Gambling addiction, or gaming addiction

The first published scientific study on the subject of pathological gambling suggested that gambling addiction is multifactorial. Its author was Gerolamo Cardano (1501-1576). Cardano was the first to raise the question of whether gambling addiction was an incurable disease. He also suggested that gambling addiction played an active psychological role, "since psychologically gambling helps with grief, melancholy, anxiety, and tension."

Cardano's works directly indicate that he knew first-hand that during the game a person experiences very specific states of mind, such as loss of control over oneself, the desire to increase bets, chasing, fixation on the issues of the game. In addition, he noted that passion for gambling leads to social and legal problems, and all together constitutes the diagnosis of "gambling addiction".

ICD-10 code

• F63 Disorders of habits and drives.
• F63.0 Pathological attraction to gambling.

A Brief Historical Essay on Gambling Addiction

Gambling has been known since ancient times. The word "gambling" comes from the Arabic word "alzar" - "dice". The first documentary sources about gambling were found among the ruins of ancient Babylon (3000 BC). The classical literature of many cultures mentions the attraction to gambling (the Old and New Testaments, the epic poem "Mahabharata" in Sanskrit, etc.). Dice were the most common game in the Middle Ages. Card games appeared in Europe during the Crusades in the 13th century.

The history of the development of legal relations in society and the emergence of negative consequences of gambling indicate that since ancient times the direct duty of the state as an institution of political power, management and protection of the interests of all strata of society has been as follows: gambling should not take place in public, attract a wide circle of people, or affect the material well-being of the general population.

It should be noted that the official prohibition of gambling and various eras of society's development did not destroy them, but only temporarily reduced the number of gambling establishments and their locations. The prohibition of gambling never guaranteed their real disappearance.

In Russia during the Soviet era and the existence of the Soviet Union, there were no casinos or gambling establishments for playing cards or slot machines. The collapse of the Soviet Union and the change in the political system of Russia very quickly led to the creation of the gambling business and gambling associations. Moscow and St. Petersburg quickly turned into a kind of parody of Las Vegas.

Due to the negative social consequences associated with the gaming business, in the spring of 2007 the Russian Government adopted a Resolution on the removal of gaming establishments outside the city boundaries.

According to A.K. Egorov (2007) and many other researchers, the relevance of the problem of gaming addiction is due to the following three reasons:

• serious social and financial problems;
• the prevalence of criminal activity among them (up to 60% of gambling addicts commit crimes);
• high suicidal risk (13-40% attempt suicide, 42-70% of patients report suicidal thoughts).

To this list should be added the high proportion of comorbid disorders (alcoholism, drug addiction, endogenous pathology) and pronounced moral and ethical degradation with all the social consequences characteristic of this group of people among gambling addicts.

Currently, there are four main categories of gambling.

1. Regular legal games - lotteries, video lotteries, bets on races, sports bets, bingo, casino, slot machines.
2. Games in illegal gambling establishments and bets with illegal bookmakers.
3. Various money bets and stakes between acquaintances, friends and work colleagues. These can be absolutely any bets and stakes that occupy a significant place in the cultural life of the population.
4. Playing on the stock exchange is not a professional duty, but takes on the character of gambling.

American psychologists were among the first to systematically study gambling addiction at the beginning of the 20th century. They believed that not only anatomical but also behavioral or “mental” personality characteristics are inherited. Based on these beliefs, it was concluded that repeated (intentional) approach to life-threatening situations that provoke an involuntary survival (self-preservation) reaction entails a biological need for such experiences. This hypothetical need, also considered necessary for the survival process, is supported by the presence of behavioral strategies that lead to the search for risky situations and is passed on to subsequent generations.

E. Moran (1975), based on Jellinek's classification of alcoholism into five types, identified five groups of pathological gambling: subcultural, neurotic, impulsive, psychopathic and symptomatic. He viewed pathological gambling as a complex system of relationships between individual constitution, family and social aspects and pressures, accessibility of gambling areas, monetary losses and the financial difficulties they entail, social isolation and family difficulties. In each type, as well as in each case of each type, different factors may have a greater influence than others.

Caster (Caster R., 1985) believed that gambling addiction takes 10-15 years to develop. He identified five main stages in the development of gambling addiction. Caster noted that the gambling addiction "virus" does not affect everyone who comes into contact with it. His observations allowed him to identify certain traits, the presence of which in a potential gambler makes him more susceptible to the virus of treatment. Such traits include low self-esteem, intolerance to rejection and disapproval, impulsiveness, high anxiety or deep depression, low tolerance for disappointment and the need for immediate satisfaction, a sense of omnipotence and a tendency to magical thinking, activity, thirst for activity, excitement, stimulation and risk.

In recent years, considerable attention has been paid to the gaming cycle, which includes a gradual change of certain states ("phases") characteristic of a pathological gambler. Understanding the dynamics of the cycle is important for the formation and solution of psychotherapeutic and pharmacotherapeutic tasks when working with problem gamblers. V.V. Zaitsev and A.F. Shaidulina (200") offered their vision of the development of phases and patient behavior, which constitutes the so-called gaming cycle: the abstinence phase, the "automatic fantasies" phase, the phase of increasing emotional tension, the phase of making a decision to play, the phase of repressing the decision made, the phase of implementing the decision made.

Other researchers (Malygin V.L., Tsygankov B.D., Khvostikov G.S., 2007) have established a certain pattern in the formation of the gambling cycle:

• the period of distress immediately following play;
• period of moderate anxiety-depressive disorders;
• period of subdepressive disorders with a predominance of asthenia or apathy;
• a period of anxiety and dysphoric disorders combined with subdepression;
• a period of narrowed consciousness (game trance) immediately preceding a breakdown.

The characterological properties of pathological gamblers are determined by the prevalence of hyperthymic, excitable and demonstrative character traits, which reach the level of accentuation only in 14.3%. The analysis of psychological defense mechanisms reflects the prevalence of defense mechanisms such as denial, repression, projection and regression.

