Clinical and Behavioral Evaluation of Pathological
Gambling in Barcelona, Spain Angels GonzMez Ib~fiez Licenciada con grado en Psicologia Pilar V. Mercad6 Licenciada en Psicolog{a M ~- Neus A y m a m l SanromA Licenciada en Psicolog[a Carolina Pastor Cordero Licenciada en Psicolog{a Ciutat Sanitgzria de Bellvitge, Hospital Pr{nceps d'Espanya, Servei de Psiquiatria Spain
This paper assesses both the clinical characteristics and gambling behavior of 45 pathological gamblers (40 male, 5 female, average age 41) in a psychiatric hospital in Barcelona, Spain. These pathological gamblers tend to have other addictions and psychiatric disorders in addition to their pathological gambling. Suicidal ideation and attempts were one of the most frequent complications with these patients. Slot and fruit machines were found to be the most preferred form of gambling. Loans and crime were frequently used by the gambler to finance his or her gambling. Nevertheless, the
Address correspondence and reprint requests to Angels GonzSlez Ib~tfiez, Villarroel, 45, 3~ 5% 08011 Barcelona, Spain.
Journal of Gambling Studies Vol. 8(3), Fall 1992 9 1992 Human Sciences Press, Inc.
299
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JOURNAL OF GAMBLING STUDIES
gambler is rarely aggressive, and legal problems resulting from serious crimes are the exception. The profile presented is similar to that found among pathological gamblers in other countries.
INTRODUCTION Pathological gambling is a disorder which is attracting more and more interest from health professionals, especially in those countries where gambling has been legalized and where it is a popular and socially accepted activity. Estimates concerning the prevalence of this disorder in the U.S. run from 0.77% in 1974, to 3.4% in 1985 (Commission on the Review of the National Policy Towards Gambling, 1976; Sommers, 1988). T h i s justifies the attention which has recently been directed toward this disorder and which has resulted in the proliferation of treatment programs for pathological gambling. The profile of the pathological gambler in the 1970's was characterized by a person aged between 41 and 50, male, married, with an average education, and employed who told lies persistently to hide his gambling behavior and who had been, as a general rule, exposed to gambling since early childhood (Nora, 1984). T h e most preferred forms of gambling among male pathological gamblers in the U.S. are: horse races, sports betting, and cards and dice (Nora, 1984); whereas females prefer cards, slot or poker machines, horses and lotteries (Lesieur, 1988). The pathological gambler has been described as showing a number of different psychosomatic symptoms such as digestive disorders, headaches, arterial hypertension, etc. (Lorenz and Yaffee, 1986; 1988). Gamblers tend to consult mental-health professionals more often than the general population, and tend to present psychiatric disorders, especially major depressive disorder, hypomanic disorder, alcohol abuse and panic disorder (McCormick, Russo, Ramirez & Taber, 1984; Linden, Pope & Jonas, 1986). In addition, the rate of suicide attempts is high among pathological gamblers (Custer and Custer, 1978). Deterioration of family life is usually evident in the gamblers' history, with a high incidence of separation and divorce compared to the general population (Kallick, Suits, Dielman & Hybels, 1979). They also show physical violence within the family nucleus and approx-
ANGELS GONZALEZ IBAI~IEZ,ET AL.
301
imately 25 % of children born into families of gambling parents present behavioral problems such as failure to adapt to school, alcohol or drug abuse, gambling delinquency, etc. (Lorenz and Yaffee, 1988; Lorenz and Shuttlesworth, 1983; Lorenz, 1981). The social cost of pathological gambling is considerable if we take into account that the involvement of these people in gambling severely limits their contribution to society; in addition the financial and social problems demand professional attention and help. The unemployment rate for gamblers is double that of the general population (Volberg and Steadman, 1988). Even those who do keep their jobs are often implicated in embezzlements, forgeries and robberies which are the most common crimes committed by gamblers in order to finance their gambling. In fact, some studies carried out in prison environments observe up to 30% pathological gamblers in these institutions, and 13 % of prisoners admit that they are in prison because of gambling related problems (Lesieur and Kline, 1985). The present day characteristics of gambling in Spain are different from those in Anglo-Saxon countries, due to its particular gambling traditions. Various types of gambling are legal in Spain, including the following: Slot machines in bars and arcades, Bingo, Casinos, National lotteries and the Lottery for the blind. All of these forms of gambling are easily accessible, particularly slot machines, which one may find in almost any bar in the country. In table one, we may observe the degree of expense involved in these forms of gambling. This study aims to evaluate (for the first time in Spain) the most relevant characteristics of this disorder by observing a sample of pathological gamblers.
METHOD
Samp/e A total of 45 patients, who came to the Pathological Gambling Unit of the Psychiatry Service at the Hospital of Bellvitge, were evaluated. Forty patients were male (89%) and 5 were female (11%). The majority of these patients were between 30 and 52 years old. The mean age was 41.
