Gambling, or game addiction

In the first published scientific study on the pathological attraction to gambling, an opinion was expressed on the multifactorality of gambling development. Its author is Gerolamo Cardano (1501-1576). Cardano first raised the question that, perhaps, a passion for the game - an incurable disease. He also assumed that the game has an active psychological role, "because psychologically the game helps with grief, with melancholy, anxiety, stress."

Cardano's work directly indicates that he knew firsthand that during the game a person experiences completely specific states of the soul, such as loss of control over himself, the desire to increase rates, chasing (chasing), fixing on the issues of the game. In addition, he noted that enthusiasm for gambling leads to social and legal problems, and all together makes a diagnosis of "gambling".

ICD-10 code

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

A short historical essay on gambling

Gambling has been known since ancient times. The word "excitement" comes from the Arabic word "alzar" - "dice". The first documentary sources of gambling were discovered among the ruins of ancient Babylon (3000 BC). In the classical literature of many cultures mention of the attraction to the game (the Old and New Testaments, the epic poem "Mahabharata" in Sanskrit, etc.). Dice playing was the most common game in the Middle Ages. Card games appeared in Europe since the time of the crusades in the XIII century.

The history of the development of legal relations in society and the emergence of negative consequences of gambling testify to the fact that for a long time the direct duty of the state as an institution of political power, management and protection of interests of all strata of society was: gambling should not be held publicly, attract a wide range of people , reflect on the material well-being of the broad masses of the population.

It should be noted that the official prohibition of gambling and various epochs of the development of society did not destroy them, but only for a time reduced the number of gaming establishments and their location. The banning of gambling never guaranteed their real extinction.

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

In connection with the negative social consequences associated with the gaming business, in the spring of 2007, the Government of Russia passed a resolution on the issuance of gambling establishments beyond the boundaries of cities.

In the opinion of A.K. Egorova (2007) and many other researchers, the urgency of the problem of game dependence is due to the following three reasons:

• serious social and financial problems;
• the prevalence of criminal activities in their midst (up to 60% of gambling addicts commit offenses);
• high suicidal risk (13-40% commit suicide, 42-70% of patients note suicidal ideation).

To this list, one should add a high proportion among the gambling addicts of comorbid disorders (alcoholism, drug addiction, endogenous pathology) and severe moral and ethical degradation with all the social consequences typical for this contingent.

Currently, there are four main categories of gambling.

1. Constant legal games - lotteries, video lotteries, betting bets, sports betting, bingo, casino, slot machines.
2. Games in illegal gambling establishments and betting from illegal bookmakers.
3. Different money wagers and bets between familiar people, friends and co-workers. It can be absolutely any wagers and bets that occupy a significant place in the cultural life of the population.
4. The game on the stock exchange, which refers not to professional duty, but acquires the character of gambling.

One of the first systematic study of gambling addiction began in the early XX century. American psychologists. They believed that not only the anatomical, but also the behavioral or "psychic" characteristics of the personality are inherited. Based on these beliefs, it was concluded that a repeated (deliberate) approach to life-threatening situations provoking an involuntary survival reaction (self-preservation), entails a biological need for such experiences. This hypothetical need, which is also considered necessary for the survival process, is supported by the presence of behavioral strategies leading to the search for risky situations, and transmitted to subsequent generations.

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

Caster (Caster R., 1985) believed that the whole way of forming gambling patients are 10-15 years. He singled out the five main stages in the development of gambling. Caster noted that the "virus" gambling afflicts far from everyone who touches it. Observations carried out by him made it possible to identify certain traits, the presence of which in the potential player makes him more susceptible to the aleicle virus. Such traits include low self-esteem, intolerance to refusals and disapproval, impulsiveness, high levels of anxiety or deep depression, low tolerance for disappointment and the need for immediate satisfaction, a sense of omnipotence and a propensity for magical thinking, activity, thirst for activity, excitement, stimulation and risk .

In recent years, considerable attention has been devoted to the game cycle, including the 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 problems when dealing with problem players. V.V. Zaitsev and A.F. Shaydulina (200 ") offered their vision of the development of phases and behavior of patients that make up the so-called game cycle: the phase of abstinence, the phase of" automatic fantasies ", the phase of increasing emotional tension, the decision-making phase, the phase of displacement of the decision, the phase of implementation of the decision.

Other researchers (Malygin VL, Tsygankov BD, Khvostikov GS, 2007) established a certain pattern of the formation of the cycle of gambling:

• a period of distress, the next immediately after the game;
• period of moderately expressed anxiety-depressive disorders;
• period of subdepressive disorders with predominance of asthenia or apathy;
• period of anxiety and dysphoric disorders in combination with subdepression;
• period of narrowed consciousness (the trance of the game), preceding directly to the breakdown.

Characterological properties of pathological gamblers are determined by the prevalence of hyperthymic, excitable and demonstrative traits of character, only in 14.3% of those attaining the level of accentuations. Analysis of the mechanisms of psychological defense reflects the predominance of protective mechanisms by the type of negation, displacement, projection and regression.

Studying the psychological characteristics of problem gamblers, most researchers point to the loss of control by the gambler over their own behavior, and this applies to all variants of gambling (from playing a tote to gaming machines). Australian researchers identify three subgroups of problem gamblers:

• with behavioral disorders;
• emotionally unstable;
• antisocial, prone to impulsive actions.