When studying the psychological characteristics of problem gamblers, most researchers point to the gambler's loss of control over his own behavior, and this applies to all types of gambling (from betting to slot machines). Australian researchers identify three subgroups of problem gamblers:

• with behavioral disorder;
• emotionally unstable;
• antisocial, prone to impulsive behavior.

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Epidemiology of gambling

Gambling is widespread throughout the world, with many countries involved in the gambling business, which brings in super profits. The prevalence of pathological addiction to gambling in the world population ranges from 1.4 to 5%

About 5% of regular casino visitors suffer from pathological gambling. On average, 60% of the population in developed countries gamble and 1-1.5% of them may be subject to gambling addiction.

The classification of crimes registered at gambling businesses, according to one of the members of the Russian Association for the Development of the Gambling Business (RARIB) Committee on Security, is as follows: crimes related to the attempted sale of counterfeit banknotes in denominations of 100, 500 and 1000 rubles: theft and embezzlement of funds; hooliganism. It is also known from various media sources that visitors to gambling establishments commit more serious crimes (arson, destruction of slot machines, shootouts with security guards and murders).

In countries with a developed gambling business, a comprehensive solution to the problems of pathological gambling has been brought to the level of state regulation:

• the state adopts laws that determine the activities of the gaming business and monitors their implementation;
• the state undertakes obligations to study epidemiology, conduct comprehensive measures to prevent gambling addiction, and treat and rehabilitate those suffering from gambling addiction;
• the state finances preventive, therapeutic and rehabilitation anti-gambling programs and optimizes the activities of commercial structures of the gaming business and public organizations in this area;
• gambling addiction must be assessed as a serious problem that threatens the mental health of citizens and leads to personal and social maladjustment;

In turn, the gaming business undertakes to finance social protection programs for the population from the negative consequences of its activities, including prevention, treatment and rehabilitation of gambling addicts.

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Social portrait of people with gambling addiction

Most authors note that these are predominantly male individuals, the average age is 21-40 years, education - secondary, incomplete higher, higher (distribution is approximately in equal proportions with some predominance of secondary education), the majority at the time of the survey were employed (42-68%), were married (37.3-73.0%). Family relationships are predominantly conflictual (on average 69.7%), comorbidity with alcoholism is 42.4%. It should also be noted that most researchers note a high proportion of alcohol heredity in patients with gambling addiction, which is on average 41-52%. In addition, suicidal tendencies among patients make up 52%. Unlawful actions - >50%. The social portrait of gamblers is supplemented by the results of a psychological examination, which indicate their emotional instability, reduced ability for self-control and reflection, antisocial attitudes, a tendency toward overvalued ideas and increased activity, which was combined with the predominance of narcissistic and borderline personality traits.

Many foreign authors provide a largely identical social characteristic of a typical player (except for age) (Caster et al., 1985).

Causes of gambling addiction

Despite the significant diversity of opinions devoted to the prerequisites that contribute to the development of gambling addiction, in most cases preference is given to biological, psychological, environmental and social factors.

Of all the components that contribute to the development of gambling addiction, the influence of the environment is relatively dominant - 36%. The influence of social factors is also great - 22%. It is clear that other predisposing factors, potentiating each other, play an equally important role in the development of pathological gambling addiction.

In the context of the above, it should be noted that patients often look for the reason and justification for their "life in the game" and its severe consequences in external "global" ones, mainly in social and environmental factors, and not in themselves. In fact, in the overwhelming majority of cases, they wanted to be successful and economically secure people.

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Clinical symptoms of gambling addiction

The syndrome of dependence in gambling addiction is represented by a pathological (often irresistible) attraction to gambling, combined with varying degrees of expression of cognitive, behavioral, emotional and somatic. It may include some signs observed in addictive disorders that arise as a result of substance abuse (pathological attraction, loss of control over gambling, AS, increased gambling tolerance, prolonged participation in gambling despite obvious signs of harmful consequences, etc.).

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Pathological gambling syndrome (gaming drive, motivational concept)

It is manifested by an uncompromising desire to participate in the game, regardless of any obstacles, be it family, work, social responsibilities, economic problems, political, professional or criminal activity, somatic diseases that require attention and treatment, in the structure of the pathological attraction to the game outside the withdrawal syndrome, pathological gamblers are dominated by ideational disorders, including obsessive ideas (fantasizing) about the features of the game, options for "obligatory" winning, combinations of a digital, card or symbolic series that bring "unconditional" victory and personal triumph. A feeling of confidence in winning and faith in one's special qualities, a state of anticipation of pleasure from the upcoming game, illusions of control over the game situation arise. Fantasizing about gambling is often accompanied by infantile ideas about the obligatory material success, the respect acquired in case of winning from the people around you and, especially, other significant persons, when "everyone and, above all, relatives will understand" that "it was not in vain that I played and believed in success." Sometimes, against the background of such fantasizing, patients hear sounds typical of gambling establishments - the noise of slot machines, roulette, music, etc. An unconscious immersion in this state occurs, which allows one to forget, to distract oneself from real everyday worries and many negative problems created both by addiction to gambling (mainly) and by life itself. In addition to the primary pathological attraction to gambling, which arises against the background of abstinence from gambling and is considered a "trigger mechanism" for breakdowns and relapses of addiction, the secondary attraction to gambling is of fundamental importance. It occurs during the process of participation in the game and indicates a significant decrease in the patient's ability to stop playing, exit the game trance and, consequently, control his behavior, despite clear signs of harmful consequences of participation in the game.