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Table 1 Legal Gambling Total Gross Income in Spain. (Total amount gambled less prizes.) In millions of pesetas (1 million pesetas = approximately $I0,000) not deflated
Slot machines in bars and arcades Bingo Casinos (incl. slot machines) National Lotteries Lottery for the blind (O.N.C.E. Coupon) Total T O T A L (deflated)
1987
1988
1989
1990
272,250 137,842
297,960 154,110
347,750 172,568
360,421 185,811
35,237 102,578
39,640 103,918
44,078 120,414
43,067 136,313
96,990 644,987 644,987
114,528 710,156 688,967
119,279 804,089 699,557
135,200 860,812 688,650
Figures provided courtesy of the Comisi6n Nacional del Juego, Ministerio del Interior.
Out of this sample, 11 patients (24.5%) did not finish their primary education, 20 patients (44.5%) finished their primary education and 14 (31%) went on to secondary education. Twenty patients (44 %) were unskilled workers, 18 (40 %) were skilled workers and only 3 of them (6%) were professionals, civil servants or entrepreneurs. Homemakers and retired men constituted 10% of the sample. With regard to their marital status, 10 patients (22 %) were single, 30 were married (67 %), 3 were separated or divorced (7 %) and 2 of them (4 %) widowed. All of the patients came voluntarily for treatment, which in all cases was the first for their gambling problem. All of them were gambling regularly at the time of evaluation.
PROCEDURE Initially, a complete psychopathological study, which included the diagnostic criteria from DSM-III-R for pathological gambling (American Psychological Association, 1987), was carried out. Later the clinical aspects and the specific behavior relating to pathological gambling were evaluated by carrying out interviews which focused on the pre-
ANGELS GONZALEZ IBAI~IEZ, ET AL.
303
vious six months. The information relating to gambling behavior, obtained directly from the patient, was later corroborated with that from close family members, or by others who were intimately related with the patient. It should be noted that we did not find any discrepancies between the information taken from the two interviews, perhaps because all of the patients came voluntarily and perhaps also because they were aware of their disorders. After the behavioral and clinical evaluation of the disorder, the patients were integrated into a cognitive and behavioral treatment program, specifically designed for pathological gambling. This is summarized in another publication (Gonzalez Ib~tfiez, 1988).
RESULTS
A total of 37 patients (82%) had never undergone psychiatric hospitalization before this treatment. The others had been sent to hospital at least on one occasion previously, the average being two times. Five patients (11%) owed their hospitalization to suicide attempts related to gambling, while 3 ( 7 % ) w e r e hospitalized because they presented a clinical disorder which required hospital treatment. Suicidal ideation was noted in a total of 19 patients (42 %), who admitted having these thoughts on repeated occasions, either with or without ideation of a specific plan to carry them out. In addition, 10 patients (22%) told us of suicide attempts caused by gambling with an average of two attempts per patient, some of whom required hospital treatment. It should be pointed out that none of the sample had tried to commit suicide for reasons apart from gambling. With regard to substance abuse, 26 patients (58 %) admitted to the frequent abuse of alcohol while the others only rarely abused it, if at all. Eighty-six percent of the gamblers were habitual smokers and only 4 patients (9%) had been habitual consumers of cannabis. No other forms of addiction were noted. Concerning specific variables related to gambling behavior, we noted that the gamblers in our sample, in general, took a considerable length of time to seek help once they had a gambling problem. To be
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more specific, 30 of our subjects (67%) sought help 1 to 5 years after the start of their gambling problem. Ten of them (22 %) had waited for between 6 to 10 years and five patients (11%) told us that they had had problems for more than 10 years. The distribution of subjects in terms of the type of gambling they participated in before the time of the evaluation is reflected in Table two. These figures illustrate that the preferred type of gambling among the patients in our sample was slot and fruit machines. Generally, the type of gambling in which the gamblers developed their problem seems to remain constant throughout the period in which they gambled, although the type of gambling varied among individuals. To be specific, 32 patients (71%) indicated having, at the time of evaluation, the same gambling problem as when they began to show excessive gambling behavior. The other 13 individuals (29%) had, at the time of the evaluation, a different gambling problem than when they began. The majority of the individuals who had changed their type of gambling, changed to gambling with slot and fruit machines more than to any other type of gambling. This was so for 10 of the 13 subjects who had changed their gambling preference (77%). Furthermore, 27 patients (60%) maintained excessive gambling behavior with types of gambling different from the type preferred initially; the two were played simultaneously, or else the subsequently preferred type was used as a substitute when the initially preferred form of gambling was unavailable. Patients spent an estimated average of 63,428 pesetas per month, with a standard deviation of 44,851 pesetas, on gambling (Note 110 pesetas = $1 U.S.).
Table 2 Types of gambling among the subjects in our sample
S bj ts Gambling type
N
%
Slot and fruit machines Bingo Casinos Illegal card games Lotteries TOTAL
30 4 2 7 2 45
66.6 8.8 4.4 15.5 4.4 100
ANGELS GONZALEZ IBAlC,IEZ, ET AL.
