Gambling, wagering something of value on an event whose outcome is determined by chance, is a very common leisure activity in most cultures. For the vast majority, gambling remains a past time but for a minority it can progress to problematic gambling or even gambling addiction.

The British Gambling Prevalence Survey [1] (2007) showed that nearly 70% of adults had gambled in the past 12 months and that the most popular gambling activities were National lottery (57%), scratch cards (20%), betting on horse races (17%) and fruit/slot machines (14%). Gambling cuts across age, gender, class and race. The British Gambling Prevalence Survey (BGPS) also found the prevalence of problem gambling (defined as gambling that disrupts or damages personal, family or recreational pursuits) to be around 0.6%, with a further 6.5% found to be at risk of developing problem gambling in future. This prevalence figure is slightly lower than found in most international studies where it is between 1 and 3%. [2] Problem gambling is more common in patients with comorbid psychiatric disorders and in those with medical problems: studies showing prevalence rates in primary care attendees of 6% [3] and between 10% and 15% in substance misusing populations. [4]

Although there exist some nosological and conceptual ambiguity as to whether problem gambling is an addictive, impulse control or obsessive-compulsive disorder, from an assessment and treatment viewpoint, it is perhaps best conceptualized as an addiction. And so just like substance use, gambling behaviours too exist on a scale of escalating severity, ranging from normal/recreational gambling, through problem gambling to gambling addiction. There is some consensus regarding the definitions of problem and pathological gambling: Problem gambling is defined as gambling that disrupts or damages personal, family or recreational pursuits; and pathological gambling (or gambling addiction) is defined as persistent and recurrent maladaptive gambling behaviour, characterized by some of the following: preoccupation with gambling, need to gamble with increasing amounts, inability to cut back or stop, 'chasing' losses, lying about gambling, adverse social and financial consequences, etc. [5]

Gambling addiction can negatively impact on the individual, family and society. Physical ill health [6] (such as gastrointestinal symptoms, cardiovascular symptoms and psychosomatic symptoms) and psychiatric comorbidity [7] are common. Depression has been noted in up to 50% of gambling addicts; anxiety-spectrum disorders, substance misuse and personality disorders are also very common. Psychiatric comorbidity in gambling addicts is often bidirectional. Excessive gambling can affect addicts' finances leading to debts, bankruptcy, job losses and relationship breakdowns. Some addicts commit crime to feed their habit. It is further estimated that for every gambling addict between 8 and 10 others (including family, friends and colleagues) are also negatively affected. [8] Spousal violence, and children of gamblers manifesting substance misuse, emotional and behavioural difficulties are also common. [9]

Despite all the above, sadly, gambling - related problems often go undetected and unaddressed, thereby burdening the individual and others. Various reasons have been given for problem gamblers remaining 'hidden': problem gamblers are reluctant help seekers and even when they do their presentations are seldom obviously attributable to gambling, lack of health care professionals' awareness of problem gambling and its varying presentations, practitioners' limited knowledge of how to identify and manage these patients, and resource restrictions.

The primary purpose of this paper is to raise awareness of gambling addiction among non-specialists. We also attempt to equip the non-specialist with basic knowledge about screening, assessment and treatment of gambling addiction.

Luke (anonymised) is a 39-year-old, separated British man. He is unemployed and lives on his own. Luke has a longstanding history of heroin and gambling addiction. Given in the section below is an objective account of his heroin addiction, and provided in a later section is Luke's own description of his gambling addiction which is the main subject of this case report.

Luke was first seen in our drug and alcohol service in 1999, following a referral from his general practitioner (GP). At initial assessment, he reported a 2 - year history of heroin, crack cocaine and alcohol use. He had started using cannabis and solvents as a teenager, and later started drinking excessively. By his late 20s he started smoking heroin and crack cocaine and soon became dependent on both substances. He was smoking between 4 and 6 bags (0.8 to 1.2 grams) of heroin and up to £40 worth of crack cocaine a day. He had never injected any drug. He had cut down his drinking to 8 units of alcohol a day. He gave no history suggestive of comorbid medical or psychiatric disorders. He had numerous cautions and convictions for drug-related offences, and was thousands of pounds in debt. His drug use was beginning to place considerable strain on his relationship with his girlfriend. He also gave a history of excessive gambling, predominantly on slot machines and roulette. Although his gambling behaviours had impacted negatively on his marital relationship and his finances, and had led to him committing several crimes, he refused any help to address this problem. Details of his gambling problem are given in the sections below.

