The Development of Pathological Gambling in Sweden Cecilia Bergh, Ph.D. Karolinska Institute, Huddinge, Sweden Eckart Kiihlhorn, Ph.D. University of Stockholm, Sweden
The development and the social, psychological and cultural conditions of pathological gambling reported by 42 interviewed pathological gamblers were compared with data from 63 pathological gamblers identified by case-finding. The two studies gave similar results. Gambling on horse races, roulette and bingo were the only types showing a progressive increase in involvement over time. When gambling heavily 40% of the pathological gamblers regularily experienced a state of altered consciousness. When abstaining from gambling withdrawal-like symptoms were experienced by a third. Fifty-two percent reported at least one family member often gambling. Pathological gambling appears to be a secret behaviour, although there are collective features in its development.
INTRODUCTION T h e causes of pathological gambling are largely u n k n o w n . Alt h o u g h it is found to be m o r e c o m m o n a m o n g m e n than w o m e n ( C u s t e r & Milt, 1985), most studies have been c o n c e r n e d with males and therefore a sex linked factor has not been shown ( M a r k & Lesieur,
Address correspondence to C. Bergh, Department of Clinical Neuroscienee,.Karolinska Institute, S-141 86 Huddinge, Sweden.
Journal of GamblingStudies Vol. 10(3), Fall 1994 9 1994 Human Sciences Press, Inc.
261
262
JOURNAL OF GAMBLING STUDIES
1992). Risk-taking, associated with sensation seeking (Zuckerman, 1979; 1984; but see Allock & Grace, 1988; Dickerson, Hinchy & Fabre, 1987) and arousal may contribute to pathological gambling (Blaszcynski, Buhrich & McConaghy, 1985; Brown, 1986; Dickerson et al., 1987). Thus, sensation-seeking, possibly related to a functional disturbance in the noradrenergic system of the brain (Roy, Adinoff, Roehrich, Lamparski et al., 1988a; Roy, DeJong & Linnoila, 1989), correlates with bet size and heart rate in the casino (Anderson & Brown, 1984). It has been suggested that pathological gambling is associated with depressive symptoms (Blaszczynski & McConaghy, 1988; McCormick, Russo, Ramirez & Taber, 1984; Roy, Custer, Lorenz & Linnoila, 1988b), a family history of affective disorders (Linden, Pope & Jonas, 1986; Roy et al., 1988b) and alcohol and drug abuse (Lesieur, Blume & Zoppa, 1986; Linden, Pope & Jonas, 1986; Roy et al., 1988b). Furthermore, gambling problems among parents of pathological gamblers, mostly the father, are more frequent than among the general population (Lesieur, Blume & Zoppa, 1986; Ramirez, McCormick, Russo & Taber, 1983). Thus, there is some information on possible causes of pathological gambling and also on its development (Custer & Mih, 1985; Lesieur, 1979; Lesieur & Custer, 1984). However, further data on the development and socio-cultural and psychological causal conditions of pathological gambling may be useful. Such data are reported in this article.
METHODS
The Interview Study Thirty-seven males and five females (median age: 37 years, range: 20-70), fulfilling the DSM-III-R criteria of pathological gambling (APA, 1987), participated. Twenty-one were recruited by advertising and eight from a center for treatment of pathological gambling. There is only one such center in Sweden, located in Avesta. Seven were referrals from out-patient psychiatric care and social welfare authorities, three were members of Gamblers Anonymous (GA) and three were gamblers recruited through GA members~
CECILIA BERGH AND ECKART K/s
263
The advertisement was addressed to gamblers, ex-gamblers and significant others and published once in two national daily newspapers. The criteria for participating were frequent gambling and indebtedness. Thirty-two persons responded. Twenty-two met the DSM-III-R criteria, when being evaluated, two were spouses and one was a mother of a gambler. A semi-structured interview, containing 106 standardized questions about family background, clinical symptoms, and course and consequences of pathological gambling was used. The majority of the variables were nominal and in some cases ordinal. Eight gamblers in treatment were interviewed at the treatment center and the rest of the sample at the hospital by one of the authors.
The Case-Finding Study The aim of the case-finding study was to estimate the prevalence of pathological gambling. The results of that study will be reported separately. However, because there is limited information on pathological gamblers in Sweden, data comparable to those of the interview study are reported here. Data on gamblers fulfilling the DSM-III-R criteria, established by reviewing medical records, were obtained through systematic casefinding within districts of probation, in- and out-patient psychiatric care and social welfare authorities in the County of Stockholm. Residents of the County of Stockholm at the center for treatment of pathological gambling, were also included. A total of 314 informants were asked and 294 (93.6%) (44 psychiatrists, 195 head social workers and 55 probation officers/therapists) participated. These identified 225 pathological gamblers during a twoyear period. The informants were asked to submit individual data on all gamblers identified. However, individual data were reported only on 57 males and six females (28%) (median age: 36 years, range: 2274). Twenty-seven were identified within psychiatric care, 19 at the treatment center, ten within probation districts and seven within social welfare authorities. A semistructured interview with 18 questions on the same issues as in the interview study was used. To exclude double reporting of gamblers, the informants submitted information on gamblers' sex, date of birth and initials of first name and surname. Five gamblers were excluded.