305
The frequency of gambling in this sample was high. Twenty subjects (44 %) told us that they went several times a day to gamble, 10 patients (22 %) gambled generally once a day, 14 patients (31%) went several times per week, while only one patient (3 %) went only several times a month. Our prototype pathological gamblers usually gambled alone (89 %), always in the same gambling locations (62 %) and openly said that they enjoyed themselves while gambling (82 %), although they felt guilty as a result of gambling, or because of its consequences (80%). They did not usually maintain behavioral rituals when they gambled (98 %), although they smoked tobacco while gambling (80 %); also, a considerable percentage consumed alcohol while gambling (47%). They lied systematically to hide their gambling, or aspects related to it (98%), and they generally incurred debts as a result of gambling (76 %). They usually incurred debts with close family (42 %), at work (33 %), with banks (27 %) and with their friends (22 %). They acquired debts to a lesser extent within their gambling circle (13 %), with finance companies (2 %), or by using other means of financing (2 %). Another method widely used by our patients to obtain gambling money was to steal from or swindle the family, friends and/or their work place, without resorting to violence. A smaller proportion committed forgery (4 %), embezzlements (2 %), or they resorted to verbal or physical aggression in order to steal from their own family, friends and/or place of employment (2%). It should be noted that none of these patients committed a criminal act against people unknown to them and 21 of the subjects (47%) had never committed any kind of crime. In spite of the fact that there is a high proportion of gamblers who commit criminal acts, only 3 patients (7%) had past or present legal problems.
DISCUSSION
Although we have attempted in this research to evaluate the clinical and behavioral variables of pathological gamblers, we are aware that the size of the sample, and its particular demographic characteristics, do not allow us to generalize from these results. Given that the area which is covered by the Hospital of Bellvitge essentially
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corresponds to a lower-middle class area, we consider that some of the data obtained describes more the demographic characteristics of this particular population rather than the distinctive characteristics of the population of pathological gamblers. A study of a sample drawn from the general population is needed. Nevertheless, it seems that pathological gambling affects people of all ages, although we found that the major proportion of our sample were mainly men around 40 years old. This data corresponds with the data given in almost all the publications on pathological gambling, where males represent the majority, if not the entirety, of the patients in treatment programs. However, we do not think that from this it should be understood that a major proportion of pathological gamblers is male, but rather, as happens with other forms of addiction, it may be explained by a smaller demand for treatment from females, because of the greater social censure women suffer when they are known to have addictive problems. In fact, it has been reported that approximately a third of pathological gamblers (in the U.S.) are women (Lesieur, 1988), although this proportion is not reflected in the n u m b e r of females partaking in the treatment programs. The presence of other psychiatric disorders among pathological gamblers seems to be a consistent finding in the studies which have considered co-morbidity. Affective disorders, substance abuse, and various personality disorders are the most frequently mentioned (McCormick et al., 1984; Linden et al. 1986; Taber, McCormick, Russo, Adkins & Ramirez, 1987; Taber, McCormick & Ramirez, 1987). In our sample the presence of depressive symptomatology was the most frequent, followed by alcohol abuse and personality disorders. The complications resulting from excessive gambling can easily cause depressive symptoms. However, a hypothesis contrary to this is also possible, namely that gambling provides a means by which patients can alleviate their depressed state (Russo et al. 1984). In our sample we observed a high rate of suicide attempts. Twenty-two percent of the patients had previously tried to commit suicide. This rate is similar to that in other studies. In a previous study, for example, 18 % of the members of Gamblers Anonymous and 24% of the Veteran's Administration Hospital patients admitted having tried to commit suicide (Custer and Custer, 1978). Furthermore, it should be noted that all our cases of attempted suicide were connected
ANGELS GONZALEZ IBAI~IEZ, ET AL.
