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AnnAls of CliniCAl PsyChiAtry AnnAls of CliniCAl PsyChiAtry 2011;23(2):105-112 strategic vs nonstrategic gambling: Characteristics of pathological gamblers based on gambling preference Brian L. Odlaug, BA BACKGROUND: Although prior studies have examined various clinical char-
Department of Psychiatry acteristics of pathological gambling (PG), limited data exist regarding the University of Minnesota clinical correlates of PG based on preferred forms of gambling. Minneapolis, MN, USA Patrick J. Marsh, MD Department of Psychiatry We grouped patients meeting DSM-IV criteria for pathological University of South Florida gambling into 3 categories of preferred forms of gambling: strategic (eg, cards, dice, sports betting, stock market), nonstrategic (eg, slots, video Suck Won Kim, MD poker, pull tabs), or both. We then compared the groups' clinical charac- Jon E. Grant, JD, MD, MPH teristics, gambling severity (using the Yale-Brown Obsessive Compulsive Department of Psychiatry Scale Modified for Pathological Gambling, the Clinical Global Impression– University of Minnesota Severity scale, and time and money spent gambling) and psychiatric Minneapolis, MN, USA RESULTS: The 440 patients included in this sample (54.1% females; mean
age 47.69 ± 11.36 years) comprised the following groups: strategic (n = 56;
12.7%), nonstrategic (n = 200; 45.5%), or both (n = 184; 41.8%). Nonstrategic
gamblers were significantly more likely to be older and female. Money
spent gambling, frequency of gambling, gambling severity, and comorbid
disorders did not differ significantly among groups.
CONCLUSIONS: These preliminary results suggest that preferred form of
gambling may be associated with certain age groups and sexes but is not
associated with any specific clinical differences. Brian L. Odlaug University of Minnesota Department of Psychiatry, Ambulatory KEYWORDS: impulse control disorders, pathological gambling,
Research Center 606 24th Avenue South, Suite 602Minneapolis, MN 55454 USA Annals of Clinical Psychiatry Vol. 23 No. 2 May 2011 strAtegiC vs nonstrAtegiC gAmbling reasons men prefer strategic forms, whereas escape from emotional trauma may underlie women's preference for Many people gamble as a hobby or for pleasure,1 but nonstrategic forms.20-22 Gamblers who prefer certain stra- some individuals develop a recognizable behavioral tegic gambling may have a heightened state of arousal23 syndrome classified as pathological gambling (PG). and low baseline levels of endorphins.24 Additionally, Epidemiologic studies estimate the prevalence of lifetime recent research suggests that substance-abusing recre- PG as 0.4% to 1.5% among adults in the United States.2-4 ational gamblers prefer strategic gambling as a means of PG is associated with impaired functioning, financial and gambling for excitement.25 interpersonal problems, and health-related problems.5-7 Although prior research suggests that gambling pref- In addition, co-occurring psychiatric conditions such as erence may inform our understanding of the heterogene- substance use (35% to 63%) and mood disorders (34% to ity of PG, these studies have been limited by the dichoto- 78%) are common in PG.4,8-10 mization of gambling into either strategic or nonstrategic. In an effort to better characterize PG and provide Many gamblers, in fact, have no gambling preference. The insight into etiology, prevention, or treatment, we con- National Research Council found that problem gamblers sidered that comparing putative subtypes of PG might were more likely than recreational gamblers to play all offer information regarding treatment response or dis- forms of gambling.5 This suggests that a lack of preferred ease course. Many psychiatric disorders have subtypes gambling style might reflect more problematic gambling or course specifiers, which provide information regard- and thus might be worth examining.
