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Pathological gambling and the DSM-VNancy M. Petry aa University of Connecticut Health Center , Farmington, CT, USA E-mail:Published online: 11 Aug 2010.

To cite this article: Nancy M. Petry (2010) Pathological gambling and the DSM-V, InternationalGambling Studies, 10:2, 113-115, DOI: 10.1080/14459795.2010.501086

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EDITORIAL

Pathological gambling and the DSM-V

The American Psychiatric Association (APA) is in the process of updating the fifth of

edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM). The DSM is

the primary classification system for diagnosing mental disorders in the United States, and

it is widely used in other countries as well.

Currently, pathological gambling is classified in the ‘Impulse-Control Disorders Not

Elsewhere Classified’ section of the DSM-IV (American Psychiatric Association, 1994).

The Substance Use Disorders Workgroup of the APA’s DSM committee has made a

recommendation to move pathological gambling to its chapter. This suggestion was based

on a vast body of literature demonstrating high rates of comorbidity between substance use

disorders and pathological gambling (Petry, Stinson & Grant, 2005; Kessler et al., 2008),

similarities in some symptom presentations (Petry, 2006), some potential parallel

biological dysfunction (Potenza et al., 2003), evidence of shared genetic liability (Slutske

et al., 2000), and overlap in treatment approaches (Hodgins, Curry & el-Guebaly, 2001;

Petry et al., 2006; Petry, Weinstock, Ledgerwood & Morasco, 2008).

In addition to recommending a change in location in DSM-V, the Workgroup has

suggested that the name of the disorder be altered. The term ‘pathological’ conjures

pejorative thoughts among providers, patients and the public. A working suggestion is

‘disordered gambling’. Terms such as ‘problem gambling’ and ‘compulsive gambling’

were considered but decided against. The former has often been used to refer to a

sub-diagnostic threshold condition and hence could lead to future confusion related to

severity, and the latter shares overlap with disorders in the anxiety disorders section of the

DSM. The final name for pathological gambling will be determined when the overall

chapter name is decided.

The most recent version of the DSM (revision IV) lists 10 criteria for pathological

gambling (American Psychiatric Association, 1994). Statistical analyses generally find

these 10 criteria tap a single uniform underlying construct (Strong & Kahler, 2007).

However, one of the ten criteria is rarely endorsed and appears to add little to diagnostic

classification accuracy. The criterion related to committing illegal acts (e.g. forgery, fraud,

theft or embezzlement) to finance gambling is the least often endorsed criterion in a

number of population surveys (Blanco, Hasin, Petry, Stinson & Grant, 2006; Gerstein

et al., 1999; Strong & Kahler, 2007), and item response theory reveals it adds little to

classification accuracy (Grant, 2010). Hence, the Workgroup has suggested that this

criterion be dropped in the next version of the DSM.

The other recommendation of the Workgroup is to reduce the number of criteria

necessary for a diagnosis of pathological gambling. Several population based studies

reveal that meeting four criteria, rather than the five currently necessary for a diagnosis,

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DOI: 10.1080/14459795.2010.501086

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improves classification accuracy (Jimenez-Murcia et al., 2009; Stinchfield, 2003;

Stinchfield, Govoni & Frisch, 2005). Additional analyses were undertaken on the

NESARC data when the legal criterion was eliminated, and similar results were found as

noted in the published studies with the threshold of four criteria (Grant, unpublished data,

2010). Hence, the Workgroup recommends that ‘pathological gambling’ be diagnosed

when one meets four of nine criteria in the next version of the DSM.

The Substance Use Disorders Workgroup received over 400 comments related to its

proposed changes during a period of open public commentary. Although not all responses

were favorable about all aspects of proposed changes to substance use disorders, the

overwhelming vast majority of comments related to pathological gambling were in support

of moving gambling to an ‘Addiction and Related Disorders’ section. Some argued to

reduce the number of criteria necessary for a diagnosis even lower than four (e.g. to two or

three criteria), but analyses from large population databases reveal that such changes would

substantially impact the prevalence rate of the disorder, by more than doubling the rate of

this disorder (Blanco et al., 2006; Welte, Barnes, Wieczorek, Tidwell & Parker, 2001).

Moreover, lowering the threshold for the first non-substance related ‘addictive’ behaviour

may set a precedence for setting the bar too low for future putative ‘behavioural addictions’

that may be introduced in subsequent versions of the DSM. Ultimately, low thresholds for

diagnoses could undermine the system of psychiatric classification more broadly and prove

a disservice to individuals with substantial psychiatric distress (Martin & Petry, 2005).