307
with gambling or its consequences: no other suicide motive was noted among the patients. If we take into account that the proportion of suicides in the Spanish population is less than 10/100,000, and that the ratio of failed to successful suicide attempts is 8:1 (Freedman, Kaplan & Sadock, 1982) we can conclude that the risk of suicide among these patients was high. Likewise, a tendency towards dual addiction is often recorded in the gambling literature. A high incidence of pathological gambling (9 %) or at least the presence of problems related to gambling (10 %), is frequently found among the patients who are hospitalized for substance dependence (Lesieur, Blume & Zoppa, 1986). In addition, some studies report that 47% of pathological gamblers in treatment programs show signs of substance abuse or dependence (McCormick et al., 1984). In our sample we also observed a tendency for the patients to exhibit addictive behavior, especially a high consumption of alcohol. This relationship between alcohol abuse or dependence and excessive gambling has been repeatedly noted in the literature on pathological gambling (Lesieur, Blume & Zoppa, 1986). Other toxic substances were not consumed in large quantities by our patients, with the exception of tobacco, from which we may deduce that, among the pathological gamblers studied, there exists a tendency to become addicted to those substances which are socially accepted and which are consumed, to a certain extent, by the rest of the population. Based on the analysis of the gambling characteristics studied, we found that a long period elapses between the time the disorder begins and the time the individual finally comes for treatment: this was more than 6 years for 33 % of the patients studied. Custer (1984) reports that some 5 years usually pass between the time a person begins gambling until there is a definite loss of control. In addition, the gambler is reluctant to accept his or her gambling as problematic, hiding and minimizing it in the presence of others. Finally there is an ignorance among the general population regarding the existence of this disorder and the possibility of treatment, which can make it difficult for an individual to recognize the disorder. All this, to some extent, explains why gamblers have had a long history of gambling when they first come for treatment. With respect to gambling preferences, slot and fruit machines were the main form of problematic gambling for the majority of the gamblers at the time of the evaluation. In order of importance, slot
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machines were followed by illegal gambling, bingo and, to a lesser extent, gambling in casinos or on lotteries. Differences are seen when the most popular types of gambling among our gamblers are compared with those observed among pathological gamblers in other countries, where other types of gambling, such as horse-racing, are more popular (Lesieur, 1988). These differences are a reflection of different gambling traditions in our country. The estimated average of 63,428 pesetas/month spent on gambling by our patients is only an approximate figure. Nevertheless, the figure is considerable if we take into account the socio-economic status of our patients, the greater part of whom are unskilled workers, and if we also consider that this n u m b e r is above the current established m i n i m u m salary in our country of 53,250 pesetas/month. Concerning the frequency with which our patients gamble, we found that the greater part of our sample gambled daily (66%); if we include the weekly gamblers this figure rises to 97 %. These figures are probably influenced by the most popular type of gambling, which as we have seen, is slot and fruit machines, whose availability and gambling features result in their frequent use. Most forms of behavior connected with gambling were consistent with those reported by the majority of publications on the subject. In general, the characteristics of our patients tally, by and large, with those reported by Custer (1984) and Lesieur (1979). The gamblers usually gamble alone, in the same gambling locations, with feelings of guilt because of their conduct, which they try to hide by lying once their gambling has become excessive, to the point of pledging the family's or others' possessions and property in order to continue gambling. Frequently they incur debts in order to finance their gambling, first with family or in the work-place, then by using legal financial sources, and, finally, they resort to fraud and other crimes when other sources for obtaining money have been exhausted and their desire to gamble has still not been satisfied. However, these criminal acts rarely involve persons unknown to the individual or violence and are appropriations of the family's and friends' possessions. According to Custer (1984) gamblers turn to crime when they find themselves in the "desperation phase," that is, the last phase of a gambler's involvement in gambling, which occurs as the problem characteristics of the pathological gambler have become fully evolved. In our sample we found that a considerable n u m b e r of patients have committed criminal acts on at
A N G E L S G O N Z t k L E Z IBAI~IEZ, E T AL.
309
least one occasion. However, these acts rarely involve legal complications, certainly because the crimes committed are not of a serious nature, and the majority of the injured parties are often intimately related with the gambler. Hence, the crimes are not reported. In fact, we found that those patients who effectively had legal problems had committed criminal acts at work. In conclusion, the profile of the pathological gambler which emerged from our study conformed to a large extent to the one found in the published literature on pathological gambling, and the differences found in the gambling behavior, for instance, in the form of gambling most often used by the gambler, may simply be due to the different traditions and types of gambling available in each country.
REFERENCES American Psychiatric Association. (1987). Diagnostic and statistical manual, (3rd edition revised). Washington, D.C. Commission on the Review of the National Policy Towards Gambling (1976). Gambling in America. Washington, D.C.: U.S. Government Printing Office. Custer, R. & Custer, L. (1978). Characteristics of the recovering compulsive gambler: A survey of 150 members of gamblers anonymous. Paper presented at the Fourth Annual Conference on Gambling, Reno, Nevada. Custer, R.L. (1984) Profile of the pathological gambler.Journal of Clinical Psychiatry, 45, (12 pt 2), 35-38. Freedman, A.N., Kaplan, H.I.. & Sadock, E.J. (1982). Tratado depsiquiatria. Tomo II. Barcelona: Salvat Editorial. Gonz~ilez Ib~ifiez, A. (1988). Joc patol@ic: Una nova addiccid. Barcelona: Tibidabo Edicions. Gonzgtlez Ib~ifiez, A. (1989). Juego patoldgico: Una nueva addicidn. Madrid: Canal Comunicaciones, S.A. Kallick, M., Suits, D., Dielman, T. & Hybels, J. (1979)A survey of American gambling attitudes and behavior. Ann Harbor, MI: Institute for Social Research. Lesieur, H. (1979). The compulsive gambler's spiral of options and involvement. Psychiatry, 42, 79-87. Lesieur, H. (1988). The female pathological gambler. In W.R. Eadington (Ed.). Gambling research, Vol. 5, (pp. 230-258). Reno, Nevada: Bureau of Business and Economic Research, University of Nevada. Lesieur H. & Klein, R. (1985). Prisoners, gambling and crime. Paper presented at the Annual Meeting of the Academy of Criminal Justice Sciences, Las Vegas, Nevada. Lesieur, H., Blume, S. & Zoppa, R. (1986). Alcoholism, drug abuse and gambling. Alcoholism: Clinical and Experimental Research, 10, 33-38. Lesieur, H. (1988). Report on pathological .gambling in New Jersey. Report to the New Jersey Governor's Advisory Commission on Gambling. Linden, R., Pope, H. & Jonas, j . (1986). Pathological gambling and major affective disorder: Preliminary findings. Journal of Clinical Psychiatry, 41, 201-203. Lorenz, V. (1981). Differences found among Catholic, Protestant and Jewish families of pathological gamblers. Paper presented at the Fifth National Conference on Gambling and Risk Taking, Lake Tahoe, Nevada.