Luke derives from a family of three; he has two younger sisters. His father died in 2008 and his mother lives abroad. He has a good relationship with his mother and one of his sisters. His maternal grandfather and two maternal uncles suffered from alcoholism but there is no other family history of substance use or mental health problems. Luke was born and raised locally, and attended normal mainstream schools. He was expelled from school at 14 for repeated disruptive behaviour and truancy. He left school with no qualifications. After leaving school, he worked sporadically for a few years. At the age of 21, he was spotted playing football by a professional scout and was offered terms to turn professional. He played in the reserves for several football clubs before quitting, as his drug and drink problems got worse.

Since 1999, Luke has been in treatment with our service for heroin dependence and crack cocaine misuse. This has been punctuated by episodes of disengagement, spells in prison and spells abroad. Given below is Luke's own account (verbatim) of his addiction to gambling and its impact on his life:

I have had a gambling addiction since I was 7 or 8 years old. There was an arcade open at the local shopping centre in the market and I used to spend every spare penny I had in there. I started doing it simply because the arcade opened in the market in the town centre and me and my friends used to hang around down there and it slowly got to be an addiction, you know. It was exciting because I was a young child really. Then it progressed over the years into cards, casinos and mainly fruit machines. So, I mean, I did have a very bad addiction to fruit machines and any kind of gambling really except for the horses because I don't know much about them. It just progressed from there. You think you are learning how to play them and you know what you're doing and then you think you can beat them then and that is what causes the addiction, because you think you can beat the machines, but you can't, and when you realize you can't, that's when you start coming out of the addiction then. What drives the addiction is the fact that you think you can beat the machines.

If I went two days, I would stay in there from 9 o'clock in the morning until it closed at 7 o'clock at night. If I got involved playing a £200 jackpot machine or a £1000 jackpot machine, sometimes I could play for 3 or 4 days solid, just leaving last thing at night and making sure I was there first thing in the morning before anyone else could get on it to make sure that they didn't win my money before I got there. One time I spent £3,000 - £4,000 over 2 or 3 days playing the same machine. That is just one machine. It was a £500 jackpot machine. Another time, just playing a £25 jackpot machine, I put £1,500 in but many times I've done things like that. You are just chasing all the time. You think you're going to get it back and you know, it's impossible to get back because you've put that much money in by the time, you know, you're not going to win it back. It's just something in your mind that's telling you you're going to get it back.

Gambling has definitely ruined my life. I have had to commit crimes to get the money to gamble. My wife was sick of my gambling. We would go on holiday and I'd spend all day playing the machines and I would think it was ok and not realize that it wasn't and how it was affecting my family life. Financially, oh yeah, I mean you play until you are skint basically, you know, you are well into a machine and you'll just play until you have no money left, and then borrow off other people, and so yeah, financially it does have a big impact on you, definitely. And also I can't remember the number of times I got into trouble with the police, trying to find money to gamble.

Yeah, I mean I'm not so bad now because I've really calmed down because I've realized that I am never going to win a fortune playing fruit machines and I'm always going to lose in the long run, you know, no matter how well I know the machines or how good I think I am at playing them. I've realized that I am not going to beat them. I just lost so much money over so many years and I realized that I was losing a lot more than I was winning and I was never ever going to be able to beat the machines. You know, you have to realize it's an addiction and you are never going to beat them and so you have to realize that, and that's why I stopped. (Luke)

In this section, we will discuss in brief what the non specialist needs to know about screening, assessment and treatment of gambling.