JOURNAL OF GAMBLING STUDIES
264
General Population Survey Data on the general population (both sexes, age: 16-84 years, Davidson, 1991) were used for some comparisons despite not being comparable with the data from the gamblers with regard to sex and age. The annual level-of-living surveys are based on a national sample of 8,000-14,000 persons interviewed each year with 500 questions. Data on income, transfers and taxes from public records were added.
Reliability of Interview Study Telephone interviews were conducted with 19 pathological gamblers in addition to their interview in the hospital. A comparison between the data from the telephone and hospital interviews regarding profession, civil status, type and frequency of gambling was then made to estimate reliability. The agreement between interview and telephone data was _> 95% on most issues, except that a fourth (24%) reported a lower gambling frequency in the telephone than in the hospital interview. One pathological gambler refused to participate. Non-replies ( < 10 %) were excluded from the study. RESULTS Since a minority of the pathological gamblers were females (Table 1) and the results from males and females were similar the data have been combined. The results from the interview and case-finding study were similar. Because the interview study was the most comprehensive the results refer to this study unless noted.
Demographic-Economic Background Habitat, Marriage, Education and Economy. There were no statistically significant differences between the case finding and interview samples demographics with the exception of marital status. While they were similar in gender, education, employment and socio-economic status, more of the gamblers in the case-finding study were married (Chi-square = 6.766; df = 2; p < .05) (Table 1). About half (52%) of the pathological gamblers had a steady relationship, but rarely with a pathological gambler as a partner
265
CECILIA BERGH AND ECKART K/s
Table 1 Demographic and socio-economic d a t a o f p a t h o l o g i c a l g a m b l e r s in the i n t e r v i e w a n d the c a s e - f i n d i n g s t u d y
Interview
Gender Males Females Total Marital Status* Never married Married Divorced Total Education Uncompleted comprehensive school Completed comprehensive school only Completed high school only Completed university Total Employment Employed Students Housewives Vocational training Unemployed Total Socio-economic Status Social group I (Professionals) Social group II (Non-manual workers) Social group III (Manual workers) Don't know Total *p < 0.05 (chi2-test).
Case-finding
N
%
N
%
37 5 42
88 12 i00
57 6 63
90 10 100
24 4 13 41
58 10 32 100
28 20 15 63
44 32 24 100
3
7
3
5
17 16 6 42
40 38 14 100
34 18 4 59
57 31 7 100
25 1 1 2 13 42
60 2 2 5 31 100
40 1 3 2 15 61
66 2 5 3 24 100
6
14
5
8
t5
36
16
25
21 42
50 -100
37 5 63
59 8 100
266
JOURNAL OF GAMBLING STUDIES
(7%). Half of the group had children and most of the gamblers (71%) were the caretakers. The majority had a fixed abode during the last 12 months (95%); the rest were living in institutions. M o r e than half of the pathological gamblers were employed (60 % ), a few were students (7 %) or housewives (2 %) and a substantial proportion was unemployed (31%). However, less than half (36%) were able to support themselves; the majority relied on additional support (sickness, social or unemployment benefit/pension, parent support or criminality). Family economic problems during childhood and adolescence were common (31%).
Social Network. Ten percent socialized with gambling peers only, 25% with non-gambling peers only, 55% with both and 10% did not socialize with peers. Almost all (90%) stated they had a close friend (median: 3 friends). Divorce, Alcohol Abuse and Gambling in Family. One third (35%) were raised in incomplete families, parents' divorce being the main reason. One third (39%) reported at least one parent being "often" drunk or alcoholic, fathers were two times as likely to have problems as mothers. There was no drug and/or alcohol abuse among partners of the pathological gamblers. One third (31%) reported at least one parent suffering from mental instability, with mothers twice as likely to have this problem as fathers. The majority of mothers had never gambled or gambled only occasionally (Fig. 1). About half (52%) reported that at least one family m e m b e r gambled "often" or was dependent. The most common types of gambling are shown in Fig. 2. The Development of Pathological Gambling Onset of Gambling. The probands were introduced to gambling in their early teens (median age: 14 years) most commonly by someone in their family (45 %), almost without exception the father, others by a teenage peer (30%), an adult friend (8%) or a work mate (3%). The rest (15 %) started gambling on their own. Gambling was often initiated in a gambling setting (49%); card games were a traditional part of family gatherings in a fourth of the cases (24%). Regular Gambling and Loss of Control. A regular pattern of gambling (_> one day/week) occurred at a median age of 20 years. Ten
267
CECILIA BERGH AND ECKART KULHORN
Figure 1 G a m b l i n g habits in b a c k g r o u n d family in t h e i n t e r v i e w
study,
(father n = 39, mother n = 42, sibling n = 39)
[] [] []
100 E c~
father mother sibling
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50
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9
years later most probands (79%) were unable to stop. The median duration of regular gambling was 14 years and of "inability to control" 3.5 years. The duration of gambling dependence was longer in the case-finding study (>_ 10 years), but unknown to the informants in 19 % of the cases. Some types of gambling became more frequent as gambling developed (Fig. 3).