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Lorenz, V. & Shuttlesworth, D.E, (1983). The impact of pathological gambling on the spouse of the gambler. Journal of Community Psychology, 11, 67-76. Lorenz, V. & Yaffee, R. (1986). Pathological gambling: Psychosomatic, emotional and marital difficulties as reported by the gambler. Journal of Gambling Behavior, 2, 40-49. Lorenz, V. & Yaffee, R. (1988). Pathological gambling: Psychosomatic, emotional and marital difficulties as reported by the spouse. Journal of Gambling Behavior, 4, 13-26. McCormick, R., Russo, A., Ramirez, L. & Taber, J. (1984). Affective disorders among pathological gamblers seeking treatment. AmericanJournal of Psychiatry~ 141, 215-218. Nora, R. (1984). Profilesurveyon compulsivegamblers. Paper presented at The Seventh International Conference on Gambling and Risk Taking, Reno, Nevada. Russo, M.A., Taber, J.F., McCormick, R.A. & Ramirez, L.F. (1984). An outcome study of an inpatient treatment program for pathological gamblers. Hospital and Community Psychiatry, 35,
(8), 823-827. Sommers, I. (1988). Pathological gambling: Estimating prevalence and group characteristics. The InternatlonalJournal of the Addictions, 23, 477-490. Taber, J.F., McCormick, R.A. & Ramirez, L.F. (1987). The prevalence and impact of major life stressors among pathological gamblers. The InternationalJournal of the Addictions, 22, 71-79. Taber, J.F., McCormick, R.A., Russo, M.A., Adkins, BJ. & Ramirez, L.F. (1987). Follow-up of pathological gamblers after treatment. AmericanJournal of Psychiatry, 144, 757-761. Volberg, R. & Steadman, H. (1988). Refining prevalence estimate of pathological gambling. American Journal of Psychiatry, 145, 502-505.
Gambling in Barcelona, Spain Angels GonzMez Ib~fiez Licenciada con grado en Psicologia Pilar V. Mercad6 Licenciada en Psicolog{a M ~- Neus A y m a m l SanromA Licenciada en Psicolog[a Carolina Pastor Cordero Licenciada en Psicolog{a Ciutat Sanitgzria de Bellvitge, Hospital Pr{nceps d'Espanya, Servei de Psiquiatria Spain
This paper assesses both the clinical characteristics and gambling behavior of 45 pathological gamblers (40 male, 5 female, average age 41) in a psychiatric hospital in Barcelona, Spain. These pathological gamblers tend to have other addictions and psychiatric disorders in addition to their pathological gambling. Suicidal ideation and attempts were one of the most frequent complications with these patients. Slot and fruit machines were found to be the most preferred form of gambling. Loans and crime were frequently used by the gambler to finance his or her gambling. Nevertheless, the
Address correspondence and reprint requests to Angels GonzSlez Ib~tfiez, Villarroel, 45, 3~ 5% 08011 Barcelona, Spain.
Journal of Gambling Studies Vol. 8(3), Fall 1992 9 1992 Human Sciences Press, Inc.
299
300
JOURNAL OF GAMBLING STUDIES
gambler is rarely aggressive, and legal problems resulting from serious crimes are the exception. The profile presented is similar to that found among pathological gamblers in other countries.
INTRODUCTION Pathological gambling is a disorder which is attracting more and more interest from health professionals, especially in those countries where gambling has been legalized and where it is a popular and socially accepted activity. Estimates concerning the prevalence of this disorder in the U.S. run from 0.77% in 1974, to 3.4% in 1985 (Commission on the Review of the National Policy Towards Gambling, 1976; Sommers, 1988). T h i s justifies the attention which has recently been directed toward this disorder and which has resulted in the proliferation of treatment programs for pathological gambling. The profile of the pathological gambler in the 1970's was characterized by a person aged between 41 and 50, male, married, with an average education, and employed who told lies persistently to hide his gambling behavior and who had been, as a general rule, exposed to gambling since early childhood (Nora, 1984). T h e most preferred forms of gambling among male pathological gamblers in the U.S. are: horse races, sports betting, and cards and dice (Nora, 1984); whereas females prefer cards, slot or poker machines, horses and lotteries (Lesieur, 1988). The pathological gambler has been described as showing a number of different psychosomatic symptoms such as digestive disorders, headaches, arterial hypertension, etc. (Lorenz and Yaffee, 1986; 1988). Gamblers tend to consult mental-health professionals more often than the general population, and tend to present psychiatric disorders, especially major depressive disorder, hypomanic disorder, alcohol abuse and panic disorder (McCormick, Russo, Ramirez & Taber, 1984; Linden, Pope & Jonas, 1986). In addition, the rate of suicide attempts is high among pathological gamblers (Custer and Custer, 1978). Deterioration of family life is usually evident in the gamblers' history, with a high incidence of separation and divorce compared to the general population (Kallick, Suits, Dielman & Hybels, 1979). They also show physical violence within the family nucleus and approx-
ANGELS GONZALEZ IBAI~IEZ,ET AL.