[1]

Epidemiology of gambling

Gambling is widespread all over the world, many countries are involved in gambling business, which brings super profits. The prevalence of pathological predilection for gambling in the world population is from 1.4 to 5%

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

The classification of crimes registered at gambling enterprises, according to one of the members of the committee of the Russian Association for the Development of the Gambling Industry (RARIB) for security, is as follows: crimes related to the attempt to sell fake banknotes worth 100, 500 and 1000 rubles: theft and theft of funds; hooliganism. From various media sources it is also known that visitors to gambling establishments commit even more serious crimes (arson, destruction of gambling machines, shootings with security and murder).

In countries with developed gambling business, a comprehensive solution to the problems of pathological gambling is 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 on the study of epidemiology, the implementation of comprehensive measures to prevent gambling, treatment and rehabilitation of gambling addicts;
• the state finances preventive, curative and rehabilitative anti-gambling programs and optimizes the activity of commercial structures of the gaming business and public organizations in this direction;
• gambling should be assessed as a serious problem that threatens the mental health of citizens, leading to personal and social disadaptation;

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

[2], [3], [4], [5],

Social portrait of persons with gambling addiction

Most authors note that these are mostly male, with an average age of 21-40 years, secondary education, incomplete higher education, higher education (the distribution is exemplary in equal proportions with some predominance of secondary education), the majority at the time of the survey worked (42-68 %), were married (37.3-73.0%). Relations in the family are mainly conflictual (an average of 69.7%), comorbidity with alcoholism 42.4%. It should also be noted that most researchers note a high proportion of alcoholic heredity in patients with gambling, which on average is 41-52%. In addition, suicidal tendencies among patients are 52%. Illegal actions -> 50%. The social portrait of gamers is supplemented by the results of a psychological survey that testifies to their emotional instability, reduced ability to self-control and reflection, antisocial attitudes, propensity to overvalued ideas and increased activity, which was combined with the prevalence of narcissistic and borderline personality traits.

In many respects, many foreign authors cite the identical social characteristics of a typical player (with the exception of age) (Caster et al, 1985).

Causes of gambling

Despite a significant variety of opinions on the prerequisites for the development of game dependence, in most cases preference is given to biological, mental, environmental and social factors.

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

In the context of the foregoing, it should be noted that often patients seek the cause and justification of their "life in the game" and its severe consequences but external "global", 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 well-off people.

[6]

Clinical symptoms of gambling

The addiction syndrome is represented by pathological (often insurmountable) attraction to gambling, combined with varying degrees of cognitive, behavioral, emotional and somatic symptoms. It may include some of the signs observed in addictive disorders that result from the abuse of surfactants (pathological attraction, loss of game control, AU, increased game tolerance, prolonged participation in gambling, despite obvious signs of harmful effects, etc.).

[7], [8]

Syndrome of pathological attraction to the game (game drive, motivational concept)

It manifests 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 requiring attention and treatment, in the structure of pathological attraction to the game outside the withdrawal syndrome the pathological players are dominated by ideatorial disorders, including obsessive ideas (fantasy) about the features of the game, variants of the "mandatory" win, combinations of c digit, card or symbolic series, bringing an "unconditional" victory and personal celebration. There is a feeling of confidence in the win and belief in their special qualities, the state of anticipation of the pleasure of the upcoming game, the illusion of controlling the game situation. Fantasy about the game is often accompanied by infantile ideas about the obligatory material success, the gained respect in the event of a win by surrounding people and, especially, other important persons, when "everyone and, above all, relatives understand" that "did not play in vain and believed in success ". Sometimes, against the background of this fantasy, patients hear the sounds typical for gaming establishments - the noise of gambling machines, roulettes, music, etc. There is an unconscious immersion in this state, which allows you to forget, to distract from real everyday worries and many negative problems created as a predilection for the game mostly), and life itself. In addition to the primary pathological attraction to the game, which occurs against the background of abstinence from the game and is considered a "triggering mechanism" of failures and relapses of dependence, the secondary attraction to the game is of fundamental importance. It arises in the process of participating in the game and indicates a significant decrease in the ability of the patient to stop playing, get out of the game trance and, consequently, control his behavior, despite the obvious signs of harmful consequences of participation in the game.