Causes of Gambling. Reasons for continued gambling in the interview and case-finding study were: an urge to get rich (57 and 36%), excitement (57 and 33%), "beginner's luck" (31 and 3%), high status and feeling of competence (21 and 9%) and looking for sociality (19 and 22 %). Other reasons were interest in sports, mental problems, life events and recreation. The causes for pathological gambling were unknown to the informants in one third of the cases. Types, Pattern and Frequency of Gambling. The main types of gambling during the gambling career are shown in Fig. 4. Two-thirds (69 %) reported more than one predominant type. Pools, roulette, card
JOURNAL OF GAMBLING STUDIES
268
Figure 2 Types of gambling (one or more) in background family in the interview study, (father n = 31, mother n = 19, sibling n = 23)
t_
9 [] []
100
father mother sibling
~m
50 .~ O
e=
I.
t_
L
games and horse races were the most frequent second types of gambling. In many cases (61%) the main type of gambling was the same as that engaged in by the father. Gambling occurred daily (41%) or weekly but not daily (52%) and a few gambled on weekends (2%) or periodically (5 %). The frequency of gambling episodes during the last 12 months were: daily or almost daily (60 %), -- twice/week (33 %) and 8% once/week.
Secret Gambling. Almost half of the pathological gamblers either concealed their gambling (46%) or its intensity (44%). Very few did not deny gambling (10%). Some commented: "I'm ashamed to tell people that I gamble at all" or: "When entering a casino bar I always look around to make sure that no one I know is around, if so I leave". The partner was mostly unaware of the pathological gambling (59 %), the majority (82%) hid their gambling from non-gambling peers and many (45%) did so to fellow gamblers. Chasing and Withdrawal Symptoms. Chasing (to bet more in order to recoup losses) occurred "often" or "always" in most (73%) and to a
269
CECILIA BERGH AND ECKART K/~ILHORN
Figure 3 Types of gambling (one or more) during the course of d e p e n d e n c e in the interview study (onset n = 4 2 , regularity n = 4 2 , loss of control n = 33)
[]
100
onset
~
regularity loss of control
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. ca
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~
~
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t_
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.--
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lesser extent in almost all of the pathological gamblers (95 %). Depression followed gambling losses in a substantial proportion of gamblers (67%). A third (33%) reported two or more withdrawal-like symptoms, e.g. restlessness, irritation, sweating and trembling, when not gambling and, when gambling heavily, many (40 %) regularly experienced a state of altered consciousness: "removed from reality", "a feeling of being totally alone, despite being in a crowd", "a trance-like state of mind" or "exaltation".
Cravingfor Gamblingand Periodsof Abstinence. The majority (74 %) reported craving for gambling when not gambling. About half of these (52 %) experienced a strong craving "often" or "always," which lead to relapses in about two thirds (65%). Several pathological gamblers (63%) had experienced periods of abstinence lasting a week or more during the last year.
JOURNAL OF GAMBLING STUDIES
270
Figure 4 M a i n t y p e o f gambling d u r i n g the p r o b a n d s g a m b l i n g c a r e e r ( i n t e r v i e w s t u d y n = 42, c a s e - f i n d i n g s t u d y n = 5 8 )
t_
[] []
100
interview case-finding
E --
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DISCUSSION
Methodological Considerations Because of the bias in the selection of the gamblers in the casefinding study it is unclear if these are representative of active gamblers. As is the case with a clinical sample (Orford, 1985), a population of gamblers within districts of probation oversamples those known to the police and excludes those not in the records. Also, gender was not kept separate in this study because of the small number of women and because results from women were similar to those of men. Possible sex differences in pathological gambling deserve attention.
Family and the Onset of Pathological Gambling Gambling problems among fathers, but not mothers of pathological gamblers are frequent (present data; Lesieur et al., 1986; Ramirez
CECILIA BERGH AND ECKART KULHORN
et al., 1983). The form of gambling engaged in was same as that engaged in by the parent. It is possible, family gambling habits play a role in the development gambling (Bolen & Boyd, 1968; Lesieur et al., 1986;
271
commonly the therefore, that of pathological Ramirez et al.,
1983). Although most probands were introduced to gambling by their father or peers, the addictive career starts only with the inability to control gambling. By this measure, pathological gambling had a relatively late onset.
