted gamblers display more physical symptoms during withdrawal.^[27]

Deficiencies in serotonin might also contribute to compulsive behavior, including a gambling addiction. There are three important points discovered after these antidepressant studies:^[28]

1. Antidepressants can reduce pathological gambling when there is an effect on serotonergic reuptake inhibitors and 5-HT1/5-HT2 receptor antagonists.
2. Pathological gambling, as part of obsessive-compulsive disorder, requires the higher doses of antidepressants as is usually required for depressive disorders.
3. In cases where participants do not have or have minimal symptoms of anxiety or depression, antidepressants still have those effect.

A limited study was presented at a conference in Berlin, suggesting opioid release differs in problem gamblers from the general population, but in a very different way from people with a substance use disorder.^[29]

The findings in one review indicated the sensitization theory is responsible.^[30] Dopamine dysregulation syndrome has been observed in the aforementioned theory in people with regard to such activities as gambling.^[31]

Some medical authors suggest that the biomedical model of problem gambling may be unhelpful because it focuses only on individuals. These authors point out that social factors may be a far more important determinant of gambling behavior than brain chemicals, and they suggest that a social model may be more useful in understanding the issue.^[32] For example, an apparent increase in problem gambling in the UK may be better understood as a consequence of changes in legislation which came into force in 2007 and enabled casinos, bookmakers, and online betting sites to advertise on TV and radio for the first time and which eased restrictions on the opening of betting shops and online gambling sites.^[33]

Pathological gambling is similar to many other impulse-control disorders such as kleptomania.^[34] According to evidence from both community- and clinic-based studies, individuals who are pathological gamblers are highly likely to exhibit other psychiatric problems concurrently, including substance use disorders, mood and anxiety disorders, or personality disorders.^[35]

Pathological gambling shows several similarities with substance use disorders. There is a partial overlap in diagnostic criteria; pathological gamblers are also likely to have a substance use disorder. The "telescoping phenomenon" reflects the rapid development from initial to problematic behavior in women compared with men. This phenomenon was initially described for alcoholism, but it has also been applied to pathological gambling. Also, biological data support a relationship between pathological gambling and substance use disorder.^[28] A comprehensive UK Gambling Commission study from 2018 has also hinted at the link between gambling addiction and a reduction in physical activity, poor diet, and overall well-being. The study links problem gambling to a myriad of issues affecting relationships, and social stability.

Psychological

Several psychological mechanisms are thought to be implicated in the development and maintenance of problem gambling.^[36] First, reward processing seems to be less sensitive with problem gamblers.^{[clarification needed]} Second, some individuals use problem gambling as an escape from the problems in their lives (an example of negative reinforcement). Third, personality factors such as narcissism, risk-seeking, sensation-seeking, and impulsivity play a role. Fourth, problem gamblers have several cognitive biases, including the illusion of control,^[37] unrealistic optimism, overconfidence and the gambler's fallacy (the incorrect belief that a series of random events tends to self-correct so that the absolute frequencies of each of various outcomes balance each other out). Fifth, problem gamblers represent a chronic state of a behavioral spin process, a gambling spin, as described by the criminal spin theory.^{[clarification needed][38]}

Spain's gambling watchdog has updated its 2019–2020 Responsible Gaming Program, classifying problem gambling as a mental disorder.^{[citation needed]}

Diagnosis

The most common instrument used to screen for "probable pathological gambling" behavior is the South Oaks Gambling Screen (SOGS) developed by Lesieur and Blume (1987) at the South Oaks Hospital in New York City.^[39] In recent years the use of SOGS has declined due to a number of criticisms, including that it overestimates false positives (Battersby, Tolchard, Thomas & Esterman, 2002).

The DSM-IV diagnostic criteria presented as a checklist is an alternative to SOGS, it focuses on the psychological motivations underpinning problem gambling and was developed by the American Psychiatric Association. It consists of ten diagnostic criteria. One frequently used screening measure based upon the DSM-IV criteria is the National Opinion Research Center DSM Screen for Gambling Problems (NODS). The Canadian Problem Gambling Inventory (CPGI) and the Victorian Gambling Screen (VGS) are newer assessment measures. The Problem Gambling Severity Index, which focuses on the harms associated with problem gambling, is composed of nine items from the longer CPGI.^[40] The VGS is also harm based and includes 15 items. The VGS has proven validity and reliability in population studies as well as Adolescents and clinic gamblers.^{[citation needed]}

Treatment

Most treatment for problem gambling involves counseling, step-based programs, self-help, peer-support, medication, or a combination of these. However, no one treatment is considered to be most efficacious and, in the United States, no medications have been approved for the treatment of pathological gambling by the U.S. Food and Drug Administration (FDA).