The presence of abstinence syndrome or withdrawal syndrome in gambling seems controversial due to the lack of cessation of drug use. Although this type of addiction also involves withdrawal/deprivation of the game. At the same time, the withdrawal syndrome includes a group of signs of varying severity and combination: emotional, behavioral, insomnia, mild vegetative, somatic disorders and increasing pathological attraction to the game. Internal emptiness, regret about losing, self-condemnation, sometimes suicidal thoughts, elements of suicidal behavior and aggression dominate the withdrawal syndrome in patients who have lost in any game the day before (the vast majority). Anxiety, subdepression and depression, dysphoria, increased irritability, emotional incontinence prevail in the structure of affective disorders. As a rule, there are sleep disorders in the form of insomnia, unpleasant dreams, scenes of game guidance, the game itself, etc. Among the vegetative disorders, increased sweating, tachypnea, flushing of the skin of the face, as well as tachycardia, hypertension, cardialgia, angina are usually noted. Asthenia, loss of appetite, cardiac and headaches, decreased performance and interest in work, alienation from family members are not uncommon. Against this background, as affective, somatic and vegetative disorders fade, an increasing obsessive desire to "take revenge", "win back", "prove" periodically arises, which is gradually replaced by an irresistible craving for the game. In the acute period of withdrawal syndrome, the pathological attraction to gambling is mainly manifested by the behavioral component (thinking about a system for overcoming obstacles that stand in the way of satisfying one's desire, avoiding people who oppose the game, getting money using a wide range of methods of deception, theft, extortion, etc.). The duration of this syndrome is from 12 hours to 2 days. In cases of winning, the condition of patients is completely different. They sleep well, have pleasant dreams. The mood is elevated, they experience a feeling of victory, superiority, good nature, are inclined to spend money, give gifts, make unrealistic plans, in particular, about partial repayment of debts. They experience an attraction to gambling, hope to repeat the success, abundantly fantasize about the upcoming game and what they will do with very large amounts of money that they will definitely win, set themselves up for moderate and careful play, believe in repeated gambling luck. The illusory idea of the ability to control the game situation and the ability to turn luck in one's favor is intensified.

Gaming Trance Syndrome

Absorption in the game, passion, inability to stop playing, despite winning or losing significantly. Most often, the game lasts from 4 to 14 hours, in fact, as long as there are funds (money) to participate in the game. The main goal of the player is to win, to conquer. It remains the same even during a long gaming trance, but it loses its original brightness and contrast. During the game, the motivational emphasis shifts from winning to the game itself, and gambling passion and overstrain gradually begin to prevail, which leads to pronounced asthenic and vascular disorders. Hypertension, tachycardia, cardialgia appear, concentration and memory weaken, gaming performance and professionalism decrease. Players completely forget rational and behavioral attitudes. Consciousness narrows and adequate response to the situation is lost, the ability to control the course of the game and fully use gaming skills disappears. The ability to stop the game in time, get up and leave the gambling establishment disappears. The patient is immersed in a peculiar state of "hanging" in the game, in which it is impossible to interrupt the game independently, and friends or relatives are not able to forcibly pull the player out of the gambling establishment due to his furious resistance. Given this feature, many players are afraid of a long game cycle and attach great importance to it. At a short distance (2-3 hours), as they believe, the ability to control the course of the game and their actions is preserved and, therefore, there is always a high probability of winning. At a long distance (over 3 to 14 hours), in their opinion, many gaming or "fighting" qualities are lost, which leads to an inevitable loss. Often at a long game distance a certain critical state occurs, in which the main motive of the game - winning - practically disappears, the desire for the game to end quickly with any result, even a loss, dominates, and then "you can calmly leave" and have a rest (gaming exhaustion syndrome). It should be noted that, while in a state of gaming trance, patients forget about all the personal and social problems created by their painful addiction. They claim that they are "resting", relaxing and recovering from hard work, and that they supposedly "have the right to do so". In reality, this is one of the myths of gamers, which, by the way, is the most important target of psychotherapists.

Winning syndrome

An elevated, sometimes euphoric, mood, a surge of energy, a sense of superiority, the joy of achieving a goal. This state is a great pleasure ("it's worth living and playing for," as patients believe). Winning creates self-confidence, self-confidence, and allows one to fantasize about the most attractive directions in life, including further success in the game and acquired wealth. It is also fixed in memory, contributing to breakdowns and relapses of the disease.

At the first stage of the formation of the dependence syndrome, the winning syndrome lasts from several hours to several days. At the same time, patients are in euphoria, display extravagance and good nature. At the stage of pronounced gambling pathology, the duration of the winning syndrome, as a rule, does not exceed 4-10 hours and, which is very characteristic, has a significantly less pronounced positive affective component.

Losing syndrome

It occurs during the game, immediately after its completion or can be postponed for one, less often, two days. Losing during the game and realizing that there is less and less chance to win back, patients experience increasing anxiety, increased irritability, a feeling of anger, sometimes regret that they started playing. Often they want to quit the game, but they are stopped by excitement, constant hope for a win, memories of winnings and significant successes fixed in memory. Aggression appears, a periodic desire to take revenge, find and punish the guilty. In such a state, in some cases, patients ask divine or devilish forces to help them, to pity them, in others - they swear and curse everything. Often they cross themselves, read prayers, pronounce spells, stroke the slot machine or, on the contrary, damage and destroy it.

After the end of the game, when the patient leaves the gambling establishment, the loss syndrome manifests itself in a depressed mood, lack of restraint, increased irritability, rudeness, sometimes aggression and destructive actions, frustration, suicidal thoughts. Sleep is disturbed, anxious dreams disturb, there is no appetite, headaches and heart pains are frequent. The painful condition is accompanied by self-condemnation, suicidal thoughts and tendencies, temporary self-criticism, promises "never to play again" (similar to promises in the state of withdrawal syndrome in alcoholism - "never to drink again"). It can last from 12 hours to 2 days, gradually fading, and is replaced by an ever-increasing desire to play.

Tolerance to the game and its dynamics

In the process of becoming addicted to gambling, patients' tolerance to prolonged participation in the game increases significantly. Thus, if at the initial stage of addiction patients spend 1.5-3.5 hours in a gambling establishment, then later, when signs of decompensation appear, they are able to spend 10-24 hours playing. In fact, as long as there is money and the gambling establishment is open. At the same time, in the category of patients over 50 years of age, gambling tolerance decreases, and patients are physically unable to participate in the game for more than 4-5 hours due to rapid exhaustion.

