CaseStudiesofMentalHealthinGeneralPractice(23)
——PathologicalGamblingDisorder

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Introductiontothecase:Gambling is the wagering of money or something of value on an event with an uncertain outcome with the intention of winning additional money and/or goods or services.Internationally,70%-85% of adults report participated in some form of gambling activity in the previous 12 months[1].Problem gambling is an urge to continuously gamble despite harmful negative consequences.The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-Ⅴ),includes gambling disorder as a behavioural addiction[2].

Problem gambling is frequently associated with other mental health disorders including depression,anxiety and alcohol abuse,so treatment for problem gambling often involves simultaneous treatment for other mental health disorders[3].

Gambling in mainland China is illegal.Gambling in Chinese local communities is a dilemma because while it is part of the community it may create problems for citizens.There are no national studies of the prevalence of problem gambling in Mainland China.Hong Kong studies and studies of overseas Chinese however suggest that Chinese people may have problem gambling rates of between 1 to 2 per cent[4].In fact,problem gambling in China needs to be detected more often and assessed and managed.Screening for problem gambling amongst people with depression and anxiety is also important[5].

1　History

Ms Chenjie is a 64 year old widow living in Australia whose husband died four years ago.Her daughter Amanda,a 38 year old real estate representative,has brought her to your general practice clinic because she is concerned with her mother′s health.Ms Chenjie has history of hypertension (for 20 years),type II diabetes mellitus (for 6 years),and chronic arthritis (for 10 years).Two weeks ago,she became restless and irritable and said to her daughter′life is not worth living ′.Amanda told you that her mother preferred to take the advice ofher doctor,and she presents to the doctor asking,′please help me to bring my mother back on track′.

2　Furtherhistory

Ms Chenjie lives with Amanda and her son-in-law.She has no grandchildren.She attends a local hotel (with TAB sign) three days a week and wagers money on the slot machines.Often she plays from mid-morning to late evening.She claims she can beat the game.Ms Chenjie also buys three lottery tickets each day.She becomes very depressed on ′unlucky days′ and when she is not at the slot machines or the lottery booth.Inother days,she sits and watches TV at home.Her daughter and son-in-law have tried to get her involved in other community activities but she resists.Amanda give her mother 1 000 A$a month for her pocket money,and Ms Chenjie herself also receives the pension.But Ms Chenjie spends all of the money on the slot machine and lottery and also borrows money from friends or asks for more money from her daughter.Ms Chenjie even turns to her son-in-law for money for dubious reasons when her daughter refuses.Amanda explains that she has tried several times to ask her mother stop gambling,but was unsuccessful ′What else can I do?′ Chenjie explains,′You both are too busy to talk with me.Let me enjoy the only joy of life′.Ms Chenjie always says she will win,′I have lost many times which is just bad luck,and it must be my turn next time -I have my sixth sense.′Amanda agreed that game is sort of a ′killing time′ activity for some older people,but is now concerned that her mother is excessively addicted.

Ms Chenjie takes several medicines for her physical conditions,however she often fails to take her medicines and monitor her blood glucose,especially on gaming days.She also smokes (two packs per day) and drinks alcohol (three glasses of wine every evening).She complains of headache and tiredness for most of the day,and has poor sleep.She says that the joint pain is serious but the slot machine is her ′pain-killer′.

3　Examination

On mental status examination,Ms Chenjie is well groomed but appears restless and nervousness,with sweating and facial flushing during the consultation.She looks embarrassed when Amanda talks with you about her gambling problem.She is cooperative,speaks slowly and is orientated in time place and person.Her mood is sad,and affect has an agitated distracted quality.Her memory is normal and she has no thought disorder or perceptual abnormalities.She said she feels hopeless at ′game free time′,but denies any suicidal ideas.Her vital signs are temperature 37 ℃,BP 150/80 mm Hg,pulse 80/min,and no current signs related to the alcohol use or diabetes.

4　Questions

4.1What is the probability psychological diagnosis?

4.2What other diagnoses should be considered?

4.3What further investigations are required?

4.4How should Ms Chenjie be treated?

5　Answers

5.1What is the probability psychological diagnosis？Pathological gambling disorder should be considered - a severe form of problem gambling.She is preoccupied with the game (many days and long hours);she has experience of repeated unsuccessful efforts to cut back or stop playing;she is restless and irritable when she stops playing;she uses the game as way of escaping from loneliness and bereavement;she returns to the game to try to get even;she spends excessive money on the game and lottery;and she lies to daughter and son-in-law to get more money for gambling.