Gamblers Anonymous (GA) is a commonly used treatment for gambling problems. Modeled after Alcoholics Anonymous, GA is a twelve-step program that emphasizes a mutual-support approach. There are three in-patient treatment centers in North America.^[41] One form of counseling, cognitive behavioral therapy (CBT) has been shown to reduce symptoms and gambling-related urges. This type of therapy focuses on the identification of gambling-related thought processes, mood and cognitive distortions that increase one's vulnerability to out-of-control gambling. Additionally, CBT approaches frequently utilize skill-building techniques geared toward relapse prevention, assertiveness and gambling refusal, problem solving and reinforcement of gambling-inconsistent activities and interests.^[42]

As to behavioral treatment, some recent research supports the use of both activity scheduling and desensitization in the treatment of gambling problems.^[43] In general, behavior analytic research in this area is growing^[44] There is evidence that the SSRI paroxetine is efficacious in the treatment of pathological gambling.^[45] Additionally, for patients with both pathological gambling and a comorbid bipolar spectrum condition, sustained-release lithium has shown efficacy in a preliminary trial.^[46] The opioid antagonist drug nalmefene has also been trialled quite successfully for the treatment of compulsive gambling.^[47] Group concepts based on CBT, such as the metacognitive training for problem gambling^[48] have also proven effective.

Step-based programs

12 Step–based programs such as Gamblers Anonymous are specific to gambling and generic to healing addiction, creating financial health, and improving mental wellness. Commercial alternatives that are designed for clinical intervention, using the best of health science and applied education practices, have been used as patient-centered tools for intervention since 2007. They include measured efficacy and resulting recovery metrics.^{[medical citation needed]}

Motivational interviewing

Motivational interviewing is one of the treatments of compulsive gambling. The motivational interviewer's basic goal is promoting readiness to change through thinking and resolving mixed feelings. Avoiding aggressive confrontation, argument, labeling, blaming, and direct persuasion, the interviewer supplies empathy and advice to compulsive gamblers who define their own goal. The focus is on promoting freedom of choice and encouraging confidence in the ability to change.^[49]

Peer support

A growing method of treatment is peer support. With the advancement of online gambling, many gamblers experiencing issues use various online peer-support groups to aid their recovery. This protects their anonymity while allowing them to attempt recovery on their own, often without having to disclose their issues to loved ones.^{[medical citation needed]}

Self-help

Research into self-help for problem gamblers has shown benefits.^[50] A study by Wendy Slutske of the University of Missouri concluded one-third of pathological gamblers overcome it by natural recovery.^[51]

Pharmaceutical treatments

Main article: Addiction § Medication

Numerous pharmaceutical approaches to treating gambling addiction have been suggested including antidepressants, atypical antipsychotic agents, mood stabilizers, and opioid antagonists, however the best approach for treatment, treatment regime including dosage and timing is not clear.^[52] There is some evidence to suggest that opioid antagonists, for example, naltrexone or nalmefene, and atypical antipsychotics such as olanzapine, may help reduce the severity of gambling symptoms in the short-term, however it is not clear if these medications are effective at improving other psychological symptoms associated with this disorder or for longer term symptom relief from problem gambling.^[52] The evidence suggesting the effectiveness of mood stabilizers is not clear.^[52]

Self-exclusion

Main article: Self-exclusion

Gambling self-exclusion (voluntary exclusion) programs are available in the US, the UK, Canada, Australia, South Africa, France, and other countries. They seem to help some (but not all) problem gamblers to gamble less often.^[53]

Some experts maintain that casinos in general arrange for self-exclusion programs as a public relations measure without actually helping many of those with problem gambling issues. A campaign of this type merely "deflects attention away from problematic products and industries", according to Natasha Dow Schull, a cultural anthropologist at New York University and author of the book Addiction by Design.^[54]