ing expected course and potential response to treatment. The goal of our study was to clarify the association Subtypes of alcohol dependence, for example, have long between preferred form of gambling and gambling symp- been considered clinically useful11,12 and may have pre- tomatology, using a large sample of treatment-seeking dictive power regarding disease course12,13 or treatment individuals with PG. Based on previous research,20,22,25 we hypothesized that: 1) nonstrategic gambling would be Thus far, only limited research has attempted to more common among women; 2) a lack of preferred gam- identify subtypes of PG. Moran16,17 identified 5 PG sub- bling choice would be associated with greater gambling types (subcultural, neurotic, impulsive, psychopathic, or severity; and 3) nonstrategic gambling would be associ- symptomatic) based on observations of 50 male patho- ated with depressive disorders, whereas strategic gambling logical gamblers with strategic gambling (horse/dog rac- would be associated with substance use disorders. ing). A different study used principal component analysis to identify 4 primary factors and matched traits associ-ated with PG: psychological distress, sensation seeking, crime and liveliness, and impulsive/antisocial behavior.18 The authors reported the presence of impulsivity and antisocial behavior as the most clinically useful, predict- Participants included adults age >18 meeting current ing the worst disease course. (past 12 months) DSM-IV criteria for PG when evaluated Studies indicate gambling preference may be clini- with the Structured Clinical Interview for Pathological cally significant and provide a means of subtyping indi- Gambling (SCI-PG).26 Patients were enrolled in 1 of sev- viduals with PG. Historically, gambling activities have eral clinical research trials investigating the effectiveness been divided into 2 groups: strategic and nonstrategic. of pharmacotherapies and psychosocial treatments for Nonstrategic games involve little or no decision making or PG.27-33 Although inclusion/exclusion criteria varied from skill, and gamblers cannot influence the outcome of the study to study, general inclusion criteria included a cur- game. Examples include slot machines, pull tabs, bingo, rent DSM-IV diagnosis of PG and the ability to provide and keno. By contrast, strategic games allow gamblers written informed consent. Persons with lifetime psy- to attempt to use knowledge of the game to influence or chotic or bipolar disorders were excluded. Other lifetime predict the outcome (eg, poker, blackjack, dog and horse disorders were not a reason for exclusion. Participants racing, sports betting, and craps/dice games).19,20 Studies were recruited over a 9-year period (2000 through 2008). examining preferred style of gambling have found that The study procedures were carried out in accor- higher rates of "action" or arousal-seeking behavior are dance with the Declaration of Helsinki. The Institutional May 2011 Vol. 23 No. 2 Annals of Clinical Psychiatry AnnAls of CliniCAl PsyChiAtry TABLE 1
Demographics of 440 pathological gamblers based on preferred type of gambling behavior
Both types
Age (± SD), years
F = 11.768 High school or less At least some col ege aStatistic: χ2 with df = 2; except for age where it was a one-way ANOVA (F = 11.768; df = 2,435).
bNonstrategic only vs Strategic only P < .05.
cNonstrategic only vs Both P < .05.
d"N"s for marital status and education differ from overall "n"s because those missing data were excluded: Marital: Nonstrategic = 200; Strategic= 55; Both = 179 Education: Nonstrategic = 182; Strategic = 54; Both = 169.
All variables are n (%) unless otherwise stated.
Review Boards of the University of Minnesota and Butler To determine preferred form of gambling, we asked Hospital approved the studies and consent statements. patients as part of the semistructured clinical interview All assessments were conducted by board-certified psy- which form of gambling, if all forms were available to chiatrists and psychologists familiar with PG treatment. them, they preferred. We also told them that "no prefer- Participants provided written informed consent after ence" was an acceptable answer. The question has not receiving a complete description of the study.
been validated. We did not give the patients a list of gam-bling forms from which to choose, but merely asked which form of gambling they preferred. If the form of gambling At the intake interview, board-certified psychiatrists (J.E.G., was unfamiliar to us, we researched it and placed it in one S.W.K.) assessed each participant using the Structured of the categories based on the criteria of whether or not the Clinical Interview for DSM-IV Axis I Disorders (SCID-I)34 player could potentially influence the outcome through and the Structured Clinical Interview for Pathological knowledge or prediction of the game. Strategic gambling Gambling (SCI-PG), a valid and reliable (k = 1.00) diagnos- consisted of poker, blackjack, dog and horse racing, sports tic instrument.26 In addition to a psychiatric assessment, we betting, and craps/dice games; nonstrategic gambling used a semistructured rater-administered questionnaire to consisted of slot machines, pull tabs, bingo, and keno. We collect detailed information on demographic and clinical did not ask which form of gambling they engaged in most features of PG (eg, preferred types of gambling, amount of often. Because mood state can affect gambling choice,35 money lost, triggers to gambling, legal and financial prob- we simply asked which form of gambling they preferred. lems related to gambling). All patients included in this anal- Therefore, due to availability of forms of gambling, it is ysis were drawn from states where multiple types of gam- possible that a patient preferred 1 form of gambling and bling (ie, both strategic and nonstrategic) were available. yet primarily engaged in a different form of gambling.
Annals of Clinical Psychiatry Vol. 23 No. 2 May 2011 strAtegiC vs nonstrAtegiC gAmbling TABLE 2
Clinical characteristics of 440 pathological gamblers based on preferred type of gambling behavior
Strategic
gambling
Age when started gambling, years
Age when gambling became a problem, years
Hours spent gambling per week
Total amount of money lost during past year (in
thousands of US dollars)
Percentage of annual income lost to gambling
during the past 12 months
PG-YBOCS total score
PG-YBOCS–Behavior subscale score
Clinical Global Impression–Severity scale
Primary triggers to gambling behavior, n (%)
Problems due to gambling, n (%)
a Statistic for type of gambling factor: 2-way ANOVA (SPSS UNIANOVA) type of gambling and sex as factors with age as covariate. Statistic shown is F and (degrees of freedom), except for Primary triggers to gambling, Other problems due to gambling, and Reasons for gambling were Multinomial regressions (SPSS NOMREG) Statistic shown is χ2 with df = 2 for Likelihood Ratio Tests.
bNonstrategic only vs Strategic only P < .05.
cNonstrategic only vs Both P < .05.
dStrategic only vs Both P < .05.