The presence of an abstinence syndrome or withdrawal syndrome in the composition of gambling seems controversial due to the absence of withdrawal of surfactants. Although and with this form of addiction there is a withdrawal / deprivation of the game. At the same time, withdrawal syndrome includes a group of signs of varying severity and combination: emotion, behavioral, dissomnestic, indistinctly expressed vegetative, somatic disorders and an increasing pathological attraction to the game. Internal emptiness, regret for loss, self-condemnation, sometimes suicidal thoughts, elements of suicidal behavior and aggression that dominate the withdrawal syndrome in patients who are losers in a game the previous day (the vast majority). In the structure of affective disorders, anxiety, subdepression and depression, dysphoria, increased irritability, emotional incontinence prevail. As a rule, there are sleep disorders in the form of insomnia, unpleasant dreams, game guidance scenes, the game itself, etc. Among vegetative disorders, usually noted increased sweating, tachypnea, reddening of the facial skin, as well as tachycardia, hypertension, cardialgia, angina. Often asthenia, worsening appetite, cardiac and headaches, decreased efficiency and interest in work, alienation from the members of seven. Against this background, as the affective, somatic and vegetative disorders disappear, the obsessive desire to "take revenge", "recoup", "prove" periodically arises, which is gradually replaced by an irresistible craving for the game. In the acute period of the withdrawal syndrome, the pathological attraction to the game is predominantly manifested by the behavioral component (considering the system of overcoming the obstacles that stand in the way of satisfying one's desire, avoiding persons who oppose the game, extracting money using a wide range of tricks of deception, theft, extortion, etc.). The duration of this syndrome is from 12 hours to 2 days. In cases of winning, the condition of the patients is quite different. They have a good dream, pleasant dreams. The mood is upbeat, they experience a sense of victory, excellence, complacency, are prone to spending money, make gifts, build unrealistic plans, in particular, about partial repayment of debts. They are attracted to the game, they are hoping to repeat the success, are plentifully fantasizing about the upcoming game and about what they will do with very large money, which will necessarily win, set themselves up for a moderate and cautious game, believe in repeated gaming luck. The illusory idea about the ability to control the game situation and the ability to turn the luck in their direction is aggravated.

Syndrome of playing trance

Absorption of the game, excitement, the inability to stop the game, despite the win or a significant loss. Most often the game lasts from 4 to 14 hours, in fact, as long as there is money (money) to participate in the game. The main goal of the player is to win, to win. It persists even with a long playing trance, but at the same time it loses its original brightness and contrast. In the process of the game, the motivational accent is shifted from the winnings to the game itself, game gambling, overvoltage, which leads to pronounced asthenic and vascular disorders, gradually begins to predominate. There is hypertension, tachycardia, cardialgia, the concentration of attention, memory weakens, game performance and professionalism decrease. Players completely forget rational and behavioral settings. The consciousness shrinks and an adequate response to the situation is lost, the ability to control the game progresses and the game skills to be fully utilized. The ability to stop the game on time, to get up and leave the gambling establishment is lost. The patient is immersed in a peculiar state of "hovering" in the game, in which it is impossible to break the game by oneself, and friends or relatives are not able to forcefully pull the player out of the gaming establishment due to his fierce resistance. Given this feature, many players are afraid of a long game cycle and attach great importance to this. At a short distance (2-3 hours), they believe, the ability to control the course of the game and its actions remains and, consequently, there is always a high probability of winning. At a long distance (over 3 to 14 hours), in their opinion, many game or "fighting" qualities are lost, which leads to a compulsory loss. Often, at a long game distance, a critical condition occurs, in which the main motive of the game - the prize - disappears, the desire predominates that the game soon ends with any result, even a loss, and then "you can calmly leave" and relax (the game exhaustion syndrome). It should be noted that while in a state of playing trance, patients forget about all personal and social problems created by painful dependence. They claim that they "rest", relax and recover after hard work, that they, allegedly, "have the right to do so". In fact - this is one of the myths of gamers, which, incidentally, is the most important target of psychotherapists.

Winning Syndrome

Raised, sometimes euphoric, mood, stuck energy, a sense of superiority, the joy of achieving the goal. This condition is a great pleasure ("for this it is worth living and playing", as the patients believe). Winning creates confidence in yourself, in your abilities, allows you to fantasize about the most attractive directions of life, including further successes in the game and acquired wealth. He, fixing and memory, contributes to breakdowns and relapses of the disease.

At the first stage of the syndrome of dependence, the syndrome of winning lasts from several hours to several days. Thus patients are in euphoria, show extravagance and good nature. At the stage of pronounced play pathology, the duration of the syndrome of the winning, as a rule, does not exceed 4-10 hours and, what is very characteristic, has a much less pronounced positive affective component.

Loss Syndrome

Occurs during the game, immediately after its completion or can be left behind for one, less often, for two days. Losing in the course of the game and realizing that there is less chance to win back, the patients experience growing alarm, increased irritability, anger, sometimes regret that they started to play. Often they want to quit the game, but they are stopped by excitement, a constant hope of winning, fixed in memory of the memory of the winnings and significant successes. There is aggression, a periodic desire to take revenge, to find and punish those responsible. Being in this state, in some cases, patients ask divine or devilish forces to help them, to regret them, in others they swear and all curse. Often they are baptized, read prayers, utter spells, stroke a slot machine or, on the contrary, damage and destroy it.

After the game is over, when the patient leaves the gambling establishment, the loss syndrome is manifested by a depressed mood, incontinence, increased irritability, rudeness, sometimes aggression and destructive actions, frustration, suicidal thoughts. The sleep is disturbed, anxious dreams disturb, there is no appetite, the head, heart often hurts. A painful condition is accompanied by self-condemnation, suicidal thoughts and tendencies, temporary self-criticism, promises to "never play again" (like promises in the state of withdrawal from alcoholism - "never drink again"). It can last from 12 hours to 2 days, gradually fades, and is replaced by an ever-increasing attraction to the game.