There is also a question as to the effectiveness of such programs, which can be difficult to enforce.^[55] In the province of Ontario, Canada, for example, the Self-Exclusion program operated by the government's Ontario Lottery and Gaming Corporation (OLG) is not effective, according to investigation conducted by the television series, revealed in late 2017. |"Gambling addicts ... said that while on the ... self-exclusion list, they entered OLG properties on a regular basis" in spite of the facial recognition technology in place at the casinos, according to the Canadian Broadcasting Corporation. As well, a CBC journalist who tested the system found that he was able to enter Ontario casinos and gamble on four distinct occasions, in spite of having been registered and photographed for the self-exclusion program. An OLG spokesman provided this response when questioned by the CBC: "We provide supports to self-excluders by training our staff, by providing disincentives, by providing facial recognition, by providing our security officers to look for players. No one element is going to be foolproof because it is not designed to be foolproof".^[54]

Impact (Australia)

According to the Productivity Commission's 2010 final report into gambling, the social cost of problem gambling is close to 4.7 billion dollars a year. Some of the harms resulting from problem gambling include depression, suicide, lower work productivity, job loss, relationship breakdown, crime and bankruptcy.^[56] A survey conducted in 2008 found that the most common motivation for fraud was problem gambling, with each incident averaging a loss of $1.1 million.^[56] According to Darren R. Christensen. Nicki A. Dowling, Alun C. Jackson and Shane A. Thomas, a survey done from 1994 to 2008 in Tasmania gave results that gambling participation rates have risen rather than fallen over this period.^[57]

Prevalence

Europe

In Europe, the rate of problem gambling is typically 0.5 to 3 percent.^[58] The "British Gambling Prevalence Survey 2007", conducted by the United Kingdom Gambling Commission, found approximately 0.6 percent of the adult population had problem gambling issues—the same percentage as in 1999.^[59] The highest prevalence of problem gambling was found among those who participated in spread betting (14.7%), fixed odds betting terminals (11.2%), and betting exchanges (9.8%).^[59] In Norway, a December 2007 study showed the amount of current problem gamblers was 0.7 percent.^[60]

With gambling addiction on the rise worldwide and across Europe in particular, those calling gambling a disease have been gaining grounds. The UK Gambling Commission announced a significant shift in their approach to gambling^[when?] through their reclassification of gambling as a disease, and therefore that it should be addressed adequately by the NHS.

The World Health Organization has also classified gambling a disease. In its 72nd World Health Assembly held on Saturday, May 25, 2019, ‘gaming disorder’ was recognized as an official illness. The 194-member meet added excessive gaming to a classified list of diseases as it revised its International Statistical Classification of Diseases and Related Health Problems (ICD-11).^{[citation needed]}

North America

Lizbeth García Quevedo, director of the Coordination with Federal Entities (CONADIC), spoke of pathological gambling as a strong addiction in Mexico: "It has very similar behaviors, that is why some experts consider it an addiction because it is similar in the behaviors, in the origins, some risk factors that can trigger pathological gambling, it can also trigger drug consumption". In Mexico there could be between one and three million people addicted to gambling. "They should be aware of what their children are doing, and on the other hand, they should motivate pro-active gambling, healthy gambling", commented Lizbeth García Quevedo. The Ministry of Health document highlights that a study on pathological gambling that analyzed 46 studies carried out in Canada, the United States, Australia, Sweden, Norway, England, Switzerland and Spain, revealed that the prevalence of pathological gambling is relatively higher among adolescents, which shows the continuity of the problem considering that many pathological gamblers state that they started their gambling behavior at an early age.^[61]

In the United States, the percentage of pathological gamblers was 0.6 percent, and the percentage of problem gamblers was 2.3 percent in 2008.^[62] Studies commissioned by the National Gambling Impact Study Commission Act has shown the prevalence rate ranges from 0.1 percent to 0.6 percent.^[63] Nevada has the highest percentage of pathological gambling; a 2002 report estimated 2.2 to 3.6 percent of Nevada residents over the age of 18 could be called problem gamblers. Also, 2.7 to 4.3 percent could be called probable pathological gamblers.^[64]

According to a 1997 meta-analysis by Harvard Medical School's division on addictions, 1.1 percent of the adult population of the United States and Canada could be called pathological gamblers.^[65] A 1996 study estimated 1.2 to 1.9 percent of adults in Canada were pathological.^[66] In Ontario, a 2006 report showed 2.6 percent of residents experienced "moderate gambling problems" and 0.8 percent had "severe gambling problems".^[67] In Quebec, an estimated 0.8 percent of the adult population were pathological gamblers in 2002.^[68] Although most who gamble do so without harm, approximately 6 million American adults are addicted to gambling.^[69]