Hazardous Gambling and Causes of Continued Gambling Gambling on horse races, roulette and bingo tended to increase with the development of pathological gambling. Possibly, therefore, these are hazardous forms of gambling, i.e. reinforcing continuous gambling due to immediate financial reward (Cornish, 1978). Epidemiological data will, however, be required to validate this suspicion. Causes for continued gambling were the urge to get rich and excitement (present data; Blaszcynski & McConaghy, 1989; Legg England & G/Stestam, 1991). High school boys worry about money (Wadden, Brown, Foster & Linnowitz, 1991) and since financial success is a concern for adolescent males (Simmons & Rosenberg, 1975), it may contribute to the development of pathological gambling. The possibility that this is the case among female gamblers as well requires collection of comparative epidemiological data. Betting to recoup losses, i.e. chasing, was common among the pathological gamblers in this study and it has been reported that the more money lost the more intense the chasing (Lesieur, 1979). Gambling addiction, therefore, may occur through intermittent reinforcement (Lesieur & Custer, 1984) because irregularly rewarded behaviour is difficult to extinguish (Ferster & Skinner, 1957).
Periods of Abstinence and Withdrawal Symptoms The probands did not always gamble. Some gained control for extended periods of time but relapsed back on occasion. Also, gambling was interrupted in the absence of money. Withdrawal-like symptoms during non-gambling periods and perceived altered consciousness when gambling heavily were not uncommon as has been reported
JOURNAL OF GAMBLING STUDIES
272
before (Taber et al., 1987; Wray & Dickerson, 1981). It is possible that these reflect an advanced stage of pathological gambling, a hypothesis which deserves further study.
Collective and Solitary Gambling In the present study, about a fifth of the pathological gamblers stated sociality as the main cause for continued gambling. The majority of the pathological gamblers reported socializing with peers of the same inclination and most had met their gambling peers in gambling settings. Although excessive gambling may be a lonesome activity (Legg England & G6testam, 1991), there are apparently some collective features in pathological gambling. Most of the pathological gamblers concealed their gambling or its intensity by lying to partners, fellow gamblers, and others increasingly as gambling progressed; this is possibly because of the fear of disapproval by society, family and friends.
CONCLUSIONS Gambling habits in family background appear to play a role in the development of pathological gambling. It takes a considerable period of time to develop gambling beyond control. Although there are collective features in the development, pathological gambling appears to be a secret behaviour. Future studies on family interactions, sex differences and the factors contributing to loss of control seem warranted.
ACKNOWLEDGEMENTS
This work was supported by grants from The Commission for Social Research (D 89/0185). We thank Drs S. R6nnberg and H. Johnsson for placing patients at our disposal and Dr P. S6dersten, anonymous reviewers and the editor for commenting on the manuscript.
CECILIA BERGH AND ECKART K/JLHORN
273
REFERENCES Allcook, C.C. & Grace, D.M. (1988). Pathological gamblers are neither impulsive nor sensation seekers. Australian and New Zealand Journal of Psychiatry, 22, 307-311. American Psychiatric Association (1987). Diagnostic and statistical manual of mental disorders (DSMIII-R) Washington, DC: Author. Anderson, G. & Brown, F. (1984). Real and laboratory gambling, sensation seeking and arousal. British Journal of Psychology, 75, 401-410. Blaszcynski, A.P., Buhrich, N. & McConaghy, N. (1985). Pathological gamblers, heroin addicts and controls compared on the EPQAddiction Scale. British Journal of Addiction, 80, 315-319. Blaszcynski, A.P. & McConaghy, N. (1988). SCL-90 assessed psychopathology in pathological gamblers. Psychological Reports, 62, 547-552. Blaszcynski, A.P. & McConaghy, N. (1989). Anxiety and/or depression in the pathogenesis of addictive gambling, The International Journal of the Addictions, 24, 337-350. Bolen, D. & Boyd, D. (t968). Gambling and the gambler. Archives of General Psychiatry, 18, 617630. Brown, R.I.F. (1986). Arousal and sensation-seeking components in the general explanation of gambling and gambling addictions. The International Journal of the Addictions, 21, 1O01-1016. Cornish, D.B. (1978). Gambling." A review of the literature and its implications for policy and research. Home Office Research Study, 42. Custer, R.L. & Mih, H. (1985). When luck runs out. New York: Facts and File Publications. Dickerson, M., Hinchy, J. & Fabre, J. (1987). Chasing, arousal and sensation-seeking in offcourse gamblers. British Journal of Addiction, 82, 673-680. Ferstet:, C.B & Skinner, B.F. (1957). Schedules of reinforcement. New York: Appleton-CenturyCrofts. Legg England, S. & G6testam, G. (1991). The nature and treatment of excessive gambling. Acta Psychiatrica Scandinavica, 84, 113-120. Lesieur, H.R. (1979). The compulsive gambler's spiral of options and involvement. Psychiatry, 42, 79-87. Lesieur, H.R. & Custer R.L. (1984). Pathological gambling: Roots, phases and treatment. The Annals of the American Academy of Political and Social Sciences, 474, 146-156. Lesieur, H.R., Blume, S.B. & Zoppa, R.M. (1986). Alcoholism, drug abuse and gambling. Alcoholism: Clinical and Experimental Research, 10, 33-38. Linden, R.D., Pope, H.G. & Jonas, J.M. (1986). Pathological gambling and major affective disorder: Preliminary findings. Journal of Clinical Psychiatry, 47, 201-203. Mark, M.E. & Lesieur, H.R. (1992). A feminist critique of problem gambling research. British Journal of Addiction, 87, 33-50. McCormick, R., Russo, A., Ramirez, L. & Taber, J. (1984). Affective disorders among pathological gamblers seeking treatment. American Journal of Psychiatry, 141, 215-218. Orford, J. (1985). Excessive appetites: A psychological view of addictions. New York: John Wiley & Sons.