Tolerance to the game and its dynamics

In the process of being involved in gambling addiction, the tolerance to prolonged participation in the game is significantly increased in patients. So, if at the initial stage of dependence patients spend at a gaming establishment 1.5-3.5 hours, then in the future, when there are signs of decompensation, they are able to hold the game for 10-24 hours. In fact, as long as there is money and works a game institution. However, in the category of patients older than 50 years, playing tolerance is reduced, and patients physically unable to participate in the game for more than 4-5 hours due to rapid exhaustion.

The syndrome of personality changes

Very quickly (6-12 months) in the formation of game dependence, there are signs of negative personal, behavioral, emotional and intellectual-mnestic disorders against the background of varying degrees of the syndrome of gambling addiction. This is - deceit, irresponsibility, conflict, violations of the production discipline, temporary or persistent indifference to work (frequent changes of work) in the family, reduced efficiency, criminality (theft, fraud, forgery, etc.) loneliness. In addition to emotional coarsening, they note a significant decrease in the demand for their appearance, personal hygiene, untidiness, etc. Affective disorders are manifested by constant anxiety, subdepression, depression, dysphoria. Suicidal thoughts and tendencies are characteristic. The circle of interests is narrowing, long-term ties with friends are lost. Gradually worsens memory, working capacity, and also ability to creative activity.

People who suffer from gambling addiction become resentful, quick-tempered, rude, "dull", sexually weak, selfish, make unreasonable demands, do not want to buy things necessary for the family, products, save on everything to save money for the game.

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

Gambling and related pathology

In patients with gambling, the symptoms of depression, schizophrenia and alcoholism are detected 3 times more often. At them in 6 times more often, than at non-playing persons, it is possible to notice signs of an antisocial personal frustration. In ICD-10, antisocial personality disorder is positioned as a dissocial personality disorder. In the presence of both diagnoses, dissocial personality disorder occurs earlier, on average 11.4 years. Alcoholism in most cases outstrips the emergence of gambling on average 2 years, drug addiction - 1-1,5 years. A study of 4499 pairs of twins also showed a direct link between various disorders in childhood, the subsequent onset of dissocial personality disorder and the onset of gambling. It is established that the genetic predisposition is at least partially, but determines the described comorbidity. Hereditary weighed by alcoholism was revealed in 41.4% of patients with gambling addiction, drug addiction - in 2.7%, mental illness - in 37.4%. According to the research data, 36% of the patients with gambling had alcohol problems, they were treated for alcoholism, more than half of the patients (53.6%) had heredity with alcoholism.

In patients with schizophrenia, the clinical manifestations of the syndrome of pathological attraction are significantly altered. According to O.Zh. Buzika (2007). In patients with schizophrenia, combined with pathological gambling, the syndrome of pathological attraction to gambling manifests less intensity than in patients only gambling and in patients with gambling, combined with a dependence on alcohol or drugs. The ideator, affective and behavioral components of the pathological drive syndrome also "differed in lesser brightness and severity."

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

Stages of gambling

The development of clinical manifestations of gambling goes through three interrelated stages: compensation, subcompensation, decompensation. They differ in the severity of the 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 "game" degradation occurs, including the personal and social components.

Compensation stage

At the compensation stage, a syndrome of pathological attraction to the game is formed, in the structure of which the ideator component predominates first, crystallize "insane and passionate thoughts", "forebodings" of indispensable gain. As Dostoevsky wrote, "self-poisoning with one's own imagination", which repeatedly repeats, is reliably fixed in consciousness, turning into a worldview concept, sometimes into "sweet" creative activity, and, consequently, produces an ever-increasing "thirst for risk." The game and the loss are only a kind of payment for immersion in the world of creative fantasies and imaginary wins, for the illusion of a holistic self, a protected feeling of loneliness, guilt, shame, fear, temporary or sometimes total insolvency, for getting out of the game and playing trance from state of deprivation and despondency. For all this dependent patients are willing to pay "in large" and pay with money, expensive property, cars, dachas, apartments, social stability and the welfare of the family, their own lives.

At this stage of gambling, there is an increase in game tolerance, a joyful sense of the game itself is fixed, game attributes are fetishized, game mythmaking is formed, the first signs of personal deviations of the moral and ethical spectrum appear. In the compensation stage, patients save their work, family, believe that "everything will somehow manage", despite the appearance of debts and troubles. The ability to spontaneous remissions is maintained. Social losses begin to create serious problems and cause alarm. Rapid entry into the stage of the formation of the disease is due to the biological and mental predisposition to gambling addiction. Averaged its duration from 6 months to 2 years.

[9]

Stage of subcompensation

At the stage of subcompensation (stabilization of the disease), such syndromes as abstinence, game trance, gain, loss, personal degradation and social maladaptation are formed. The components of the withdrawal syndrome - mental, autonomic, somatic disorders - are manifested as a characteristic and easily recognizable symptomatology. Tolerance to the game is high and stable. Patients can play for 5-20 hours a day. Strongly expressed secondary attraction to the game. Spontaneous remissions, during which patients lead an orderly lifestyle and work, are rarely observed. These "light intervals" easily replace the long episodes of the game. Winning brings a sense of confidence, strength and omnipotence. Patients overestimate cognitive abilities and intuitive qualities, the ability to "anticipate" the result. Attitude to constant failures frivolous and uncritical. They make desperate attempts to return the lost money, often make large bets. Systematic setbacks in the game lead to a significant change in behavior, which is accompanied by increasingly frequent cases of fraud of relatives, friends, employers. In the game trance, the patients find salvation from disappointments and bad mood. The sleep is upset, most of the dreams become unsettling and unpleasant. Family relations are on the verge of collapse or are already broken. Patients are looking for a way out in big winnings and big luck. Finally, the day comes when all possible legal financial resources are exhausted and a "system failure" occurs. It is at this stage that for the first time there are thoughts of suicide and a desire to hide from everyone (from family, friends, creditors). Some players have a phase of refusing to fight for a big win, a decrease in game tolerance, and disappointment. It is in this condition, under the pressure of close relatives, players agree to treatment. The duration of this stage is 3-6 years.