According to a survey of 11th and 12th graders in Wood County, Ohio found that the percentage who reported being unable to control their gambling rose to 8.3 percent in 2022, up from just 4.2 percent in 2018. The reasons for the increase cited, are the time spent online during the COVID-19 pandemic, gambling-like elements put into video games, and the increased legalization of sports betting in a number of U.S. states.^[70]

According to Jennifer Trimpey, as the legality of online sport betting and online casino gambling increase across the United States, almost all governments of states with legal online gambling offer state-run self-exclusion programs, and most major online betting operators provide their own self-exclusion programs as well.^[71]

Signs of a gambling problem include:^{[69][medical citation needed]}

• Using income or savings to gamble while letting bills go unpaid
• Repeated unsuccessful attempts to stop gambling
• Chasing losses
• Losing sleep over thoughts of gambling
• Arguing with friends or family about gambling behavior
• Feeling depressed or suicidal because of gambling losses

South America

For Isabel Sánchez Sosa, coordinator of the Compulsive Gamblers Association of Argentina, "gambling addiction is growing a lot in the country because the offer is impressive" and in this sense she asserted that the presence of bingos is a common issue in all neighborhoods. In the province of Buenos Aires there are 46 bingos.^[72]

Oceania (Australia)

Casinos and poker machines in pubs and clubs facilitate problem gambling in Australia. The building of new hotels and casinos has been described as "one of the most active construction markets in Australia"; for example, AUD$860 million was allocated to rebuild and expand the Star Complex in Sydney.^[73]

A 2010 study, conducted in the Northern Territory by researchers from the Australian National University (ANU) and Southern Cross University (SCU), found that the proximity of a person's residence to a gambling venue is significant in terms of prevalence. Harmful gambling in the study was prevalent among those living within 100 metres of any gambling venue, and was over 50% higher than among those living ten kilometres from a venue. The study's data stated:

Specifically, people who lived 100 metres from their favourite venue visited an estimated average of 3.4 times per month. This compared to an average of 2.8 times per month for people living one kilometre away, and 2.2 times per month for people living ten kilometres away.^[74]

According to the Productivity Commission's 2016 report into gambling, 0.5% to 1% (80,000 to 160,000)^[75] of the Australian adult population had significant problems resulting from gambling. A further 1.4% to 2.1% (230,000 to 350,000) of the Australian adult population experienced moderate risks making them likely to be vulnerable to problem gambling.^[76] Estimates show that problem gamblers account for an average of 41% of the total gaming machine spending.^[76]

See also

• Gamblers Anonymous
• Gambler's Lament, an ancient poem about gambling
• Gambling Commission (Great Britain)
• GamCare
• Gaming law
• National Council on Problem Gambling (Singapore)
• National Council on Problem Gambling (United States)
• Problem Gambling Foundation of New Zealand
• Video game addiction