301
imately 25 % of children born into families of gambling parents present behavioral problems such as failure to adapt to school, alcohol or drug abuse, gambling delinquency, etc. (Lorenz and Yaffee, 1988; Lorenz and Shuttlesworth, 1983; Lorenz, 1981). The social cost of pathological gambling is considerable if we take into account that the involvement of these people in gambling severely limits their contribution to society; in addition the financial and social problems demand professional attention and help. The unemployment rate for gamblers is double that of the general population (Volberg and Steadman, 1988). Even those who do keep their jobs are often implicated in embezzlements, forgeries and robberies which are the most common crimes committed by gamblers in order to finance their gambling. In fact, some studies carried out in prison environments observe up to 30% pathological gamblers in these institutions, and 13 % of prisoners admit that they are in prison because of gambling related problems (Lesieur and Kline, 1985). The present day characteristics of gambling in Spain are different from those in Anglo-Saxon countries, due to its particular gambling traditions. Various types of gambling are legal in Spain, including the following: Slot machines in bars and arcades, Bingo, Casinos, National lotteries and the Lottery for the blind. All of these forms of gambling are easily accessible, particularly slot machines, which one may find in almost any bar in the country. In table one, we may observe the degree of expense involved in these forms of gambling. This study aims to evaluate (for the first time in Spain) the most relevant characteristics of this disorder by observing a sample of pathological gamblers.
METHOD
Samp/e A total of 45 patients, who came to the Pathological Gambling Unit of the Psychiatry Service at the Hospital of Bellvitge, were evaluated. Forty patients were male (89%) and 5 were female (11%). The majority of these patients were between 30 and 52 years old. The mean age was 41.
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JOURNAL OF GAMBLING STUDIES
Table 1 Legal Gambling Total Gross Income in Spain. (Total amount gambled less prizes.) In millions of pesetas (1 million pesetas = approximately $I0,000) not deflated
Slot machines in bars and arcades Bingo Casinos (incl. slot machines) National Lotteries Lottery for the blind (O.N.C.E. Coupon) Total T O T A L (deflated)
1987
1988
1989
1990
272,250 137,842
297,960 154,110
347,750 172,568
360,421 185,811
35,237 102,578
39,640 103,918
44,078 120,414
43,067 136,313
96,990 644,987 644,987
114,528 710,156 688,967
119,279 804,089 699,557
135,200 860,812 688,650
Figures provided courtesy of the Comisi6n Nacional del Juego, Ministerio del Interior.
Out of this sample, 11 patients (24.5%) did not finish their primary education, 20 patients (44.5%) finished their primary education and 14 (31%) went on to secondary education. Twenty patients (44 %) were unskilled workers, 18 (40 %) were skilled workers and only 3 of them (6%) were professionals, civil servants or entrepreneurs. Homemakers and retired men constituted 10% of the sample. With regard to their marital status, 10 patients (22 %) were single, 30 were married (67 %), 3 were separated or divorced (7 %) and 2 of them (4 %) widowed. All of the patients came voluntarily for treatment, which in all cases was the first for their gambling problem. All of them were gambling regularly at the time of evaluation.
PROCEDURE Initially, a complete psychopathological study, which included the diagnostic criteria from DSM-III-R for pathological gambling (American Psychological Association, 1987), was carried out. Later the clinical aspects and the specific behavior relating to pathological gambling were evaluated by carrying out interviews which focused on the pre-
ANGELS GONZALEZ IBAI~IEZ, ET AL.
303
vious six months. The information relating to gambling behavior, obtained directly from the patient, was later corroborated with that from close family members, or by others who were intimately related with the patient. It should be noted that we did not find any discrepancies between the information taken from the two interviews, perhaps because all of the patients came voluntarily and perhaps also because they were aware of their disorders. After the behavioral and clinical evaluation of the disorder, the patients were integrated into a cognitive and behavioral treatment program, specifically designed for pathological gambling. This is summarized in another publication (Gonzalez Ib~tfiez, 1988).