Moving pathological gambling to the substance use disorders section and reducing the

criteria and diagnosis threshold are likely to improve screening and treatment efforts in

high-risk populations. A new name for the disorder is also likely to be a welcome change.

It is hoped that these suggested alterations will improve diagnosis, treatment and research

efforts to better understand and ultimately prevent this disorder.

References

American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders(4th ed.). Washington, DC: American Psychiatric Association.

Blanco, C., Hasin, D.S., Petry, N., Stinson, F.S., & Grant, B.F. (2006). Sex differences in subclinicaland DSM-IV pathological gambling: Results from the National Epidemiologic Survey onAlcohol and Related Conditions. Psychological Medicine, 36, 943–953.

Gerstein, D.R., Volberg, R.A., Toce, M.T., Harwood, H., Johnson, R.A., Buie, T. et al., (1999).Gambling impact and behavior study: Report to the National Gambling Impact StudyCommission. Chicago, IL: National Opinion Research Center.

Grant, B.F. (2010). Unpublished data analysis from the National Epidemiological Survey of Alcoholand Related Conditions.

Hodgins, D.C., Currie, S.R., & el-Guebaly, N. (2001). Motivational enhancement and self-helptreatments for problem gambling. Journal of Consulting and Clinical Psychology, 69,50–57.

Jimenez-Murcia, S., Stinchfield, R., Alvarez-Moya, E., Jaurrieta, N., Bueno, B., Granero, R. et al.(2009). Reliability, validity, and classification accuracy of a Spanish translation of a measure ofDSM-IV diagnostic criteria for pathological gambling. Journal of Gambling Studies, 25,93–104.

Kessler, R.C., Hwang, I., LaBrie, R., Petukhova, M., Sampson, N.A., Winters, K.C. et al. (2008).DSM-IV pathological gambling in the National Comorbidity Survey Replication. PsychologicalMedicine, 38, 1351–1360.

Martin, P.R., & Petry, N.M. (2005). Are non-substance-related addictions really addictions?American Journal on Addictions, 14, 1–7.

Petry, N.M. (2006). Should the scope of addictive behaviors be broadened to include pathologicalgambling? Addiction, 101, 152–160.

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Petry, N.M., Ammerman, Y., Bohl, J., Doersch, A., Gay, H., Kadden, R. et al. (2006). Cognitive-behavioral therapy for pathological gamblers. Journal of Consulting and Clinical Psychology,74, 555–567.

Petry, N.M., Stinson, F.S., & Grant, B.F. (2005). Comorbidity of DSM-IV pathological gamblingand psychiatric disorders: Results from the National Epidemiologic Survey on Alcohol andRelated Conditions. Journal of Clinical Psychiatry, 66, 564–574.

Petry, N.M., Weinstock, J., Ledgerwood, D., & Morasco, B. (2008). A randomized trial of briefinterventions for problem and pathological gamblers. Journal of Consulting and ClinicalPsychology, 76, 318–328.

Potenza, M.N., Leung, H.C., Blumberg, H.P., Peterson, B.S., Fulbright, R.K., Lacadie, C.M. et al.(2003). An fMRI Stroop task study of ventromedial prefrontal cortical function in pathologicalgamblers. American Journal of Psychiatry, 160, 1990–1994.

Slutske, W.S., Eisen, S., True, W.R., Lyons, M.J., Goldberg, J., & Tsuang, M. (2000). Commongenetic vulnerability for pathological gambling and alcohol dependence in men. Archives ofGeneral Psychiatry, 57, 666–673.

Stinchfield, R. (2003). Reliability, validity, and classification accuracy of a measure of DSM-IVdiagnostic criteria for pathological gambling. American Journal of Psychiatry, 160, 180–182.

Stinchfield, R., Govoni, R., & Frisch, G.R. (2005). DSM-IV diagnostic criteria for pathologicalgambling: Reliability, validity, and classification accuracy. American Journal on Addictions, 14,73–82.

Strong, D.R., & Kahler, C.W. (2007). Evaluation of the continuum of gambling problems using theDSM-IV. Addiction, 102, 713–721.

Welte, J., Barnes, G., Wieczorek, W., Tidwell, M.C., & Parker, J. (2001). Alcohol and gamblingpathology among U.S. adults. Prevalence, demographic patterns and comorbidity. Journal ofStudies on Alcohol, 62, 706–712.

Nancy M. Petry

University of Connecticut Health Center

Farmington, CT, USA

Email: npetry@uchc.edu

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