References

1. David Zendle; Rachel Meyer; Harriet Over (June 2019). "Adolescents and loot boxes: links with problem gambling and motivations for purchase". Royal Society Open Science. 6 (6): 190049. Bibcode:2019RSOS....690049Z. doi:10.1098/rsos.190049. PMC 6599795. PMID 31312481.
2. Nestler EJ (December 2013). "Cellular basis of memory for addiction". Dialogues in Clinical Neuroscience. 15 (4): 431–443. PMC 3898681. PMID 24459410. Despite the importance of numerous psychosocial factors, at its core, drug addiction involves a biological process: the ability of repeated exposure to a drug of abuse to induce changes in a vulnerable brain that drive the compulsive seeking and taking of drugs, and loss of control over drug use, that define a state of addiction. ... A large body of literature has demonstrated that such ΔFosB induction in D1-type [nucleus accumbens] neurons increases an animal's sensitivity to drug as well as natural rewards and promotes drug self-administration, presumably through a process of positive reinforcement ... Another ΔFosB target is cFos: as ΔFosB accumulates with repeated drug exposure it represses c-Fos and contributes to the molecular switch whereby ΔFosB is selectively induced in the chronic drug-treated state.⁴¹ ... Moreover, there is increasing evidence that, despite a range of genetic risks for addiction across the population, exposure to sufficiently high doses of a drug for long periods of time can transform someone who has relatively lower genetic loading into an addict.
3. Malenka RC, Nestler EJ, Hyman SE (2009). "Chapter 15: Reinforcement and Addictive Disorders". In Sydor A, Brown RY (eds.). Molecular Neuropharmacology: A Foundation for Clinical Neuroscience (2nd ed.). New York: McGraw-Hill Medical. pp. 364–375. ISBN 9780071481274.
4. Volkow ND, Koob GF, McLellan AT (January 2016). "Neurobiologic Advances from the Brain Disease Model of Addiction". New England Journal of Medicine. 374 (4): 363–371. doi:10.1056/NEJMra1511480. PMC 6135257. PMID 26816013. Substance-use disorder: A diagnostic term in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) referring to recurrent use of alcohol or other drugs that causes clinically and functionally significant impairment, such as health problems, disability, and failure to meet major responsibilities at work, school, or home. Depending on the level of severity, this disorder is classified as mild, moderate, or severe.
   Addiction: A term used to indicate the most severe, chronic stage of substance-use disorder, in which there is a substantial loss of self-control, as indicated by compulsive drug taking despite the desire to stop taking the drug. In the DSM-5, the term addiction is synonymous with the classification of severe substance-use disorder.
5. Eades, John (2003). Gambling Addiction: The Problem, the Pain, and the Path to Recovery. Vine Books. ISBN 978-0-8307-3425-2.^{[page needed]}
6. Petry, Nancy (September 2006). "Should the Scope of Addictive Behaviors be Broadened to Include Pathological Gambling?". Addiction. 101 (s1): 152–60. doi:10.1111/j.1360-0443.2006.01593.x. PMID 16930172.
7. Potenza, M. N. (October 12, 2008). "The neurobiology of pathological gambling and drug addiction: an overview and new findings". Philosophical Transactions of the Royal Society B: Biological Sciences. 363 (1507): 3181–3189. doi:10.1098/rstb.2008.0100. PMC 2607329. PMID 18640909.
8. (PDF) (Report). gamblingresearch.org.au. p. i. Archived from the original (PDF) on August 19, 2006.
9. Vorvick, Linda; Merrill, Michelle (February 18, 2010). "Pathological Gambling". University of Maryland Medical Center. Retrieved April 4, 2012.
10. Christensen, D. R.; Jackson, Alun C.; Dowling, Nicki A.; Volberg, Rachel A.; Thomas, Shane A. (2014). "An Examination of a Proposed DSM-IV Pathological Gambling Hierarchy in a Treatment Seeking Population: Similarities with Substance Dependence and Evidence for Three Classification Systems". Journal of Gambling Studies. 31 (3): 1–20. doi:10.1007/s10899-014-9449-2. hdl:10133/3418. PMID 24627139. S2CID 728917.