Screening
We do not recommend that all patients seen by non-specialists be screened for gambling addiction but we suggest that high risk patients should be screened - i.e. those presenting with non-specific psychosomatic symptoms, or those with psychiatric conditions such as depression, anxiety and substance misuse. Several screening tools are used to screen for problem gambling but the most commonly used is the SOGS (South Oaks Gambling Screen). [10] This is a 20-item questionnaire that can be self-administered and has robust psychometric properties. But we recommend, because of its brevity, the Lie/Bet screen. [11] The Lie/Bet screen is a 2-question screening instrument; the questions are - 'Have you ever felt the need to bet more and more money?' and 'Have you ever had to lie to people important to you about how much you gamble?' A positive response to either question identifies a pathological gambler. Finally, please note that screening is only the initial step in the diagnostic process, and patients who screen positive should be assessed in greater detail and/or referred on (see next section).

Assessment
A detailed discussion of the assessment of gambling addiction is beyond the remit of this paper but see Box 1 for key aspects of assessment. [12]

Treatment
Unless resources permit, it is best to refer all patients who screen positive (with or without further detailed assessment) to specialists for further management. Specialist treatment services for gambling addicts are limited but there are some NHS (in the UK) and various non-statutory sector agencies that offer specialist input to gamblers and their families. The best advice to the non-specialist who identifies (through screening and/or assessment) a problem/pathological gambler would be to refer the patient to the local addiction service or a specialist gambling service, if one is available. Many of the non-statutory agencies take self-referrals (from patients) so patients could be sign-posted to these services. GamCare (www.gamcare.org.uk) and Gamblers Anonymous (GA) (www.gamblersanonymous.org.uk) are two of the most common non-statutory gambling treatment services available in the UK. GamCare is a non-governmental organization and a charity that 'provides support, information and advice to anyone suffering through a gambling problem.' Services offered by GamCare include a telephone helpline, net line, forums, chat rooms, counseling (face to face and online), psychotherapy, group therapy and support for families. Gamblers Anonymous (GA) is a self-help group modeled on Alcoholics Anonymous. It is based on the '12-step' model' and sees total abstinence as the treatment goal. GA also runs support groups for families and friends affected by their loved one's gambling (Gam-Anon).

Treatments for problem gambling can be either pharmacological or psychological and psychological interventions are the mainstay of treatment.

Pharmacological treatments: Serotonin, noradrenaline, endogenous opioids and dopamine have all been implicated in the pathophysiology of problem gambling and hence pharmacotherapies have targeted these neurochemical systems; [13] and they include SSRIs (such as paroxetine, fluvoxamine and sertraline), opioid antagonists (naltrexone), mood stabilizers (such as lithium, carbamazepine and valproate) and atypical antipsychotics (such as olanzapine). Although these drug trials have found promising results, no drug, to date, has been approved for use in problem gambling in the UK or USA. Most often, the choice of pharmacotherapy is dictated by the type of comorbid psychiatric condition.

Psychological treatments: These include behavioural treatments, cognitive treatments and combined cognitive behavioural interventions (most commonly used). Problem gamblers have been found to have various cognitive distortions or biases such as illusion of control, false beliefs about randomness and chance, superstitious beliefs and so on. As gambling is primarily about judging the probability of outcomes and decision making, it naturally follows that cognitive distortions will lead to impaired judgment and poor decision making. Hence cognitive treatments attempt to correct these cognitive distortions. Cognitive behavioral treatments attempt to alter the gambler's cognitions and behaviours. [14]

Gambling tends to be a 'hidden' addiction and gambling addicts' needs often go unmet. We hope we have succeeded in raising clinicians' awareness of gambling addiction, thereby ensuring that gamblers' needs will be recognized and adequately addressed.

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13. Petry NM. Pathological gambling: Etiology, comorbidity and treatment. Washington, DC, American Psychological Association, 2005, p. 415.    
14. Ladouceur R, Sylvain C, Boutin C, Doucet C. Understanding and treating the pathological gambler. John Wiley & Sons. England;2002.    

I thank Luke (anonymised) for his permission to publish this case report.