Stage of decompensation

This stage corresponds to the second and third stages of the syndrome of gambling addiction. The ideator component of the attraction syndrome is weakened and the feeling of "certainty" in its gain. Significantly reduced criticism to the obvious signs of the dangerous consequences of gambling. In the discussion of patients there is a small register of really strong motives for abstinence, which, as a rule, does not stop them from participating in gambling. The patients notice a significant moral and ethical decline and emotional coarsening. Suicidal tendencies are often realized. Expressed affective disorder with a predominance of depression. Sexual interest and sexual desire decrease. Family breakdown, problems with work arise (most often work is lost) and law enforcement agencies. The somatic state is characterized by worsening of cardiovascular diseases (arterial hypertension, angina pectoris, etc.). Diseases of the digestive system, etc.

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

Diagnosis of pathological dependence on gambling

The pathological tendency to gambling is discussed in the chapter "Disorders of personality and behavior in adulthood" under F6O-F69 "Disorders of habits and drives" ICD-10. The pathological attraction to gambling (F63.0) consists in frequent repeated episodes of participation in gambling, which dominates the life of the subject and leads to a decrease in social, professional, material and family values. Patients can risk their work, borrow large amounts and break the law in order to raise money or evade the payment of debts. They describe the strong attraction to gambling, which is difficult to control, as well as mastering the thoughts and ideas of the act of the game and those circumstances that accompany this act. These possessive notions and attraction are usually intensified at a time when stresses occur in their lives. This disorder is also called compulsive participation in gambling, but this term is controversial, since the behavior indicated is not compulsive in nature, nor because of the connection of these disorders with the obsessive-compulsive neurosis.

[10], [11]

Diagnostic instructions

The main feature is the recurring participation in gambling, which continues and often deepens, despite social consequences, such as impoverishment, disruption of intra-family relations and ruin of personal life.

[12],

Differential diagnostics

The pathological attraction to gambling should be distinguished from:

• inclinations to gambling and betting (Z72.6):
• frequent gambling for pleasure or money; such people usually restrain their attraction when they face great losses or other adverse consequences of gambling;
• excessive participation in gambling of manic patients (F30); gambling of sociopathic personalities (F60.2 *); these people show a broader persistent violation of social behavior, manifested and aggressive acts, through which they show their indifference to the well-being and feelings of others.

To pathological gambling should also include:

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

At the heart of gambling addiction (pathological gambling, ludomania) lies the pathological attraction to gambling, which belongs to the sphere of mental pathology. Consequently, like other mental illnesses, gambling, there is a sequence of clinical syndromes, their dynamics, staging, which together reflect the evolutionary development of pathology. The severity of defeat by gambling is determined by the strength and dynamics of attraction to the game, loss of control, tolerance, the 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 make up the essence of the individual stages of the disease, which in turn largely determine the level of rehabilitation potential of gambling addicts.

[13], [14], [15], [16]

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 that determines the features of the formation of dependence and the way out of it. The diagnosis of rehabilitation potential is based on the correlation of objective data on heredity, predisposition, health status, type, severity and consequences of the disease , features of personal (spiritual) development and social status of patients. The levels of rehabilitation potential of gambling addicts have been established (the concept of TN Dudko). For medical assistance, patients with a medium and low level of rehabilitation potential, the specific weight of patients with a high level of rehabilitation potential, no more than 10%, are mostly treated. The main components of the levels of rehabilitation potential of gambling addicts naturally have their own certain relativity. There is a significant fluctuation in the diagnostic features inherent in each of the four blocks characterizing high, medium or low levels of rehabilitation potential.

With monoigromania (in the absence of comorbidity), each of the levels of rehabilitation potential is most often characterized by the following features

High level of rehabilitation potential

Predisposition. Low specific gravity of hereditary burden of mental and narcological diseases (up to 10-15%). Psychic and physical development is predominantly within the norm, the environment of upbringing is safe.

Clinical picture. The stage of compensation and the appearance of the first signs of subcommission; the initial (first) stage of the game addiction syndrome, high tolerance to the game and even its growth; low intensity of game abstinence syndrome. Gaps between game episodes, especially after another loss, can reach several months. For a high level of rehabilitation potential, there is a mandatory presence of spontaneous remissions, including long-term remissions after a loss and even a gain. Kistaliziroetsya fetishization of game attributes, illusions of control of the game situation. Increases the secondary attraction to the game. Gradual involvement in the study of "game theory." Prevail abstinence from alcohol abuse. The duration of the addiction syndrome is 1-3 years.