Personality change syndrome

Very quickly (6-12 months) during the formation of gambling addiction, signs of negative personality, behavioral, emotional and intellectual-mnestic disorders appear against the background of varying degrees of severity of the gambling addiction syndrome. These are lying, irresponsibility, conflict, violations of industrial discipline, temporary or persistent indifference to work (frequent job changes) in the family, decreased performance, criminality (theft, fraud, forgery, etc.) loneliness. In addition to emotional coarsening, a significant decrease in the exactingness to one's appearance, personal hygiene, untidiness, etc. is noted. Affective disorders are manifested by constant anxiety, subdepression, depression, dysphoria. Suicidal thoughts and tendencies are characteristic. The range of interests narrows, long-term connections with friends are lost. Memory, performance, as well as the ability for creative activity gradually deteriorate.

People suffering from gambling addiction become touchy, quick-tempered, rude, "dull", sexually weak, selfish, make unreasonable demands, do not want to buy things and food necessary for the family, save on everything in order to save money for the game.

Personal degradation and social maladjustment not only prevented patients from participating in gambling, but also contributed to the progression and stabilization of the disease.

Gambling addiction and related pathology

Gambling addicts are 3 times more likely to have symptoms of depression, schizophrenia, and alcoholism. They are 6 times more likely than non-gamblers to have symptoms of antisocial personality disorder. In ICD-10, antisocial personality disorder is classified as antisocial personality disorder. In the presence of both diagnoses, antisocial personality disorder occurs earlier, on average by 11.4 years. Alcoholism in most cases precedes the onset of gambling addiction by an average of 2 years, drug addiction - by 1-1.5 years. A study of 4,499 pairs of twins also showed a direct link between various disorders in childhood, the subsequent onset of antisocial personality disorder, and the onset of gambling addiction. It was found that genetic predisposition, at least partially, determines the described comorbidity. A hereditary burden of alcoholism was found in 41.4% of patients with gambling addiction, drug addiction - in 2.7%, mental illness - in 37.4%. According to research data, 36% of the examined patients with gambling addiction had problems with alcohol, they were treated for alcoholism, more than half of the patients (53.6%) had a hereditary burden of alcoholism.

In patients with schizophrenia, the clinical manifestations of the syndrome of pathological attraction are significantly modified. According to O.Zh. Buzik (2007), in patients with schizophrenia combined with pathological gambling, the syndrome of pathological attraction to gambling is manifested with less intensity than in patients with gambling addiction alone and in patients with gambling addiction combined with alcohol or drug addiction. The ideational, affective and behavioral components of the syndrome of pathological attraction were also "less vivid and pronounced."

Pathological gamblers may suffer from overeating and are prone to using various substances and drugs in large doses, 30% have compulsive sexual disorders, 25% have an addiction to shopping. Obsessive-copulsive disorders are determined in at least 50% of gamblers, depression is diagnosed in 43%, bipolar affective disorders - in 7%, schizophrenia - in 5%. These statistics indicate that obsessive-compulsive and emotional disorders (depression, affective pathology) play a major role in the formation of pathological gambling.

Stages of gambling addiction

The development of clinical manifestations of gambling addiction goes through three interrelated stages: compensation, subcompensation, decompensation. They differ from each other in the severity of qualitative manifestations of syndromic disorders, as well as the severity of their manifestation. Naturally, severe disorders are clearly visible in the second and third stages of the disease, when "gaming" degradation occurs, including personal and social components.

Compensation stage

At the compensation stage, a syndrome of pathological attraction to gambling is formed, in the structure of which the ideational component initially prevails, "mad and passionate thoughts" and "presentiments" of inevitable winning crystallize. As F. Dostoevsky wrote, "self-poisoning with one's own fantasy" occurs, which, repeated many times, is reliably fixed in the consciousness, turning into a worldview concept, sometimes into a "sweet" creative activity, and, consequently, produces an ever-increasing "thirst for risk". Gambling and losing are only a kind of payment for immersion in the world of creative fantasies and imaginary winnings, for the illusion of a holistic "I", a protected feeling of loneliness, guilt, shame, fear, temporary or sometimes total failure, for an exit from a state of deprivation and despondency during the game and game trance. For all this, addicted patients are ready to pay “big time” and pay with money, expensive property, cars, summer houses, apartments, social stability and family well-being, and their own lives.

At this stage of gambling addiction, there is an increase in gaming tolerance, a joyful feeling of the game itself is recorded, gaming attributes are fetishized, gaming myth-making is formed, the first signs of personal deviations of the moral and ethical spectrum appear. At the compensation stage, patients keep their jobs, families, believe that “everything will work out somehow”, despite the debts and troubles that have appeared. The ability for spontaneous remissions is preserved. Social losses begin to create serious problems and cause anxiety. Rapid entry into the stage of disease formation is due to biological and mental predisposition to gaming addiction. Its average duration is from 6 months to 2 years.

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Subcompensation stage

At the stage of subcompensation (disease stabilization), such syndromes as withdrawal, gambling trance, winning, losing, personal degradation and social maladjustment are formed. The components of the withdrawal gambling syndrome - mental, vegetative, somatic disorders - are manifested by characteristic and easily recognizable symptoms. Tolerance to gambling is high and stable. Patients can play for 5-20 hours a day. Secondary attraction to gambling is strongly expressed. Spontaneous remissions, during which patients lead an orderly lifestyle and work, are rarely observed. These "bright intervals" easily replace long episodes of gambling. Winning brings a feeling of confidence, strength and omnipotence. Patients overestimate cognitive abilities and intuitive qualities, the ability to "foresee" the result. The attitude to constant failures is frivolous and uncritical. They make desperate attempts to get back the money they have lost, and often place large bets. Systematic failures in the game lead to a significant change in behavior, which is accompanied by increasingly frequent cases of deception of relatives, friends, and employers. In a gambling trance, patients find salvation from disappointments and bad moods. Sleep is upset, most dreams become disturbing and unpleasant. Family relationships are on the verge of collapse or have already been broken. Patients seek a way out in big wins and great luck. Finally, the day comes when all possible legal financial resources are exhausted and a "system failure" occurs. It is at this stage that thoughts of suicide and the desire to hide from everyone (from family, friends, creditors) first appear. Some players enter a phase of giving up the fight for a big win, gambling tolerance decreases, and disappointment sets in. It is in this state that, under pressure from close relatives, players agree to treatment. The duration of this stage is 3-6 years.