Ramirez, L.F., McCormick, R.A., Russo, A.M. & Taber, J.I. (1983). Patterns of substance abuse in pathological gamblers undergoing treatment. Addictive Behaviors, 8, 425-428. Roy, A., Adinoff, B., Roehrich, L., Lamparski, D., Custer, R., Lorenz, V., Barbaccia, M., Guidotti, A., Costa, E. & Linnoila, M. (1988a). Pathological gambling. A psychobiological study. Archives of General Psychiatry, 45, 369-373. Roy A., Custer, R., Lorenz, V. & Linnoila, M. (1988b). Depressed pathological gamblers. Acta Psychiatrica Scandinavica, 77, 163-165. Roy, A., DeJong, J. & Linnoila, M. (1989). Extraversion in pathological gamblers. Archives of General Psychiatry, 46, 679-681. Simmons, R.G., & Rosenberg, F. (1975). Sex, sex roles and self-image. Journal of Youth and Adolescence, 4, 229-258. Taber, J.I., McCormick, R.A., Russo, A.M., Adkins, B.J. & Ramirez, L.F. (1987). Follow-up of pathological gamblers after treatment. AmeriCan Journal of Psychiatry, 144, 757-761.
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OF GAMBLING STUDIES
Wadden, T.A., Brown, G., Foster, G.D. & Linnowitz, J.R. (1991). Salience of weight-related worries in adolescent males and females. InternationalJournal of Eating Disorders, 4, 407-414. Wray, I. & Dickerson, M.G. (1981). Cessation of high frequency gambling and withdrawal symptoms. British Journal of Addiction, 76, 401-405. Zuckerman, M. (1979). Sensation seeking: Beyond the optimal level of arousal. New Jersey: Erlbaum. Zuckerman, M. (1984). Sensation seeking. A comparative approach to a human trait. Behavioural and Brain Sciences, 7, 413-471.
The development and the social, psychological and cultural conditions of pathological gambling reported by 42 interviewed pathological gamblers were compared with data from 63 pathological gamblers identified by case-finding. The two studies gave similar results. Gambling on horse races, roulette and bingo were the only types showing a progressive increase in involvement over time. When gambling heavily 40% of the pathological gamblers regularily experienced a state of altered consciousness. When abstaining from gambling withdrawal-like symptoms were experienced by a third. Fifty-two percent reported at least one family member often gambling. Pathological gambling appears to be a secret behaviour, although there are collective features in its development.
INTRODUCTION T h e causes of pathological gambling are largely u n k n o w n . Alt h o u g h it is found to be m o r e c o m m o n a m o n g m e n than w o m e n ( C u s t e r & Milt, 1985), most studies have been c o n c e r n e d with males and therefore a sex linked factor has not been shown ( M a r k & Lesieur,
Address correspondence to C. Bergh, Department of Clinical Neuroscienee,.Karolinska Institute, S-141 86 Huddinge, Sweden.
Journal of GamblingStudies Vol. 10(3), Fall 1994 9 1994 Human Sciences Press, Inc.