RESULTS
A total of 37 patients (82%) had never undergone psychiatric hospitalization before this treatment. The others had been sent to hospital at least on one occasion previously, the average being two times. Five patients (11%) owed their hospitalization to suicide attempts related to gambling, while 3 ( 7 % ) w e r e hospitalized because they presented a clinical disorder which required hospital treatment. Suicidal ideation was noted in a total of 19 patients (42 %), who admitted having these thoughts on repeated occasions, either with or without ideation of a specific plan to carry them out. In addition, 10 patients (22%) told us of suicide attempts caused by gambling with an average of two attempts per patient, some of whom required hospital treatment. It should be pointed out that none of the sample had tried to commit suicide for reasons apart from gambling. With regard to substance abuse, 26 patients (58 %) admitted to the frequent abuse of alcohol while the others only rarely abused it, if at all. Eighty-six percent of the gamblers were habitual smokers and only 4 patients (9%) had been habitual consumers of cannabis. No other forms of addiction were noted. Concerning specific variables related to gambling behavior, we noted that the gamblers in our sample, in general, took a considerable length of time to seek help once they had a gambling problem. To be
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more specific, 30 of our subjects (67%) sought help 1 to 5 years after the start of their gambling problem. Ten of them (22 %) had waited for between 6 to 10 years and five patients (11%) told us that they had had problems for more than 10 years. The distribution of subjects in terms of the type of gambling they participated in before the time of the evaluation is reflected in Table two. These figures illustrate that the preferred type of gambling among the patients in our sample was slot and fruit machines. Generally, the type of gambling in which the gamblers developed their problem seems to remain constant throughout the period in which they gambled, although the type of gambling varied among individuals. To be specific, 32 patients (71%) indicated having, at the time of evaluation, the same gambling problem as when they began to show excessive gambling behavior. The other 13 individuals (29%) had, at the time of the evaluation, a different gambling problem than when they began. The majority of the individuals who had changed their type of gambling, changed to gambling with slot and fruit machines more than to any other type of gambling. This was so for 10 of the 13 subjects who had changed their gambling preference (77%). Furthermore, 27 patients (60%) maintained excessive gambling behavior with types of gambling different from the type preferred initially; the two were played simultaneously, or else the subsequently preferred type was used as a substitute when the initially preferred form of gambling was unavailable. Patients spent an estimated average of 63,428 pesetas per month, with a standard deviation of 44,851 pesetas, on gambling (Note 110 pesetas = $1 U.S.).
Table 2 Types of gambling among the subjects in our sample
S bj ts Gambling type
N
%
Slot and fruit machines Bingo Casinos Illegal card games Lotteries TOTAL
30 4 2 7 2 45
66.6 8.8 4.4 15.5 4.4 100
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The frequency of gambling in this sample was high. Twenty subjects (44 %) told us that they went several times a day to gamble, 10 patients (22 %) gambled generally once a day, 14 patients (31%) went several times per week, while only one patient (3 %) went only several times a month. Our prototype pathological gamblers usually gambled alone (89 %), always in the same gambling locations (62 %) and openly said that they enjoyed themselves while gambling (82 %), although they felt guilty as a result of gambling, or because of its consequences (80%). They did not usually maintain behavioral rituals when they gambled (98 %), although they smoked tobacco while gambling (80 %); also, a considerable percentage consumed alcohol while gambling (47%). They lied systematically to hide their gambling, or aspects related to it (98%), and they generally incurred debts as a result of gambling (76 %). They usually incurred debts with close family (42 %), at work (33 %), with banks (27 %) and with their friends (22 %). They acquired debts to a lesser extent within their gambling circle (13 %), with finance companies (2 %), or by using other means of financing (2 %). Another method widely used by our patients to obtain gambling money was to steal from or swindle the family, friends and/or their work place, without resorting to violence. A smaller proportion committed forgery (4 %), embezzlements (2 %), or they resorted to verbal or physical aggression in order to steal from their own family, friends and/or place of employment (2%). It should be noted that none of these patients committed a criminal act against people unknown to them and 21 of the subjects (47%) had never committed any kind of crime. In spite of the fact that there is a high proportion of gamblers who commit criminal acts, only 3 patients (7%) had past or present legal problems.
DISCUSSION
Although we have attempted in this research to evaluate the clinical and behavioral variables of pathological gamblers, we are aware that the size of the sample, and its particular demographic characteristics, do not allow us to generalize from these results. Given that the area which is covered by the Hospital of Bellvitge essentially
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corresponds to a lower-middle class area, we consider that some of the data obtained describes more the demographic characteristics of this particular population rather than the distinctive characteristics of the population of pathological gamblers. A study of a sample drawn from the general population is needed. Nevertheless, it seems that pathological gambling affects people of all ages, although we found that the major proportion of our sample were mainly men around 40 years old. This data corresponds with the data given in almost all the publications on pathological gambling, where males represent the majority, if not the entirety, of the patients in treatment programs. However, we do not think that from this it should be understood that a major proportion of pathological gamblers is male, but rather, as happens with other forms of addiction, it may be explained by a smaller demand for treatment from females, because of the greater social censure women suffer when they are known to have addictive problems. In fact, it has been reported that approximately a third of pathological gamblers (in the U.S.) are women (Lesieur, 1988), although this proportion is not reflected in the n u m b e r of females partaking in the treatment programs. The presence of other psychiatric disorders among pathological gamblers seems to be a consistent finding in the studies which have considered co-morbidity. Affective disorders, substance abuse, and various personality disorders are the most frequently mentioned (McCormick et al., 1984; Linden et al. 1986; Taber, McCormick, Russo, Adkins & Ramirez, 1987; Taber, McCormick & Ramirez, 1987). In our sample the presence of depressive symptomatology was the most frequent, followed by alcohol abuse and personality disorders. The complications resulting from excessive gambling can easily cause depressive symptoms. However, a hypothesis contrary to this is also possible, namely that gambling provides a means by which patients can alleviate their depressed state (Russo et al. 1984). In our sample we observed a high rate of suicide attempts. Twenty-two percent of the patients had previously tried to commit suicide. This rate is similar to that in other studies. In a previous study, for example, 18 % of the members of Gamblers Anonymous and 24% of the Veteran's Administration Hospital patients admitted having tried to commit suicide (Custer and Custer, 1978). Furthermore, it should be noted that all our cases of attempted suicide were connected