Decompensation stage

This stage corresponds to the second and third stages of the gambling addiction syndrome. The ideational component of the attraction syndrome and the feeling of "confidence" in one's winnings weaken. Criticism of obvious signs of dangerous consequences of gambling addiction significantly decreases. In the reasoning of patients, there is a small list of really weighty motives for abstinence, which, as a rule, does not stop them from participating in gambling. Patients note a significant moral and ethical decline and emotional coarsening. Suicidal tendencies are often realized. Affective disorders with a predominance of depression are expressed. Sexual interest and sexual desire decrease. Families are destroyed, problems with work (most often, work is lost) and law enforcement agencies arise. The somatic state is characterized by an exacerbation of cardiovascular diseases (arterial hypertension, angina pectoris, etc.), diseases of the digestive system, etc.

The duration of formation of this stage is from 7 to 15 years.

Diagnosis of pathological gambling addiction

Pathological gambling is discussed in the chapter on Adult Personality and Behavior Disorders under the heading F6O–F69 Habit and impulse disorders of ICD-10. Pathological gambling (F63.0) consists of frequent, repeated episodes of gambling that dominate the subject's life and lead to a decline in social, professional, material, and family values. Patients may risk their jobs, borrow large sums, and break the law in order to obtain money or avoid repaying debts. They describe a strong urge to gamble, which is difficult to control, as well as obsessive thoughts and images of the act of gambling and the circumstances that accompany it. These obsessive ideas and images are usually intensified at times when there are stresses in their lives. This disorder is also called compulsive gambling, but this term is controversial since the behavior is not compulsive in nature or because of the association of these disorders with obsessive-compulsive neurosis.

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Diagnostic guidelines

The main symptom is a constantly repeated involvement in gambling, which continues and often deepens despite social consequences such as impoverishment, disruption of family relationships and ruination of personal life.

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Differential diagnostics

Pathological gambling should be distinguished from:

• gambling and betting tendencies (Z72.6):
• frequent gambling for pleasure or money; such people usually restrain their desire when faced with large losses or other adverse consequences of gambling;
• excessive gambling in manic patients (F30); gambling in sociopathic personalities (F60.2*); these people exhibit a more widespread and persistent disturbance of social behavior, manifested in aggressive behavior, through which they show their indifference to the well-being and feelings of others.

Pathological gambling also includes:

• obsessive attraction to gambling;
• Compulsive gambling. Stages of gambling addiction and rehabilitation potential in pathological gambling

The basis of gambling addiction (pathological gambling, ludomania) is a pathological attraction to gambling, which belongs to the sphere of mental pathology. Therefore, like other mental illnesses, gambling addiction is characterized by a sequence of occurrence of clinical syndromes of the disease, their dynamics, staging, which together reflect the evolutionary development of pathology. The severity of the defeat of gambling addiction is determined by the strength and dynamics of the attraction to the game, loss of control, tolerance, severity of the withdrawal syndrome, the degree of personal and social degradation. It is the differences in the severity and stability of the syndromes of gambling addiction that constitute the essence of individual stages of the disease, which in turn largely determine the level of rehabilitation potential of patients with gambling addiction.

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Rehabilitation potential for pathological gambling

In recent years, considerable attention has been paid to the personal potential of patients with addictive disorders and, in particular, to the rehabilitation potential, which determines the characteristics of the formation of addiction and recovery from it. Diagnostics of rehabilitation potential is based on the ratio of objective data on heredity, predisposition, health status, type, severity and consequences of the disease, characteristics of personal (spiritual) development and social status of patients. The levels of rehabilitation potential of patients with gambling addiction have been established (the concept of T.N. Dudko). Patients with medium and low levels of rehabilitation potential mainly seek medical help, the proportion of patients with a high level of rehabilitation potential is no more than 10%. The main components of the levels of rehabilitation potential of patients with gambling addiction, naturally, have their own certain relativity. Significant fluctuations in diagnostic features inherent in each of the four blocks characterizing high, medium or low levels of rehabilitation potential are noted.

In the case of monogamy (in the absence of comorbidity), each level of rehabilitation potential most often has the following features:

High level of rehabilitation potential

Predisposition. Low proportion of hereditary burden of mental and drug-related diseases (up to 10-15%). Mental and physical development is mostly within normal limits, the upbringing environment is favorable.

Clinical picture. Compensation stage and appearance of the first signs of subcompensation; initial (first) stage of gambling addiction syndrome, high tolerance to gambling and even its growth; low intensity of gambling withdrawal syndrome. Gaps between gambling episodes, especially after another loss, can reach several months. A high level of rehabilitation potential is characterized by the obligatory presence of spontaneous remissions, including long-term remissions after a loss and even a win. Fetishization of gambling attributes, the illusion of control over the gambling situation are crystallized. Secondary attraction to gambling increases. Gradually involved in the study of "gaming theory". Abstinence from alcohol abuse prevails. Duration of the addiction syndrome is 1-3 years.

Personality changes. Moral and ethical deviations in the form of "petty" lies, violation of obligations, responsibility, episodes of borrowing money for gambling, returning money, but not always on time. The first episodes of theft in the family. Some decrease in criticism, frivolous attitude to the facts of the consequences of addiction, anxious thoughts about the changed behavior. After work, there is no desire to return home because of the "boring atmosphere of family existence". Signs of affective disorders of the neurotic series appear in the form of incontinence, conflict, moderately expressed anxiety-depressive disorders.

Social consequences. The appearance of the first signs of social maladjustment, including deterioration of family relationships, minor conflicts at work or school due to decreased responsibility; some narrowing of the range of interests; reduction of time for usual leisure activities (family, sports, physical education, art, tourism).