261
262
JOURNAL OF GAMBLING STUDIES
1992). Risk-taking, associated with sensation seeking (Zuckerman, 1979; 1984; but see Allock & Grace, 1988; Dickerson, Hinchy & Fabre, 1987) and arousal may contribute to pathological gambling (Blaszcynski, Buhrich & McConaghy, 1985; Brown, 1986; Dickerson et al., 1987). Thus, sensation-seeking, possibly related to a functional disturbance in the noradrenergic system of the brain (Roy, Adinoff, Roehrich, Lamparski et al., 1988a; Roy, DeJong & Linnoila, 1989), correlates with bet size and heart rate in the casino (Anderson & Brown, 1984). It has been suggested that pathological gambling is associated with depressive symptoms (Blaszczynski & McConaghy, 1988; McCormick, Russo, Ramirez & Taber, 1984; Roy, Custer, Lorenz & Linnoila, 1988b), a family history of affective disorders (Linden, Pope & Jonas, 1986; Roy et al., 1988b) and alcohol and drug abuse (Lesieur, Blume & Zoppa, 1986; Linden, Pope & Jonas, 1986; Roy et al., 1988b). Furthermore, gambling problems among parents of pathological gamblers, mostly the father, are more frequent than among the general population (Lesieur, Blume & Zoppa, 1986; Ramirez, McCormick, Russo & Taber, 1983). Thus, there is some information on possible causes of pathological gambling and also on its development (Custer & Mih, 1985; Lesieur, 1979; Lesieur & Custer, 1984). However, further data on the development and socio-cultural and psychological causal conditions of pathological gambling may be useful. Such data are reported in this article.
METHODS
The Interview Study Thirty-seven males and five females (median age: 37 years, range: 20-70), fulfilling the DSM-III-R criteria of pathological gambling (APA, 1987), participated. Twenty-one were recruited by advertising and eight from a center for treatment of pathological gambling. There is only one such center in Sweden, located in Avesta. Seven were referrals from out-patient psychiatric care and social welfare authorities, three were members of Gamblers Anonymous (GA) and three were gamblers recruited through GA members~
CECILIA BERGH AND ECKART K/s
263
The advertisement was addressed to gamblers, ex-gamblers and significant others and published once in two national daily newspapers. The criteria for participating were frequent gambling and indebtedness. Thirty-two persons responded. Twenty-two met the DSM-III-R criteria, when being evaluated, two were spouses and one was a mother of a gambler. A semi-structured interview, containing 106 standardized questions about family background, clinical symptoms, and course and consequences of pathological gambling was used. The majority of the variables were nominal and in some cases ordinal. Eight gamblers in treatment were interviewed at the treatment center and the rest of the sample at the hospital by one of the authors.
The Case-Finding Study The aim of the case-finding study was to estimate the prevalence of pathological gambling. The results of that study will be reported separately. However, because there is limited information on pathological gamblers in Sweden, data comparable to those of the interview study are reported here. Data on gamblers fulfilling the DSM-III-R criteria, established by reviewing medical records, were obtained through systematic casefinding within districts of probation, in- and out-patient psychiatric care and social welfare authorities in the County of Stockholm. Residents of the County of Stockholm at the center for treatment of pathological gambling, were also included. A total of 314 informants were asked and 294 (93.6%) (44 psychiatrists, 195 head social workers and 55 probation officers/therapists) participated. These identified 225 pathological gamblers during a twoyear period. The informants were asked to submit individual data on all gamblers identified. However, individual data were reported only on 57 males and six females (28%) (median age: 36 years, range: 2274). Twenty-seven were identified within psychiatric care, 19 at the treatment center, ten within probation districts and seven within social welfare authorities. A semistructured interview with 18 questions on the same issues as in the interview study was used. To exclude double reporting of gamblers, the informants submitted information on gamblers' sex, date of birth and initials of first name and surname. Five gamblers were excluded.
JOURNAL OF GAMBLING STUDIES
264
General Population Survey Data on the general population (both sexes, age: 16-84 years, Davidson, 1991) were used for some comparisons despite not being comparable with the data from the gamblers with regard to sex and age. The annual level-of-living surveys are based on a national sample of 8,000-14,000 persons interviewed each year with 500 questions. Data on income, transfers and taxes from public records were added.
Reliability of Interview Study Telephone interviews were conducted with 19 pathological gamblers in addition to their interview in the hospital. A comparison between the data from the telephone and hospital interviews regarding profession, civil status, type and frequency of gambling was then made to estimate reliability. The agreement between interview and telephone data was _> 95% on most issues, except that a fourth (24%) reported a lower gambling frequency in the telephone than in the hospital interview. One pathological gambler refused to participate. Non-replies ( < 10 %) were excluded from the study. RESULTS Since a minority of the pathological gamblers were females (Table 1) and the results from males and females were similar the data have been combined. The results from the interview and case-finding study were similar. Because the interview study was the most comprehensive the results refer to this study unless noted.
Demographic-Economic Background Habitat, Marriage, Education and Economy. There were no statistically significant differences between the case finding and interview samples demographics with the exception of marital status. While they were similar in gender, education, employment and socio-economic status, more of the gamblers in the case-finding study were married (Chi-square = 6.766; df = 2; p < .05) (Table 1). About half (52%) of the pathological gamblers had a steady relationship, but rarely with a pathological gambler as a partner
265
CECILIA BERGH AND ECKART K/s
Table 1 Demographic and socio-economic d a t a o f p a t h o l o g i c a l g a m b l e r s in the i n t e r v i e w a n d the c a s e - f i n d i n g s t u d y
Interview
Gender Males Females Total Marital Status* Never married Married Divorced Total Education Uncompleted comprehensive school Completed comprehensive school only Completed high school only Completed university Total Employment Employed Students Housewives Vocational training Unemployed Total Socio-economic Status Social group I (Professionals) Social group II (Non-manual workers) Social group III (Manual workers) Don't know Total *p < 0.05 (chi2-test).