Personal change. Moral and ethical deviations in the form of "petty" lies, violations of obligations, responsibilities, episodes of borrowing money for the game, repaying money, but not always on the promised date. The first episodes of thieving in the family. Some decrease in criticism, frivolous attitude to the facts of the consequences of dependence, disturbing thoughts about the changed behavior. After work, I do not want to return home because of the "boring atmosphere of family existence." There are signs of affective disorders of the neurotic series in the form of incontinence, conflict, moderately expressed anxiety-depressive disorders.

Social consequences. Appearance of the first signs of social maladjustment, including deterioration of family relations, small conflicts in the place of work or study due to a decrease in responsibility; some narrowing of the circle of interests; reduction of time for the usual leisure time (family, sport, physical culture, art, tourism).

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

The average level of rehabilitation potential

Predisposition. The average relative weight of hereditary burden of mental and narcological diseases (20-25%); education in an incomplete family, often with uneven or conflict relations between family members. Often deviant behavior and related uneven performance in school, inconstancy of hobbies. Increased suggestibility.

Clinical picture. Stage of subcompensation. The middle (second) stage of the game addiction syndrome; Stably high tolerance to the game; the severity of the game AS and post-abstinence disorders. Expressed a secondary attraction after the start of the game, the patient is unable to interrupt the game started. The stability of the formed ideology of participation in gambling, a "persistent system" for the protection of one's convictions. The illusion of controlling the game. Frivolous attitude to the abuse of alcohol and other surfactants. The duration of the addiction syndrome is at least three years.

Personal changes. Constant conflict with parents and family; reduction of moral and ethical qualities: theft of money not only in the family, but also in the place of work, fraud, hooliganism, growth of debts. Reduction of sexual desire and potency, avoidance of meetings with spouse (spouse).

Sharp decrease in criticism to the facts of personal and social collapse. Periodically increasing desire to work intensively and hard, especially in case of threat of dismissal. Expressed affective disorders in the form of psychogenic depressions, sleep disorders, suicidal tendencies (mostly thoughts and demonstrative threats to commit suicide).

Social consequences. Family and social disadaptation. Negative dynamics of family relations; family withdrawals, the threat of divorce or divorce. Conflict in the place of work or study. Prosecution. Frequent dismissals from work. Narrowing of the circle of interests.

Low level of rehabilitation potential

Predisposition. High specific weight of hereditary burden of mental and narcological diseases (more than 30%). Education in an incomplete family, destructive relations between family members, alcohol abuse of one or two family members, neurotic development, personal deviations, uneven school performance, inconstancy of hobbies, hobby for money games.

Symptoms. The stage of decompensation. The second or third stage of the game addiction syndrome; stable or slightly reduced tolerance to the game; the severity of gambling withdrawal syndrome and post-abstinence disorders. Spontaneous remissions are almost not observed, they are often caused by external motivators - disease, lack of money, imprisonment. Participation or non-participation in the game depends on the availability or absence of money. There is some disappointment in the fetishization of game attributes and the control of the game situation. The intensity of the euphorizing component of gambling trance and syndrome decreases, the loss syndrome largely loses its inherent bright negatively colored emotionality and painful regret. Losing is perceived as something ordinary, there is only an easy hope - "maybe you'll be lucky next time." The ideology of participation in gambling and the "persistent system" of defending one's beliefs remain, but when they are presented, one can trace insecurity and pessimism. Very often, patients abuse alcohol and other surfactants. The duration of the dependence syndrome is not less than 5 years, Personal changes. Conflict relations with parents and with family. The expressed decrease in moral and ethical qualities: theft, fraud, hooliganism, the growth of debts and the absence of any aspirations for their return. Reducing sexual desire and sexual potency. Rough 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, suzidal tendencies. Saying suicidal thoughts and committing suicidal attempts.

Social consequences. Expressed family and social disadaptation. Continuing deterioration in family relationships, family withdrawals, the threat of divorce or divorce. Conflict in the place of work or study. Prosecution. Systematic unemployment or work with a lower qualification level. The patient is indifferent to work, mainly pursuing the goal of "somehow earn". A narrow range of social interests.

Differentiation of patients according to the level of rehabilitation potential allows to forecast the prospect of treatment, create and implement the most optimal programs of treatment and rehabilitation process for patients and psycho-corrective programs for their relatives.

Treatment of gambling and rehabilitation of patients with addiction to gambling

Observations made it possible to establish that the following main factors determine the consent and, consequently, the external and internal motivation of the gambling addicts for treatment and rehabilitation:

• significant deterioration of the family (family conflicts, threat of divorce or divorce) and social status (troubles at work, threat of dismissal or dismissal, debts), accompanied by feelings of guilt, feelings of personal and social collapse;
• psychological pressure of members of the family, immediate environment or society in connection with the unsolvability of long-term psychotraumatic problems and the growing consequences of maladaptation;
• the appearance of subjectively palpable morbid signs of deterioration in mental health - neurotic and depressive disorders, as well as suicidal tendencies caused by addiction to gambling.

Treatment and rehabilitation of pathological gamblers begins with the first contact of the patient with the doctor, when the foundation is laid for the subsequent creation and consolidation of relations in the form of a contract and a joint plan for overcoming dependence and recovery.

