10 Addictions psychiatry10.9 Non-substance addictive behaviours
10.9 Non substance addictive behaviours
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Written by Resident Doctor Committee · Published
Classification
Feature | ICD-11 |
|---|---|
Gambling grouping | Gambling disorder (6C50), a disorder due to addictive behaviours |
Criteria | Impaired control, increasing priority and continuing despite harm, with distress or impairment |
Duration | Usually at least 12 months, shorter if severe |
Gaming | Gaming disorder (6C51) |
ICD-11 diagnosis depends on the pattern, its persistence and its effects on functioning, not on a fixed symptom count.
Epidemiology
Fewer than 1% of British adults, about 0.5% to 0.9%, are classed as problem gamblers in national household surveys.
Comorbidity is the dominant epidemiological feature, because problem gambling is strongly associated with other psychiatric disorders.
Why gambling persists
Variable ratio reinforcement rewards an unpredictable number of responses, so people gamble at high rates and the behaviour resists extinction.
Losses disguised as wins are celebrated with lights and sounds, though a £1 stake returning 40p is a 60p loss.
The gambler's fallacy is the belief that red is "due" after six blacks, though its probability on a European wheel stays 18 in 37.
The illusion of control is the belief that choosing numbers or pressing stop buttons improves the odds.
Chasing means gambling again or raising stakes to win back losses.
Assessment
Gambling harm may present as depression, self-harm, debt, relationship breakdown or crime, so clinicians should ask directly in higher-risk groups.
Suicide risk may be highest immediately after a gambling episode.
Screen | Items | Positive result |
|---|---|---|
Problem Gambling Severity Index (PGSI) | 9, scored 0 to 27 | 8 or more |
South Oaks Gambling Screen | 20 | 5 or more |
On the NODS-CLiP screen, any positive answer prompts a fuller assessment.
Gambling in mania follows elevated mood, reduced sleep and grandiosity, whereas gambling disorder persists across mood states.
Medication-induced gambling
Aripiprazole is associated with gambling disorder and other impulse-control problems, such as urges to shop, eat or engage in sexual behaviour.
This is attributed to its partial agonism at dopamine D2 and D3 receptors, unlike other antipsychotics, which antagonise postsynaptic D2 receptors.
Some cases resolve when the dose is reduced or the drug is stopped.
In Parkinson's disease, impulse control disorders affect about 14% overall and 17% of people taking dopamine agonists.
Treatment
Treatment | Evidence and use |
|---|---|
Cognitive behavioural therapy (CBT) | Some evidence; gambling-specific group CBT (8 to 10 sessions) or individual CBT (6 to 8) |
Motivational interviewing | Some evidence; helps ambivalence |
Opioid antagonists, usually naltrexone | Most consistent trial evidence for reducing urges and gambling; used after psychological treatment has not been enough |
Selective serotonin reuptake inhibitors (SSRIs) | Some evidence |
Mood stabilisers | Some evidence |
No medicine is licensed in the UK for gambling disorder, so naltrexone is used off-label and started by a specialist.
Before naltrexone, check renal and liver function, exclude opioid use and advise avoiding opioids.
The suggested regimen is 25 mg daily for 3 days, then 50 mg daily for 4 to 6 months, monitoring liver function.
GAMSTOP excludes a person from online operators licensed in Great Britain for 6 months, 1 year or 5 years.