Case-finding
N
%
N
%
37 5 42
88 12 i00
57 6 63
90 10 100
24 4 13 41
58 10 32 100
28 20 15 63
44 32 24 100
3
7
3
5
17 16 6 42
40 38 14 100
34 18 4 59
57 31 7 100
25 1 1 2 13 42
60 2 2 5 31 100
40 1 3 2 15 61
66 2 5 3 24 100
6
14
5
8
t5
36
16
25
21 42
50 -100
37 5 63
59 8 100
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(7%). Half of the group had children and most of the gamblers (71%) were the caretakers. The majority had a fixed abode during the last 12 months (95%); the rest were living in institutions. M o r e than half of the pathological gamblers were employed (60 % ), a few were students (7 %) or housewives (2 %) and a substantial proportion was unemployed (31%). However, less than half (36%) were able to support themselves; the majority relied on additional support (sickness, social or unemployment benefit/pension, parent support or criminality). Family economic problems during childhood and adolescence were common (31%).
Social Network. Ten percent socialized with gambling peers only, 25% with non-gambling peers only, 55% with both and 10% did not socialize with peers. Almost all (90%) stated they had a close friend (median: 3 friends). Divorce, Alcohol Abuse and Gambling in Family. One third (35%) were raised in incomplete families, parents' divorce being the main reason. One third (39%) reported at least one parent being "often" drunk or alcoholic, fathers were two times as likely to have problems as mothers. There was no drug and/or alcohol abuse among partners of the pathological gamblers. One third (31%) reported at least one parent suffering from mental instability, with mothers twice as likely to have this problem as fathers. The majority of mothers had never gambled or gambled only occasionally (Fig. 1). About half (52%) reported that at least one family m e m b e r gambled "often" or was dependent. The most common types of gambling are shown in Fig. 2. The Development of Pathological Gambling Onset of Gambling. The probands were introduced to gambling in their early teens (median age: 14 years) most commonly by someone in their family (45 %), almost without exception the father, others by a teenage peer (30%), an adult friend (8%) or a work mate (3%). The rest (15 %) started gambling on their own. Gambling was often initiated in a gambling setting (49%); card games were a traditional part of family gatherings in a fourth of the cases (24%). Regular Gambling and Loss of Control. A regular pattern of gambling (_> one day/week) occurred at a median age of 20 years. Ten
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CECILIA BERGH AND ECKART KULHORN
Figure 1 G a m b l i n g habits in b a c k g r o u n d family in t h e i n t e r v i e w
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years later most probands (79%) were unable to stop. The median duration of regular gambling was 14 years and of "inability to control" 3.5 years. The duration of gambling dependence was longer in the case-finding study (>_ 10 years), but unknown to the informants in 19 % of the cases. Some types of gambling became more frequent as gambling developed (Fig. 3).
Causes of Gambling. Reasons for continued gambling in the interview and case-finding study were: an urge to get rich (57 and 36%), excitement (57 and 33%), "beginner's luck" (31 and 3%), high status and feeling of competence (21 and 9%) and looking for sociality (19 and 22 %). Other reasons were interest in sports, mental problems, life events and recreation. The causes for pathological gambling were unknown to the informants in one third of the cases. Types, Pattern and Frequency of Gambling. The main types of gambling during the gambling career are shown in Fig. 4. Two-thirds (69 %) reported more than one predominant type. Pools, roulette, card
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Figure 2 Types of gambling (one or more) in background family in the interview study, (father n = 31, mother n = 19, sibling n = 23)
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games and horse races were the most frequent second types of gambling. In many cases (61%) the main type of gambling was the same as that engaged in by the father. Gambling occurred daily (41%) or weekly but not daily (52%) and a few gambled on weekends (2%) or periodically (5 %). The frequency of gambling episodes during the last 12 months were: daily or almost daily (60 %), -- twice/week (33 %) and 8% once/week.
Secret Gambling. Almost half of the pathological gamblers either concealed their gambling (46%) or its intensity (44%). Very few did not deny gambling (10%). Some commented: "I'm ashamed to tell people that I gamble at all" or: "When entering a casino bar I always look around to make sure that no one I know is around, if so I leave". The partner was mostly unaware of the pathological gambling (59 %), the majority (82%) hid their gambling from non-gambling peers and many (45%) did so to fellow gamblers. Chasing and Withdrawal Symptoms. Chasing (to bet more in order to recoup losses) occurred "often" or "always" in most (73%) and to a
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CECILIA BERGH AND ECKART K/~ILHORN
Figure 3 Types of gambling (one or more) during the course of d e p e n d e n c e in the interview study (onset n = 4 2 , regularity n = 4 2 , loss of control n = 33)
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lesser extent in almost all of the pathological gamblers (95 %). Depression followed gambling losses in a substantial proportion of gamblers (67%). A third (33%) reported two or more withdrawal-like symptoms, e.g. restlessness, irritation, sweating and trembling, when not gambling and, when gambling heavily, many (40 %) regularly experienced a state of altered consciousness: "removed from reality", "a feeling of being totally alone, despite being in a crowd", "a trance-like state of mind" or "exaltation".