Most experts believe that when providing patients with gambling addiction therapeutic and rehabilitation assistance should use a systematic approach based on the principles of complexity, multidisciplinarity, continuity of periods and stages, and long-term. The principle of complexity presupposes the unity of medical, psychological, psychotherapeutic and social methods for the rehabilitation of patients, including examination, diagnosis, pharmacotherapy, psychotherapy and sociotherapy. The principle of multidisciplinarity is based on the use of a brigade (command) approach to work, in which the efforts and experience of a doctor psychiatrist-narcologist, clinical psychologist combine. Psychotherapist, social worker and other experts in the field of diagnostics and rehabilitation. The principle of continuity is based on sin periods: pre-rehabilitation, rehabilitation and prophylactic. The first includes the use of diagnostic technologies, the treatment of acute and subacute states due to gambling addiction (treatment of game AS, post-abstinence disorders, suppression of pathological attraction to the game, motivation to participate in rehabilitation programs). Its duration is usually 2-4 weeks. Actually, the rehabilitation period includes the whole complex of therapeutic, psychotherapeutic and social measures aimed at restoring mental health, suppression of attraction to the game, normalization of family relations, social status. Usually it takes 9 to 12 months to solve his tasks. The preventive period is aimed at preventing relapses of the disease, including medical 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: an outpatient clinic, a half-hospital (day hospital) and a 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 is carried out and out-patient conditions, in some cases in hospitals.

The main indications for the treatment of patients gambling in hospital conditions include:

• severe manifestations of gambling abstinence syndrome, including unrestrained, uncorrected attraction to the game and objectively confirmed daily or very frequent visits to gambling establishments, accompanied by alcohol abuse;
• pronounced affective pathology, including depression and dysphoria;
• combination with dependence on surfactants and psychopathies in the stage of decompensation;
• combination with endogenous mental illnesses in the stage of exacerbation;
• pronounced suicidal risk, including suicidal tendencies of their tendency to their implementation;
• complex family relations, manifested by an increase in hostility and threatening the disintegration of the family.

The total duration of medical and rehabilitation care, given the extent 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 no specific psychopharmacological and psychotherapeutic treatment for gambling and related disorders for today. There are no standards for drug treatment. Medication should be combined with a different kind of psychotherapy. Medicines are selected based on the generality or similarity of some mental disorders in pathological gambling and the well-known psychopathological conditions

Psychotherapy

In the practical guide to treatment of the game dependence of the Massachusetts Department of Health (2004), four variants of psychotherapeutic and therapeutic effects are distinguished:

• minimization of harmful consequences of the game for the player and his microsocium (family, friends, colleagues);
• Risk reduction in situations directly related to money;
• ability to cope with anxiety, depression, loneliness, stress through mastering new forms of behavior;
• satisfaction of the need for entertainment and communication through a less destructive and more balanced form of leisure.

Researchers at the University of Laval in Quebec (Hnjod et al. 1994, Sylvain et al 1997) have developed a treatment model, also based on cognitive behavioral therapy, which includes four components:

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

For persons with an easy degree of game dependence, psychodynamic psychotherapy is used as an option for "quick" treatment. It is believed that the game - the replacement of an unsatisfied need, which should be identified and implemented.

Of the other psychotherapeutic techniques, desensitization of eye movements (Henry, 1996), acupuncture, hypnosis, meditation, biofeedback, the use of exercise during leisure and the 12-step program of the Society of Anonymous Players should be noted.

The 12 Steps Program

According to a number of researchers (Stuart, Brown, 1988; Zaitsev VV, Shaydulina AF, 2003), one of the ways of self-improvement, changing attitudes to gambling and developing active opposition to pathological dependence is the ideology of a group of anonymous players with well-structured and carefully designed "12-step" program. A 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 program of anonymous players. The only condition for membership is the desire to stop the game and visit groups of anonymous players. For the first time, the anonymous players' societies were remembered in the USA in 1957. Currently, they operate in many countries, including Russia (Moscow, St. Petersburg, etc.).

It is believed that approximately 70-90% of visitors to anonymous player groups are eliminated during the first stages of participation in treatment and only 10% become active members. Of these, only 10% experience remission within a year or more (Brown, 1985).

Family psychotherapy. The compulsory components of an integrated approach to the treatment and rehabilitation of patients with gambling addiction include family psychotherapy. A.F. Shaydulina (2007) describes four stereotypes of family reaction ("negation", "active actions", "isolation", "adequate reaction"), which we have to deal with when working with patients and their families. Changing the behavior of family members, it was possible to gradually change the behavior of the player. The patients acquired new behavior skills, the motives for participating in the treatment and rehabilitation process and changing their own lives were strengthened.

In the SIC of Addiction (Rehabilitation Institute), the concept of rehabilitation potential has been developed, on the basis of which the strategy and tactics of medical and rehabilitation work are determined (Dudko TN). Depending on the level of rehabilitation potential, various variants of complex approaches are used, and also the question of the duration of the treatment and rehabilitation process. In all cases, the strategy and tactics of medical and rehabilitation care is based on a systemic approach that includes the use of principles and technologies for the rehabilitation of patients with addictive disorders.

Medicamental treatment of gambling

Apply neuroleptics, tranquilizers, anticonvulsants, antidepressants, neurometabolic drugs, blockers of opiate receptors.