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with gambling or its consequences: no other suicide motive was noted among the patients. If we take into account that the proportion of suicides in the Spanish population is less than 10/100,000, and that the ratio of failed to successful suicide attempts is 8:1 (Freedman, Kaplan & Sadock, 1982) we can conclude that the risk of suicide among these patients was high. Likewise, a tendency towards dual addiction is often recorded in the gambling literature. A high incidence of pathological gambling (9 %) or at least the presence of problems related to gambling (10 %), is frequently found among the patients who are hospitalized for substance dependence (Lesieur, Blume & Zoppa, 1986). In addition, some studies report that 47% of pathological gamblers in treatment programs show signs of substance abuse or dependence (McCormick et al., 1984). In our sample we also observed a tendency for the patients to exhibit addictive behavior, especially a high consumption of alcohol. This relationship between alcohol abuse or dependence and excessive gambling has been repeatedly noted in the literature on pathological gambling (Lesieur, Blume & Zoppa, 1986). Other toxic substances were not consumed in large quantities by our patients, with the exception of tobacco, from which we may deduce that, among the pathological gamblers studied, there exists a tendency to become addicted to those substances which are socially accepted and which are consumed, to a certain extent, by the rest of the population. Based on the analysis of the gambling characteristics studied, we found that a long period elapses between the time the disorder begins and the time the individual finally comes for treatment: this was more than 6 years for 33 % of the patients studied. Custer (1984) reports that some 5 years usually pass between the time a person begins gambling until there is a definite loss of control. In addition, the gambler is reluctant to accept his or her gambling as problematic, hiding and minimizing it in the presence of others. Finally there is an ignorance among the general population regarding the existence of this disorder and the possibility of treatment, which can make it difficult for an individual to recognize the disorder. All this, to some extent, explains why gamblers have had a long history of gambling when they first come for treatment. With respect to gambling preferences, slot and fruit machines were the main form of problematic gambling for the majority of the gamblers at the time of the evaluation. In order of importance, slot
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machines were followed by illegal gambling, bingo and, to a lesser extent, gambling in casinos or on lotteries. Differences are seen when the most popular types of gambling among our gamblers are compared with those observed among pathological gamblers in other countries, where other types of gambling, such as horse-racing, are more popular (Lesieur, 1988). These differences are a reflection of different gambling traditions in our country. The estimated average of 63,428 pesetas/month spent on gambling by our patients is only an approximate figure. Nevertheless, the figure is considerable if we take into account the socio-economic status of our patients, the greater part of whom are unskilled workers, and if we also consider that this n u m b e r is above the current established m i n i m u m salary in our country of 53,250 pesetas/month. Concerning the frequency with which our patients gamble, we found that the greater part of our sample gambled daily (66%); if we include the weekly gamblers this figure rises to 97 %. These figures are probably influenced by the most popular type of gambling, which as we have seen, is slot and fruit machines, whose availability and gambling features result in their frequent use. Most forms of behavior connected with gambling were consistent with those reported by the majority of publications on the subject. In general, the characteristics of our patients tally, by and large, with those reported by Custer (1984) and Lesieur (1979). The gamblers usually gamble alone, in the same gambling locations, with feelings of guilt because of their conduct, which they try to hide by lying once their gambling has become excessive, to the point of pledging the family's or others' possessions and property in order to continue gambling. Frequently they incur debts in order to finance their gambling, first with family or in the work-place, then by using legal financial sources, and, finally, they resort to fraud and other crimes when other sources for obtaining money have been exhausted and their desire to gamble has still not been satisfied. However, these criminal acts rarely involve persons unknown to the individual or violence and are appropriations of the family's and friends' possessions. According to Custer (1984) gamblers turn to crime when they find themselves in the "desperation phase," that is, the last phase of a gambler's involvement in gambling, which occurs as the problem characteristics of the pathological gambler have become fully evolved. In our sample we found that a considerable n u m b e r of patients have committed criminal acts on at
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least one occasion. However, these acts rarely involve legal complications, certainly because the crimes committed are not of a serious nature, and the majority of the injured parties are often intimately related with the gambler. Hence, the crimes are not reported. In fact, we found that those patients who effectively had legal problems had committed criminal acts at work. In conclusion, the profile of the pathological gambler which emerged from our study conformed to a large extent to the one found in the published literature on pathological gambling, and the differences found in the gambling behavior, for instance, in the form of gambling most often used by the gambler, may simply be due to the different traditions and types of gambling available in each country.
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