Cravingfor Gamblingand Periodsof Abstinence. The majority (74 %) reported craving for gambling when not gambling. About half of these (52 %) experienced a strong craving "often" or "always," which lead to relapses in about two thirds (65%). Several pathological gamblers (63%) had experienced periods of abstinence lasting a week or more during the last year.
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Figure 4 M a i n t y p e o f gambling d u r i n g the p r o b a n d s g a m b l i n g c a r e e r ( i n t e r v i e w s t u d y n = 42, c a s e - f i n d i n g s t u d y n = 5 8 )
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DISCUSSION
Methodological Considerations Because of the bias in the selection of the gamblers in the casefinding study it is unclear if these are representative of active gamblers. As is the case with a clinical sample (Orford, 1985), a population of gamblers within districts of probation oversamples those known to the police and excludes those not in the records. Also, gender was not kept separate in this study because of the small number of women and because results from women were similar to those of men. Possible sex differences in pathological gambling deserve attention.
Family and the Onset of Pathological Gambling Gambling problems among fathers, but not mothers of pathological gamblers are frequent (present data; Lesieur et al., 1986; Ramirez
CECILIA BERGH AND ECKART KULHORN
et al., 1983). The form of gambling engaged in was same as that engaged in by the parent. It is possible, family gambling habits play a role in the development gambling (Bolen & Boyd, 1968; Lesieur et al., 1986;
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commonly the therefore, that of pathological Ramirez et al.,
1983). Although most probands were introduced to gambling by their father or peers, the addictive career starts only with the inability to control gambling. By this measure, pathological gambling had a relatively late onset.
Hazardous Gambling and Causes of Continued Gambling Gambling on horse races, roulette and bingo tended to increase with the development of pathological gambling. Possibly, therefore, these are hazardous forms of gambling, i.e. reinforcing continuous gambling due to immediate financial reward (Cornish, 1978). Epidemiological data will, however, be required to validate this suspicion. Causes for continued gambling were the urge to get rich and excitement (present data; Blaszcynski & McConaghy, 1989; Legg England & G/Stestam, 1991). High school boys worry about money (Wadden, Brown, Foster & Linnowitz, 1991) and since financial success is a concern for adolescent males (Simmons & Rosenberg, 1975), it may contribute to the development of pathological gambling. The possibility that this is the case among female gamblers as well requires collection of comparative epidemiological data. Betting to recoup losses, i.e. chasing, was common among the pathological gamblers in this study and it has been reported that the more money lost the more intense the chasing (Lesieur, 1979). Gambling addiction, therefore, may occur through intermittent reinforcement (Lesieur & Custer, 1984) because irregularly rewarded behaviour is difficult to extinguish (Ferster & Skinner, 1957).
Periods of Abstinence and Withdrawal Symptoms The probands did not always gamble. Some gained control for extended periods of time but relapsed back on occasion. Also, gambling was interrupted in the absence of money. Withdrawal-like symptoms during non-gambling periods and perceived altered consciousness when gambling heavily were not uncommon as has been reported
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before (Taber et al., 1987; Wray & Dickerson, 1981). It is possible that these reflect an advanced stage of pathological gambling, a hypothesis which deserves further study.
Collective and Solitary Gambling In the present study, about a fifth of the pathological gamblers stated sociality as the main cause for continued gambling. The majority of the pathological gamblers reported socializing with peers of the same inclination and most had met their gambling peers in gambling settings. Although excessive gambling may be a lonesome activity (Legg England & G6testam, 1991), there are apparently some collective features in pathological gambling. Most of the pathological gamblers concealed their gambling or its intensity by lying to partners, fellow gamblers, and others increasingly as gambling progressed; this is possibly because of the fear of disapproval by society, family and friends.
CONCLUSIONS Gambling habits in family background appear to play a role in the development of pathological gambling. It takes a considerable period of time to develop gambling beyond control. Although there are collective features in the development, pathological gambling appears to be a secret behaviour. Future studies on family interactions, sex differences and the factors contributing to loss of control seem warranted.
ACKNOWLEDGEMENTS
This work was supported by grants from The Commission for Social Research (D 89/0185). We thank Drs S. R6nnberg and H. Johnsson for placing patients at our disposal and Dr P. S6dersten, anonymous reviewers and the editor for commenting on the manuscript.
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