In the pre-rehabilitation period (mainly curative) with abstinence disorders, pathological players mostly use psychopharmacotherapy. A combination of one of the stimulating antidepressants (prozac in a dose of up to 60 mg per day, paroxetine (paxil) in a dose of up to 40 mg per day, velbutrin at a dose of 225-450 mg per day, amineptin (surverector) at a dose of 100-500 mg per day ) with sedatives (amitriptyline in moderate doses), as well as with neuroleptics (stelazine, clozapine, chlorprotixen). Successfully used a combination of clomipramine with high enough doses of neuroleptics: perphenazine (etaperazine) at a dose of up to 60 mg, stelazine up to 30 mg, clozapine (leponex) at a dose of up to 75 mg. The choice of drugs is determined by the nature of depressive affect. Thus, with the prevalence of depression, the combination of clomipramine (anaphranil) is most preferable. With a precipitated anxiety, it is advisable to combine amitriptyline with clozapine (leponex) and phenazepam. From serotonergic antidepressants, a positive effect is achieved with the administration of fluvoxamine (fevarin). In addition, with a tendency to anxious-phobic reactions tranquilizers of the benzodiazepine series were used. Given the negative effect of tranquilizers on cognitive function, medications with minimal miorelaxing and sedative effects are preferred: tranxene up to 30 mg, alprazolam (xanax) in doses up to 1.5 mg, lexomil at a dose of up to 12 mg per day.

A significant place in the therapy of gambling is given to naltrexone. V.V. Khaiykov (2007) believes that the leading place in the self-report of gambling addicts taking naltrexone was occupied by:

• decrease in the brightness of gaming trance experiences, up to almost complete leveling of the emotional component of the game;
• a significant weakening of the fixation on the game with the ability to observe the environment, assess the situation, respond to calls, etc .;
• the emergence of the possibility of stopping the game to a catastrophic loss;
• the appearance of "fatigue from the game", "loss of interest," previously either not at all characteristic, or coming much later (2 or more times).

Treatment with naltrexone can be carried out, beginning with the withdrawal and post-withdrawal periods, the dosage is 50-100 mg per day, the duration of treatment is 2-16 weeks. In patients using naltrexone, the desire for play and anxiety decrease rather quickly, the mood improves. With an arbitrary reduction in the dose or discontinuation of naltrexone, the attraction was enhanced.

Treatment and rehabilitation of patients with a high level of rehabilitation potential is usually carried out in an outpatient setting. From psychotherapeutic methods preference is given to rational psychotherapy, auto-training, neurolinguistic programming, bodily-oriented therapy, keeping diaries, doing homework. An important place is taken by the technique 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 from group sessions, including visits to groups of anonymous players, but willingly agree to individual work and medication. 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 need additional and longer treatment. For the most part, these are persons with comorbid forms of addictions. But even if these are patients with mono-dependence, then, first of all, the method of rational psychotherapy should be used. Including, in addition to motivating for treatment, a thorough study of the hyimites and syndromes of the disease, the medical and social consequences of gambling. Medication is prescribed for a long time. To the above methods of psychotherapy, you can add hypnosis sessions (after ascertaining the degree of hypnosis and setting the patient to this kind of psychotherapy). Patients are recommended to visit groups of anonymous players. Conducting family therapy - in all cases, a mandatory condition. Naltrexone is prescribed courses for two to three months with interruptions of up to two weeks, during which it is necessary to investigate the dynamics of the mental state and attitudes towards the game. With stable remission, naltrexone treatment continues for 6-9 months. In the preventive period of rehabilitation in cases of acute exacerbation, small doses of anticonvulsants are recommended (carbamazepine in a dose of 50-150 mg per day), with the appearance of affective disorders - antidepressants [citalopram in 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 per night], small doses of tranquilizers (phenazelam, afobazol, diazepam, phenibut).

Effectiveness of gambling treatment

Igromania - a disease graded. Persistent 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 gambling sufferers contain a number of contradictory points of view, which is largely due to the complexity of the organization of the treatment rehabilitation process and the difficulty of observing its basic principles. Often, only certain methods or technologies are evaluated: behavioral therapy, psychodynamic approaches, the work of groups of anonymous players, drug treatment, etc. According to Bughold (1985), when using the psychotherapeutic methodologies of communities of anonymous players, remission is achieved in 10% of patients. Only through the use of combination therapy, including individual, collective therapy "and the mandatory participation in the work of groups of anonymous players, you can achieve higher efficiency (55%).

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

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

[17], [18], [19], [20], [21],

What is the prediction gambling?

The forecast of game dependence is determined by many factors.

Signs of a good prognosis when involving patients in the treatment and rehabilitation program:

• high level of rehabilitation potential, including successful heredity, constructive family, positive dynamics of physical and personal development, good premorbid, social and professional anamnesis;
• later the formation of pathological dependence, the presence of spontaneous remissions, light or medium degree of disease (stage of compensation or subcompensation);
• strong marital relations, the desire to preserve the family, attachment to the family;
• the availability of work and a system of social and psychological support from the family and other significant persons;
• absence of debts or real ability and aspiration to pay off debts (mental discomfort in the presence of money debts);
• stable motivation for treatment, ability to be in the formed motivational field and use the experience of latent positive motives for refusing to participate in gambling;
• long-term participation in treatment and rehabilitation programs, visits to groups of anonymous players.