In patients with a high level of rehabilitation potential, all the characteristic signs of gambling addiction are noted, including not only the appearance of clinically outlined symptoms of craving disorders, but also mild moral and ethical changes, affective disorders and a decrease in criticism of the negative manifestations of gambling addiction.

Average level of rehabilitation potential

Predisposition. Average proportion of hereditary burden of mental and drug addiction diseases (20-25%); upbringing in a single-parent family, often with uneven or conflictual relationships between family members. Often deviant behavior and associated uneven academic performance at school, inconsistency of hobbies. Increased suggestibility.

Clinical picture. Subcompensation stage. Middle (second) stage of gambling addiction syndrome; consistently high tolerance to gambling; severity of gambling AS and post-abstinence disorders. Secondary attraction after the start of the game is expressed, the patient is unable to interrupt the game once started. Stability of the formed ideology of participation in gambling, a “strong system” of protecting one’s beliefs. Illusion of control over the game. Frivolous attitude to the abuse of alcohol and other psychoactive substances. The duration of the addiction syndrome is at least three years.

Personality changes. Constant conflictual relationships with parents and family; decrease in moral and ethical qualities: stealing money not only from the family but also from work, fraud, hooliganism, increasing debts. Decreased sexual desire and potency, avoiding meetings with the spouse.

A sharp decrease in criticism of facts of personal and social collapse. Periodically increasing desire to work intensively and a lot, especially when threatened with dismissal. Expressed affective disorders in the form of psychogenic depression, sleep disorders, suicidal tendencies (mainly thoughts and demonstrative threats to commit suicide).

Social consequences. Family and social maladjustment. Negative dynamics of family relationships; leaving the family, threat of divorce or divorce. Conflicts at work or school. Legal prosecution. Frequent dismissals from work. Narrowing of the circle of interests.

Low level of rehabilitation potential

Predisposition. High proportion of hereditary burden of mental and drug-related diseases (more than 30%). Growing up in a single-parent family, destructive relationships between family members, alcohol abuse by one or two family members, neurotic development, personality deviations, uneven academic performance at school, inconsistency of hobbies, passion for gambling.

Symptoms. Decompensation stage. The second or third stage of gambling addiction syndrome; stable or slightly reduced tolerance to gambling; severity of gambling withdrawal syndrome and post-withdrawal disorders. Spontaneous remissions are almost never observed, they are often caused by external motivators - illness, lack of money, imprisonment. Participation or non-participation in the game depends on the presence or absence of money. Some disappointment in the fetishization of gaming attributes and control of the gaming situation is noted. The intensity of the euphoric component of the gaming trance and the winning syndrome decreases, the losing syndrome largely loses its inherent bright negatively colored emotionality and painful regret. Losing is perceived as something ordinary, there is only a slight hope - "maybe I'll get lucky next time." The ideology of participation in gambling and the "persistent system" of protecting one's beliefs remain, but when they are presented, uncertainty and pessimism can be traced. Very often patients abuse alcohol and other psychoactive substances. The duration of the dependence syndrome is not less than 5 years. Personality changes. Conflictual relationships with parents and family. A marked decrease in moral and ethical qualities: theft, fraud, hooliganism, growing debts and the absence of any desire to return them. Decreased sexual desire and sexual potency. A severe decrease in criticism of the disease, alienation of the facts of personal and social collapse. Indifference to the family. Persistent affective disorders in the form of dysphoria, depression, sleep disorders, suicidal tendencies. Expressing suicidal thoughts and committing suicide attempts.

Social consequences. Pronounced family and social maladjustment. Continuous deterioration of family relationships, leaving the family, threat of divorce or divorce. Conflicts at work or school. Legal prosecution. Systematic unemployment or work with a lower qualification level. The patient is indifferent to work, mainly pursuing the goal of "somehow earning money". Narrow range of social interests.

Differentiation of patients by the level of rehabilitation potential allows us to predict the prospects of treatment, create and implement the most optimal programs of treatment and rehabilitation process for patients and psychocorrectional programs for their relatives.

Treatment of gambling addiction and rehabilitation of patients with gambling addiction

Observations have shown that consent and, consequently, external and internal motivation of gambling addicts for treatment and rehabilitation are determined by the following main factors:

• significant deterioration of family (family conflicts, threat of divorce or divorce) and social status (problems at work, threat of dismissal or dismissal, debts), accompanied by feelings of guilt, feelings of personal and social collapse;
• psychological pressure from family members, immediate environment or society due to the insolubility of long-term psychotraumatic problems and the growing consequences of maladaptation;
• the emergence of subjectively perceptible painful signs of deteriorating mental health - neurotic and depressive disorders, as well as suicidal tendencies caused by an addiction to gambling.

Treatment and rehabilitation of pathological gamblers begins at the first contact between the patient and the doctor, when the foundation is laid for the subsequent creation and consolidation of relationships in the form of an agreement and a joint plan for overcoming addiction and recovery.

Most experts believe that when providing treatment and rehabilitation care to patients with gambling addiction, a systemic approach should be used, based on the principles of complexity, multidisciplinarity, continuity of periods and stages, and long-term nature. The principle of complexity assumes the unity of medical, psychological, psychotherapeutic and social methods of patient rehabilitation, including examination, diagnostics, pharmacotherapy, psychotherapy and sociotherapy. The principle of multidisciplinarity is based on the use of a team approach to work, which combines the efforts and experience of a psychiatrist-narcologist, clinical psychologist, psychotherapist, social worker and other specialists in the field of diagnostics and rehabilitation. The principle of continuity is based on three periods: pre-rehabilitation, rehabilitation itself and preventive. The first includes the use of diagnostic technologies, treatment of acute and subacute conditions caused by gambling addiction (treatment of gambling AS, post-abstinence disorders, suppression of pathological craving for gambling, motivation to participate in rehabilitation programs). Its duration is usually 2-4 weeks. The rehabilitation period itself includes a full range of medical, psychotherapeutic and social measures aimed at restoring mental health, suppressing craving for gambling, normalizing family relationships, social status. Usually, it takes from 9 to 12 months to solve its problems. The preventive period is aimed at preventing relapses of the disease, includes drug and psychotherapeutic support and optimization of the patient's social attitudes. Its duration is not less than one year.

