Pathological Gambling: A Clinical Guide to Treatment

Pathological gambling is a common psychiatric disorder that is often not screened for by mental health professionals. Even when it is identified, many clinicians are unclear about how to manage pathological gamblers because of a lack of standard practice guidelines. Should it be treated like an addiction or like an obsessive-compulsive disorder? What types of psychotherapy work, and for how many sessions? Recently, scholarly research in pathological gambling has been increasing. As a result, there have been notable strides in understanding the neurobiology, epidemiology, and phenomenology of pathological gambling. Despite these advances, there is a large treatment gap between the number of pathological gamblers who need treatment and the numbers of available gambling treatment providers.

Pathological Gambling: A Clinical Guide to Treatment is the first book focusing on the treatment of pathological gamblers to be published by American Psychiatric Publishing, Inc. The book's overall purpose is to describe the clinical fundamentals of pathological gambling, from etiology to management. The book is not meant to be a comprehensive analysis of pathological gambling; instead, it concisely summarizes the most relevant clinical research findings from the past 15 years. To achieve this end, the editors have included writings from some of the most accomplished and prolific gambling researchers. To date, most of the books on treatment of pathological gambling have been first-person accounts or clinical excerpts. This book is unique in that it draws on evidence-based research in presenting treatment algorithms.

The book is organized into four sections: public health and epidemiology, clinical characteristics of pathological gamblers, etiology of pathological gambling, and prevention and treatment of pathological gambling. Part 1 provides an overview of the range of gambling behaviors and describes the impact of gambling on public health, taking both costs and benefits into consideration. The chapter on epidemiology is succinct, summarizing multiple epidemiologic studies on pathological gambling and calling for more longitudinal data. One element that is missing from this section is an overview of the history of gambling in the United States. Appreciation of America's ambivalence toward gambling, ranging from periods of prohibition to current widespread legalization, would have given the reader an appreciation of how rapidly gambling has expanded and why there is a need for mental health professionals to be aware of this disorder.

The chapters on the clinical characteristics of pathological gamblers (part 2) are especially strong and address the issues of how to conceptualize and subtype pathological gamblers. The tables on comorbidity are particularly informative and clearly summarize several years of research effort. The remainder of the section is dedicated to describing clinical features of pathological gamblers, focusing on adolescents, the elderly, and gender differences. This section, especially for readers who are unfamiliar with pathological gamblers, will dispel some of the myths of what pathological gamblers look like—they are not necessarily overweight, middle-aged white men who hang around racetracks and smoke cigars. One important clinical characteristic that is not included is a description of specific cultural factors that can contribute to pathological gambling. For example, certain cultures, such as some Asian cultures, are more permissive with gambling, which may lead to distinct vulnerabilities to pathological gambling.

Part 3 provides an overview of the behavioral and biological theories that are thought to explain the etiology of pathological gambling. Each chapter is concise and summarizes much of the known work in a few pages. The biological chapter is especially strong, being written in a way that can be easily understood regardless of the reader's level of familiarity with neuroscience. Although the authors emphasize a biopsychosocial model, little attention is given to the sociological factors that might contribute to pathological gambling. Common and clinically relevant issues, such as increased access to gambling, the role of changing technologies, and societal views on gambling, are important factors for clinicians to be aware of.

The final section, part 4, is divided into prevention and treatment. The authors spend a great deal of time emphasizing the fact that prevention efforts for pathological gambling are in the early stages. Prevention is an often-neglected area of treatment that every health care professional needs to utilize. There is no doubt, even though it has not yet been substantiated by data, that prevention efforts with gamblers will save significant amounts of time and money. The remainder of the chapter describes two forms of treatment for pathological gamblers that have the most supporting data, cognitive-behavioral therapy and pharmacologic management. These treatments are well described, and, because the number of studies is small, the review is comprehensive. Absent from these chapters is a section on other common forms of psychotherapeutic approaches to treating pathological gamblers, such as psychodynamic, supportive, motivational enhancement, and family therapy. Research into the efficacy of these forms of treatment is ongoing, yet they are commonly used by current gambling treatment providers.

The book concludes with a chapter on screening instruments and assessments that can be used in clinical practice. Many of these scales were used in research studies, thereby encouraging the clinician to bridge the gap from research into practice. This section is especially important given the small amount of treatment outcome data. Readers will, hopefully, be encouraged to use these scales to build up databases on pathological gambling treatment effectiveness.

The book does not have a concluding chapter but instead has as a series of appendixes that is extremely informative. These appendixes include screening instruments and gambling symptom severity measures that can, literally, be taken from the book and used immediately in the office.

In summary, Pathological Gambling: A Clinical Guide to Treatment is a well written and conceptually engaging book. Regardless of the reader's familiarity with pathological gambling, the book provides concise chapters that summarize the most recent research findings into clinically relevant messages. Because this is a relatively new field, there are more questions than answers, leaving the reader wanting to know more and wanting to read more about how to treat pathological gamblers. Overall, it is up-to-date, is organized well, and serves as a fundamental starting point for the treatment of pathological gamblers.

Dr. Fong is affiliated with the University of California, Los Angeles (UCLA) Neuropsychiatric Institute and Hospital and is director of the UCLA gambling studies program.