11. American Psychiatric Association (May 18, 2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Washington, DC: American Psychiatric Publishing.
12. "Gambling addiction: Symptoms, triggers, and treatment". www.medicalnewstoday.com. June 19, 2018. Retrieved November 4, 2021.
13. Ivoska, William (2022). "Behavioral Health Barometer Wood County Youth" (PDF). barometer.2022.final.pdf. Retrieved April 24, 2023.
14. Potenza, Marc N; Fiellin, David A; Heninger, George R; Rounsaville, Bruce J; Mazure, Carolyn M (September 2002). "Gambling". Journal of General Internal Medicine. 17 (9): 721–732. doi:10.1046/j.1525-1497.2002.10812.x. ISSN 0884-8734. PMC 1495100. PMID 12220370.
15. "Compulsive gambling - Symptoms and causes". Mayo Clinic. Retrieved November 4, 2021.
16. Paul, Laura. . Disney family.com. Disney. Archived from the original on July 16, 2011.
17. Moreyra, Paula; Ibáñez, Angela; Saiz-Ruiz, Jerónimo; Nissenson, Kore; Blanco, Carlos (2000). "Review of the Phenomenology, Etiology and Treatment of Pathological Gambling". German Journal of Psychiatry. 3 (2): 37–52. ISSN 1433-1055.
18. Volberg, Rachel (March 2002). "The Epidemiology of Pathological Gambling". Psychiatric Annals. 32 (3): 171–178. doi:10.3928/0048-5713-20020301-06.
19. Kaminer, Yifrah; Burleson, Joseph; Jadamec, Agnes (September 2002). "Gambling Behavior in Adolescent Substance Abuse". Substance Abuse. 23 (3): 191–198. doi:10.1080/08897070209511489. PMID 12444352.
20. Kausch, Otto (December 2003). "Patterns of Substance Abuse Among Treatment-Seeking Pathological Gamblers". Journal of Substance Abuse Treatment. 25 (4): 263–270. doi:10.1016/S0740-5472(03)00117-X. PMID 14693255.
21. Ladd, George; Petry, Nancy (August 2003). "A Comparison of Pathological Gamblers with and without Substance Abuse Treatment Histories". Experimental and Clinical Psychopharmacology. 11 (3): 202–209. doi:10.1037/1064-1297.11.3.202. PMID 12940499.
22. Kausch, Otto (September 2003). "Suicide Attempts Among Veterans Seeking Treatment for Pathological Gambling". Journal of Clinical Psychiatry. 64 (9): 1031–1038. doi:10.4088/JCP.v64n0908. PMID 14628978.
23. Hagan, Kate (April 21, 2010). "Gambling linked to one in five suicidal patients". The Age. Melbourne. Retrieved May 7, 2012.
24. . Archived from the original on May 5, 2015. Retrieved June 7, 2015.
25. . CINewsNow.com. Broadcast Interactive. Archived from the original on June 29, 2012. Retrieved May 7, 2012.
26. Roy, Alec; Adinoff, Brian; Roehrich, Laurie; Lamparski, Danuta; Custer, Robert; Lorenz, Valerie; Barbaccia, Maria; Guidotti, Alessandro; Costa, Erminio; Linnoila, Markku (April 1988). "Pathological Gambling: A Psychobiological Study". Archives of General Psychiatry. 45 (4): 369–373. doi:10.1001/archpsyc.1988.01800280085011. PMID 2451490.
27. Griffiths, Mark (November 2003). "Action plan: Problem Gambling". The Psychologist. 16 (11): 582–585.
28. Grant, Jon E.; Kim, Suck Won (September 1, 2006). "Medication Management of Pathological Gambling". Minnesota Medicine. 89 (9): 44–48. ISSN 0026-556X. PMC 1857322. PMID 17024925.
29. Shweta Iyer (October 18, 2014). "Gambling Addicts' Brains Don't Have The Same Opioid Systems As Others". Retrieved September 3, 2015. (source: Mick I, et al. Endogenous opioid release in pathological gamblers after an oral amphetamine challenge. At The European College of Neuropsychopharmacology Congress. 2014.)
30. Probst, Catharina C.; van Eimeren, Thilo (2013). "The Functional Anatomy of Impulse Control Disorders". Current Neurology and Neuroscience Reports. 13 (10): 386. doi:10.1007/s11910-013-0386-8. ISSN 1528-4042. PMC 3779310. PMID 23963609.
31. Olsen, Christopher M. (2011). "Natural Rewards, Neuroplasticity, and Non-Drug Addictions". Neuropharmacology. 61 (7): 1109–1122. doi:10.1016/j.neuropharm.2011.03.010. ISSN 0028-3908. PMC 3139704. PMID 21459101.
32. Moscrop, A. (2011). "Medicalisation, morality, and addiction: Why we should be wary of problem gamblers in primary care". British Journal of General Practice. 61 (593): 836–838. doi:10.3399/bjgp11X613197. PMC 3223781. PMID 22137420.