Conditions for the implementation of treatment and rehabilitation care: outpatient, semi-hospital (day hospital) and hospital. The choice of specific conditions is determined by the level of rehabilitation potential, the severity of pathological gambling, its comorbidity with other mental illnesses and the social status of patients. More often, treatment and rehabilitation are carried out on an outpatient basis, in some cases in hospitals.

The main indications for treatment of patients with gambling addiction in hospital settings include:

• severe manifestations of gambling withdrawal syndrome, including an uncontrollable, uncontrollable urge to gamble and objectively confirmed daily or very frequent visits to gambling establishments, accompanied by alcohol abuse;
• pronounced affective pathology, including depression and dysphoria;
• combination with addiction to psychoactive substances and psychopathy in the stage of decompensation;
• combination with endogenous mental illnesses in the acute stage;
• pronounced suicidal risk, including suicidal statements and tendencies to carry them out;
• difficult family relationships, manifested by increasing hostility and threatening the breakup of the family.

The total duration of treatment and rehabilitation care, taking into account the progradient nature of the disease, is determined by the stabilization of therapeutic remissions and social adaptation of patients, but should be at least 2 years.

It should be noted that there is currently no specific psychopharmacological and psychotherapeutic treatment for gambling addiction and related disorders. There are no standards for drug treatment. Drug treatment should be combined with various types of psychotherapy. Medicines are selected based on the commonality or similarity of some mental disorders in pathological gambling and well-known psychopathological conditions.

Psychotherapy

The Massachusetts Department of Public Health's 2004 Guide to Treatment of Problem Gambling identifies four options for psychotherapeutic and therapeutic intervention:

• minimizing the harmful consequences of the game for the player and his micro-society (family, friends, colleagues);
• reducing risk in situations directly related to money;
• the ability to cope with anxiety, depression, loneliness, stress through mastering new forms of behavior;
• satisfying the need for entertainment and communication through a less destructive and more balanced form of leisure.

Researchers from Laval University in Quebec (Hnjod et al. 1994; Sylvain et ni. 1997) created a treatment model, also based on cognitive-behavioural therapy, which includes four components:

• correcting logical distortions related to gambling (cognitive restructuring);
• choosing a solution (precise definition of the problem, collection of necessary information, proposals for different options with a study of the consequences, a list of the advantages and disadvantages of each option, implementation and evaluation of the decision taken);
• teaching social skills (communication, quantitative thinking), as well as managing emotions and learning to refuse; relaxation along with physical activity and meditation; elements of symbol drama);
• training in relapse prevention skills - behavioral therapy, including hyposensitization and aversion techniques.

For people with a mild degree of gambling addiction, psychodynamic psychotherapy is used as a "quick" treatment option. It is believed that gambling is a substitute for an unmet need that should be identified and realized.

Other psychotherapeutic techniques include eye movement desensitization (Henry, 1996), acupuncture, hypnosis, meditation, biofeedback, leisure-time exercise, and the 12-step program of Gamblers Anonymous.

12 Step Program

According to a number of researchers (Stewart, Brown, 1988; Zaitsev V.V., Shaidulina A.F., 2003), one of the ways of self-improvement, changing attitudes toward gambling and developing personal responsibility for active resistance to pathological addiction is the ideology of a group of anonymous gamblers with a well-structured and carefully developed "12-step" program. The proven belief that people with similar problems can help each other and be an example for each other is the fundamental conceptual principle of the anonymous gamblers program. The only requirement for membership is the desire to stop gambling and attend anonymous gamblers groups. The first societies of anonymous gamblers were remembered in the USA in 1957. Currently, they function in many countries, including Russia (Moscow, St. Petersburg, etc.).

It is believed that approximately 70-90% of Gamblers Anonymous group members drop out early in treatment, and only 10% become active members. Of these, only 10% experience remission for a year or more (Brown, 1985).

Family psychotherapy. Family psychotherapy is a mandatory component of a comprehensive approach to the treatment and rehabilitation of patients with gambling addiction. A.F. Shaidulina (2007) describes four stereotypes of family reactions ("denial", "active actions", "isolation", "adequate reaction"), which are encountered in the process of working with patients and their families. By changing the behavior of family members, it was possible to gradually change the behavior of the player. Patients acquired new behavioral skills, their motives for participating in the treatment and rehabilitation process and changing their own lives increased.

The Scientific and Research Center of Narcology (Rehabilitation Institute) has developed a concept of rehabilitation potential, on the basis of which the strategy and tactics of treatment and rehabilitation work are determined (Dudko T.N.). Depending on the level of rehabilitation potential, various options for complex approaches are used, and the issue of the duration of the treatment and rehabilitation process is also considered. In all cases, the strategy and tactics of treatment and rehabilitation care are based on a systemic approach, including the use of principles and technologies for the recovery of patients with addictive disorders.

Drug treatment of gambling addiction

Neuroleptics, tranquilizers, anticonvulsants, antidepressants, neurometabolic agents, and opiate receptor blockers are used.

In the pre-rehabilitation period (mainly therapeutic) for withdrawal disorders in pathological gamblers, psychopharmacotherapy is mainly used. A combination of one of the stimulant antidepressants is recommended (Prozac at a dose of up to 60 mg per day, Paroxetine (Paxil) at a dose of up to 40 mg per day, Wellbutrin at a dose of 225-450 mg per day, Amineptine (Survector) at a dose of 100-500 mg per day) with sedatives (Amitriptyline in medium doses), as well as with neuroleptics (Stelazine, Clozapine, Chlorprothixene). A combination of Clomipramine with fairly high doses of neuroleptics is successfully used: Perphenazine (Etaperazine) at a dose of up to 60 mg, Stelazine at a dose of up to 30 mg, Clozapine (Leponex) at a dose of up to 75 mg. The choice of drugs is determined by the nature of the depressive affect. Thus, with the prevalence of melancholy, the most preferable combination is clomipramine (anafranil). In case of anxiety, it is advisable to combine amitriptyline with clozapine (leponex) and phenazepam. Of the serotonergic antidepressants, a positive effect is achieved by prescribing fluvoxamine (fevarin). In addition, with a tendency to anxiety-phobic reactions, benzodiazepine tranquilizers were used. Given the data on the negative effect of tranquilizers on cognitive function, drugs with minimal muscle relaxant and sedative effects are more preferable: tranxen up to 30 mg, alprazolam (xanax) in a dose of up to 1.5 mg, lexomil in a dose of up to 12 mg per day.