5.2What other diagnoses should be considered?Other mental health problems,such as manic or hypomanic episodes need to be differentiated from the pathological gambling.Patients with pathological gambling may exhibit behaviour during a gambling binge that resembles a manic episode.However,once the individual is away from the gambling,these manic-like features dissipate.People with elevated mood can behave in uncharacteristic ways and take risks like gambling but this occurs along with other symptoms of the mood disorder- and is episodic behaviour which only occurs during an episode of mood disturbance.

Co-morbidity:Ms Chenjie has smoking and alcohol drinking problem.Alcohol abuse is often associated with pathological gambling disorder.And gamblers are often nicotine-dependent;smoking is associated with increased severity of gambling problems and psychiatric symptoms.A 2008 Australian study found people with a gambling problem were nearly 20 times more likely to display severe psychological distress,more than four times more likely to drink alcohol at harmful levels than people without a gambling problem and nearly 2.5 times more likely to be depressed[6].

5.3What further investigations are required?Screening tools can be used to identify potential cases of problem gambling,to provide a definitive diagnosis and to assess the therapeutic need.The most important role of general practitioners is to find (screen) people for problem gambling.However,many general practitioners are not screening for gambling problems in their patients,both in Australia and in China[7].

The gold standard for determining whether a person has pathological gambling is the DSM-IV criteria however it is NOT a measurement (screening) tool.There are many screening tools available,for instance Gamblers Anonymous Twenty Questions (GA20) and South Oaks Gambling Screen (SOGS).In consideration of the limited time available of general practitioners,Thomas and his colleagues proposed the use of a ′One-item Screening Tool′ that is found to have good psychometric qualities in a large representative Victorian survey,so the GP should simply ask patients,"Have you ever had an issue with your gambling?"[5,8]as an appropriate screening question.

Further investigations that would be worthwhile in light of the high blood pressure and diabetes would include FBE,U+E,LFT,TSH,Lipids,Glucose,HbA1c,ECG and urine tests.

5.4How should Ms Chenjie be treated?In most countries,gambling is heavily stigmatised.For instance,gambling in China is identified (officially and socially) as one of ′social tumours′ together with prostitution and drug abuse.There are majors barrier to help-seeking for gamblers,especially for older people who have complex comorbidities and physical problems,which may mask the underlying gambling problems.Family and community members should be provided information about pathological gambling disorder:the patient has a mental disorder and need help to manage and treatment.

The most treatment approaches for pathological gambling are provided by mental health services or specialists.However,general practitioners can work with specialist as shown in a collaborative model[9].Psychological approaches for problem gambling can be provided by both specialist or trained general practitioners.

Cognitive behavioural therapy (CBT) and Motivational interviewing(MI) are two of the most established and researched psychological therapies for a wide range of mental health problem,including problem gambling[10].The provider should be appropriate trained and qualified.

Pharmacological approaches should also be considered in the overall context of the patient presentation.In practice,antidepressants〔selective serotonin reputable inhibitors (SSRIs)〕 are the most frequent medicine used in the treatment of depression of problem gamblers.

General practitioners of course need to also manage Ms Chenjie′s physical illnesses.Of note,the Motivational interviewing approach may well beuseful not only for the gambling but to facilitate behaviour changes for better management of her hypertension,diabetes and lifestyle.

1Volberg RA,Nysse-Carris KL,Gerstein DR.2006 California problem gambling prevalence survey[Z].Chicago:National Opinion Research Center,2006.

2American Psychiatric Association.Diagnostic and statistical manual of mental disorders[Z].5th ed.2013.

3Lorains FK,Cowlishaw S,Thomas SA.Prevalence of comorbid disorders in problem and pathological gambling:Systematic review and meta-analysis of population surveys[J].Addiction,2011,106(3):490-498.

4Wong LK,So MT,Phil M.Prevalence estimates of problem and pathological gambling in Hong Kong[J].Psychiatry,2003,160(7):1353-1354.

5Thomas SA,Piterman L,Jackson AC.Problem gambling:What do general practitioners need to know and do about it? [J].MAJ,2008,189(3):135-136.

6Thomas SA,Jackson AC.Risk and protective factors and comorbidities in problem gambling[Z].Report to beyondblue,Monash University and the University of Melbourne,2008.

7Problem Gambling Research and Treatment Centre.Guideline for screening,assessment and treatment in problem gambling[Z].Monash University,2011.

8Rockloff MJ,Ehrich J,Themessi-Huber M,et al.Validation of a one item screen for problem gambling[J].J Gambl Stud,2011,27(4):701-707.

9Blashki B,Judd F,Piterman L.General practice psychiatry[Z].2007.

10Sharpe L,Tarrier N.Towards a cognitive-behavioural theory of problem gambling[J].British Journal of Psychiatry,1993,162(3):407-412.