33. "Moran E. Letter: Gambling with lives". Guardian. April 21, 2009. Retrieved April 10, 2014.
34. Abbott, Max (June 2001). (PDF) (Report). The New Zealand Department of Internal Affairs. p. 28. Archived from the original (PDF) on March 21, 2012. Retrieved July 26, 2012.
35. Black, Donald; Shaw, Martha (October 2008). "Psychiatric Comorbidity Associated With Pathological Gambling". Psychiatric Times. 25 (12).
36. Gobet, Fernand; Schiller, Marvin, eds. (2014). Problem gambling: Cognition, prevention and treatment. London: Palgrave Macmillan. ISBN 9781137272416.
37. Hudgens-Haney, Matthew E; Hamm, Jordan P; Goodie, Adam S; Krusemark, Elizabeth A; McDowell, Jennifer E; Clementz, Brett A (2013). "Neural Correlates of Perceived Control and Risky Decision Making in Pathological Gamblers". Biological Psychology. 92 (2): 365–372. doi:10.1016/j.biopsycho.2012.11.015. PMID 23201037. S2CID 41277445.
38. Bensimon, M.; Baruch, A.; Ronel, N. (2013). "The experience of gambling in an illegal casino: The gambling spin process". European Journal of Criminology. 10 (1): 3–21. doi:10.1177/1477370812455124. S2CID 143862937.
39. Lesieur, H. R.; Blume, S. B. (September 1, 1987). "The South Oaks Gambling Screen (SOGS): a new instrument for the identification of pathological gamblers". American Journal of Psychiatry. 144 (9): 1184–1188. doi:10.1176/ajp.144.9.1184. PMID 3631315.
40. . ProblemGambling.ca. Centre for Addiction and Mental Health. Archived from the original on February 22, 2010.
41. "Treatment Facilities | National Council on Problem Gambling". www.ncpgambling.org. Retrieved September 15, 2016.
42. "Cognitive–Behavioral Therapy for Pathological Gamblers" (PDF).
43. Dowling, Nicki; Jackson, Alun C.; Thomas, Shane A. (2008). "Behavioral Interventions in the Treatment of Pathological Gambling: A Review of Activity Scheduling and Desensitization". International Journal of Behavioral Consultation and Therapy. 4 (2): 172–188. doi:10.1037/h0100841. hdl:10536/DRO/DU:30059283.
44. Weatherly, Jeffrey N.; Flannery, Kathryn A. (2007). "Facing the challenge: The behavior analysis of gambling". The Behavior Analyst Today. 9 (2): 130–142. doi:10.1037/h0100652.
45. Kim SW, Grant JE, Adson DE, Shin YC, Zaninelli R (2002). "A double-blind placebo-controlled study of the efficacy and safety of paroxetine in the treatment of pathological gambling". Journal of Clinical Psychiatry. 63 (6): 501–507. doi:10.4088/JCP.v63n0606. PMID 12088161.
46. Hollander E, Pallanti S, Allen A, Sood E, Baldini Rossi N (2005). "Does sustained release lithium reduce impulsive gambling and affective instability versus placebo in pathological gamblers with bipolar spectrum disorders?". American Journal of Psychiatry. 162 (1): 137–145. doi:10.1176/appi.ajp.162.1.137. PMID 15625212.
47. "Best Practice in Problem Gambling Services" (PDF). Gambling Research Panel. June 1, 2003. Retrieved September 22, 2015.
48. Gehlenborg, Josefine; Bücker, Lara; Berthold, Mira; Miegel, Franziska; Moritz, Steffen (September 21, 2020). "Feasibility, Acceptance, and Safety of Metacognitive Training for Problem and Pathological Gamblers (Gambling-MCT): A Pilot Study". Journal of Gambling Studies. 37 (2): 663–687. doi:10.1007/s10899-020-09975-w. ISSN 1573-3602. PMC 8144133. PMID 32955694.
49. Harvard Medical School (2004). "The Harvard mental health letter". Factiva. 20 (9): 1.
50. (PDF). Archived from the original (PDF) on March 20, 2009.
51. Slutske, Wendy (February 2006). "Natural Recovery and Treatment-Seeking in Pathological Gambling: Results of Two U.S. National Surveys". American Journal of Psychiatry. 163 (2): 297–302. doi:10.1176/appi.ajp.163.2.297. PMID 16449485.
52. Dowling, Nicki; Merkouris, Stephanie; Lubman, Dan; Thomas, Shane; Bowden-Jones, Henrietta; Cowlishaw, Sean (September 22, 2022). "Pharmacological interventions for the treatment of disordered and problem gambling". The Cochrane Database of Systematic Reviews. 9 (9): CD008936. doi:10.1002/14651858.CD008936.pub2. ISSN 1469-493X. PMC 9492444. PMID 36130734.