Naltrexone plays a significant role in the therapy of gambling addiction. V.V. Khaikov (2007) believes that the leading place in the self-report of gambling addicts who took naltrexone was occupied by:

• a decrease in the brightness of the experiences of the game trance, up to an almost complete leveling of the emotional component of the game;
• significant weakening of fixation on the game with the ability to observe the surroundings, assess the situation, respond to calls, etc.;
• the possibility of stopping the game before a catastrophic loss;
• the appearance of “game fatigue”, “loss of interest”, which was either not typical before or occurred much later (2 or more times).

Naltrexone treatment can be carried out starting from the abstinence and post-abstinence periods, the dosage is 50-100 mg per day, the duration of treatment is 2-16 weeks. In patients using naltrexone, the desire to gamble and anxiety decreases quite quickly, and the mood improves. With an unauthorized reduction in the dose or cessation of naltrexone, the desire increases.

Treatment and rehabilitation of patients with a high level of rehabilitation potential is usually carried out in an outpatient setting. Of the psychotherapeutic methods, preference is given to rational psychotherapy, autogenic training, neurolinguistic programming, body-oriented therapy, keeping diaries, and doing homework. An important place is occupied by the method of transactional analysis, which is carried out not only with the patient, but also with family members. Patients with a high level of rehabilitation potential often refuse group sessions, including visiting anonymous gamblers groups, but willingly agree to individual work and taking medications. Drug treatment is symptomatic, non-intensive and short-term. The course of treatment with naltrexone is at least three months.

Patients with an average level of rehabilitation potential require additional and longer treatment. Mostly, these are people with comorbid forms of addiction. But even if these are patients with mono-addiction, then, first of all, it is necessary to use the method of rational psychotherapy. In addition to motivation for treatment, it includes a thorough study of the hymitomas and syndromes of the disease, medical and social consequences of gambling addiction. Drug treatment is prescribed for a long time. Hypnosis sessions can be added to the above psychotherapy methods (after determining the degree of hypnotizability and setting the patient up for this type of psychotherapy). Patients are recommended to attend anonymous gamblers groups. Family therapy is a must in all cases. Naltrexone is prescribed in courses of two to three months with breaks of up to two weeks, during which it is necessary to study the dynamics of the mental state and attitude to the game. With stable remission, naltrexone treatment is continued for 6-9 months. In the preventive rehabilitation period, in cases of exacerbation of cravings, small doses of anticonvulsants are recommended (carbamazepine at a dose of 50-150 mg per day), in the event of affective disorders - antidepressants [citalopram at a dose of 35 mg per day, fluvoxamine at a dose of 200-300 mg per day, cipramil (at a dose of 20 mg in the morning), mirtazapine (remeron) at a dose of 15-30 mg at night], small doses of tranquilizers (phenazelam, afobazole, diazepam, phenibut).

Effectiveness of gambling addiction treatment

Gambling addiction is a progressive disease. Stable spontaneous or therapeutic remissions are mainly observed in patients with a high level of rehabilitation potential. Scientific publications on the effectiveness of treatment and rehabilitation of patients with gambling addiction contain a number of contradictory points of view, which is largely due to the complexity of organizing the treatment and rehabilitation process and the difficulty of observing its basic principles. Often, the effectiveness of only individual methods or technologies is assessed: behavioral therapy, psychodynamic approaches, the work of anonymous gamblers groups, drug treatment, etc. According to Bujold (1985), when using the psychotherapeutic method of anonymous gamblers communities, remission is achieved in 10% of patients. Only as a result of using combined therapy, including individual, collective therapy and mandatory participation in anonymous gamblers groups, can higher efficiency be achieved (55%).

The conducted follow-up examination of gambling addicts with an average level of rehabilitation potential allowed us to identify six-month remissions in 43.7% of patients and remissions lasting more than one year in 25%. The duration of remissions is directly proportional to the duration of treatment, i.e. the period of systematic medical and psychotherapeutic work with patients and their relatives.

Treatment and rehabilitation in a hospital setting for at least 28 days allowed to achieve stable remission for one year in 54% of patients. R.L. Caster, using individual and group psychotherapy, as well as participation of gambling addicts in groups of anonymous players, achieved stable improvement in 50% of cases. V.V. Zaitsev, A.F. Shaidulina (2003) note that the psychotherapy cycle of 15-20 sessions developed by them allowed to achieve a therapeutic effect in 55-65% of patients. In all cases, to achieve high and stable efficiency, treatment should be comprehensive, consistent and long-term.

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What is the prognosis for gambling addiction?

The prognosis for gambling addiction is determined by many factors.

Signs of a good prognosis when patients are involved in a treatment and rehabilitation program:

• a high level of rehabilitation potential, including favorable heredity, a constructive family, positive dynamics of physical and personal development, a good premorbid, social and professional history;
• late development of pathological dependence, presence of spontaneous remissions, mild or moderate degree of the disease (compensation or subcompensation stage);
• strong marital relationships, desire to preserve the family, attachment to the family;
• availability of work and a system of social and psychological support from family and significant others;
• absence of debts or real ability and desire to pay off debts (mental discomfort in the presence of monetary debts);
• stable motivation for treatment, the ability to be in a formed motivational field and use the experience of latent positive motives to refuse to participate in gambling;
• long-term participation in treatment and rehabilitation programs, attending anonymous gamblers groups.