53. Gainsbury, Sally M. (January 22, 2013). "Review of Self-exclusion from Gambling Venues as an Intervention for Problem Gambling". Journal of Gambling Studies. 30 (2): 229–251. doi:10.1007/s10899-013-9362-0. PMC 4016676. PMID 23338831.
54. 'Nobody stopped me' at the casino: Ontario self-exclusion program fails to keep gambling addicts out
55. Casino Industry in Asia Pacific: Development, Operation, and Impact, page 153
56. Productivity Commission Inquiry Report, Gambling, Vol 1, 2010</
57. Christensen, Darren R.; Dowling, Nicki A.; Jackson, Alun C.; Thomas, Shane A. (December 1, 2015). "Gambling Participation and Problem Gambling Severity in a Stratified Random Survey: Findings from the Second Social and Economic Impact Study of Gambling in Tasmania". Journal of Gambling Studies. 31 (4): 1317–1335. doi:10.1007/s10899-014-9495-9. hdl:11343/283028. ISSN 1573-3602. PMID 25167843. S2CID 23762935.
58. "Problem Gaming" (PDF). European Gaming and Betting Association. Retrieved April 4, 2012.
59. Wardle, Heather; Sproston, Kerry; Orford, Jim; Erens, Bob; Griffiths, Mark; Constantine, Rebecca; Pigott, Sarah (September 2007). (PDF). National Centre for Social Research. p. 10. Archived from the original (PDF) on November 28, 2009.
60. Pengespill og Pengespillproblem i Norge 2007 (Report). SINTEF. December 2007. p. 3.
61. . September 11, 2016. Archived from the original on September 11, 2016. Retrieved October 28, 2022.
62. . American Gaming Association. Archived from the original on November 16, 2012. Retrieved April 4, 2012.
63. National Opinion Research Center (April 1, 1999). "The Prevalence and Correlates of Gambling Problems Among Adults". Gambling Impact and Behavior Study. National Gambling Impact Study Commission. p. 25.
64. Voberg, Rachel (March 22, 2002). (PDF) (Report). Nevada Department of Human Resources. Archived from the original (PDF) on March 18, 2012. Retrieved April 8, 2012.
65. Shaffer, Howard; Hall, Mathew; Vander Bilt, Joni (September 1999). "Estimating the Prevalence of Disordered Gambling Behavior in the United States and Canada: A Research Synthesis". American Journal of Public Health. 89 (9): 1369–1377. doi:10.2105/AJPH.89.9.1369. PMC 1508762. PMID 10474555.
66. Ladouceur, Robert (June 1996). "The Prevalence of Pathological Gambling in Canada". Journal of Gambling Studies. 12 (2): 129–142. doi:10.1007/BF01539170. PMID 24233912. S2CID 32686402.
67. Weibe, Jamie; Mun, Phil; Kauffman, Nadine (September 2006). Gambling and Problem Gambling in Ontario (Report). Responsible Gambling Council. hdl:1880/48245.
68. Ladouceur, Robert; Jacques, Christian; Chevalier, Serge; Sévigny, Serge; Hamel, Denis (July 2005). "Prevalence of Pathological Gambling in Quebec in 2002" (PDF). The Canadian Journal of Psychiatry. 50 (8): 451–456. doi:10.1177/070674370505000804. PMID 16127962. S2CID 2096562.
69. "Don't Let Betting on the Super Bowl Take Control: The National Council on Problem Gambling Offers Help and Hope to Gambling Addicts" (PDF) (Press release). National Council on Problem Gambling (US). January 31, 2013.
70. Ansberry, Clare (December 18, 2022). "Problem Gambling Is on the Rise Among Young Men". The Wall Street Journal. Retrieved December 19, 2022.
71. Trimpey, Jennifer. "Self-exclusion for problem gamblers: A comprehensive overview of self-exclusion programs and efficacy in the US". Syracuse.com. Retrieved October 9, 2023.
72. Clarín.com (May 19, 2010). "Cada vez son más los jugadores compulsivos en la Argentina". Clarín (in Spanish). Retrieved October 28, 2022.
73. "Hotel refurbishment market continues boom phase". Hotel Management. HM – The business of Accommodation. January 11, 2012. Retrieved December 15, 2013.
74. Martin Young, Bruce Doran & Francis Markham (December 6, 2013). "Too close to home: people who live near pokie venues at risk". The Conversation Australia. Retrieved December 15, 2013.
75. "Statistics of Gambling Addiction 2016". North American Foundation for Gambling Addiction Help.
76. Productivity Commission Inquiry Report, Gambling, Vol 1, 2010, p. 203