All variables are mean (± SD) unless otherwise noted.
NS The covariate age was nonsignificant and therefore was excluded from the model.
PG-YBOCS: Yale-Brown Obsessive Compulsive Scale modified for Pathological Gambling. We assessed current PG symptom severity using 2 ill"). The CGI-S has demonstrated excellent validity as a valid and reliable measures: measure of PG symptom severity over the past 7 days.38 • The Yale-Brown Obsessive Compulsive Scale Modified for Pathological Gambling (PG-YBOCS)—a valid and reliable 10-question, clinician-administered Based on self-report of preferred gambling type, the par- scale—assesses symptom severity over the past 7 ticipants were divided into 3 groups: strategic gamblers days,36 with excellent inter-rater reliabilities on both (ie, preferred cards, dice, or sports betting), nonstrategic the urge (ICC = 0.99) and behavior (ICC = 0.98) sub- gamblers (ie, preferred slots, bingo, video poker, or pull- scales.36 The first 5 items comprise the urge/thought tabs), and gamblers who endorsed no preference for subscale, and items 6 through 10 comprise the behav- either strategic or nonstrategic gambling. We compared ior subscale. Each item is rated on a 0 to 4 scale, with these 3 groups on demographic variables, measures of higher scores reflecting greater severity. current gambling severity, and co-occurring disorders. • The Clinical Global Impression-Severity scale (CGI-S)37 Between-group differences were tested using 1-way is a valid and reliable 7-item scale with scores ranging ANOVAs and Pearson χ2. Because of age and sex differ- from 1 ("not ill at all") to 7 ("among the most severely ences, 2-way ANOVA (SPSS UNIANOVA) was used with May 2011 Vol. 23 No. 2 Annals of Clinical Psychiatry AnnAls of CliniCAl PsyChiAtry (12.7%; 95% CI: 9.8% to 16.3%) preferred strategic games, Clinical characteristics of 440 pathological gamblers based on preferred type of gambling behavior
(Continued) and 184 (41.8%; 95% CI: 37.2% to 46.6%) reported no pref- erence for either strategic or nonstrategic gambling. Strategic
gambling
The nonstrategic gambling group was significantly older than the other 2 groups (TABLE 1). A significant dif-
Age when started gambling, years
ference in sex also was noted among the groups (TABLE
Age when gambling became a problem, years
1). Nonstrategic gamblers were significantly more likely
Hours spent gambling per week
to be female (71.5%) (P < .001). Strategic gamblers were Total amount of money lost during past year (in
more likely, on a trend level, to have at least some college thousands of US dollars)
education (79.6%) (P = .015). Percentage of annual income lost to gambling
during the past 12 months
PG-YBOCS total score
Strategic gamblers reported significantly younger age of first gambling experience (22.5 ± 11.4 years) (P < .001).
PG-YBOCS–Behavior subscale score
Nonstrategic gamblers were significantly more likely to gamble while feeling sad, lonely, or bored (P < .001). The Clinical Global Impression–Severity scale
groups did not differ significantly on measures of gam- Primary triggers to gambling behavior, n (%)
bling severity (TABLE 2).
The rate of reported financial problems was high (78.1%) for all 3 groups. On average, the sample lost 66.8% of their gross yearly income to gambling. Financial Problems due to gambling, n (%)
problems did not differ significantly among groups. The percentage of gamblers reporting work-related problems (eg, late for work, decreased job performance, absen- teeism) or relationship problems (eg, marital discord, a Statistic for type of gambling factor: 2-way ANOVA (SPSS UNIANOVA) type of gambling and sex as factors with age as covariate. Statistic shown is F and (degrees of freedom), not spending time with friends due to gambling) were except for Primary triggers to gambling, Other problems due to gambling, and Reasons for gambling were Multinomial regressions (SPSS NOMREG) Statistic shown is χ2 with df = 2 for Likelihood Ratio Tests.
numerically higher in the nonstrategic group. Bankruptcy bNonstrategic only vs Strategic only P < .05.
c (19.1%) and other legal problems (20.5%) were common Nonstrategic only vs Both P < .05.
dStrategic only vs Both P < .05.
type of gambling and sex as factors and age as a covari- throughout the sample, with no significant differences All variables are mean (± SD) unless otherwise noted.
ate for most analyses. Multinomial regressions (SPSS NS The covariate age was nonsignificant and therefore was excluded from the model.
NOMREG) were used for primary triggers to gambling PG-YBOCS: Yale-Brown Obsessive Compulsive Scale modified for Pathological Gambling. and other problems due to gambling.
All comparison tests were 2-tailed. A Bonferroni Current psychiatric comorbidity is presented in TABLE 3.
correction was used to correct for multiple comparions, We found high rates of co-occurring disorders with PG, yielding an α level of 0.05 to determine statistical sig- with depressive (30.2%) and substance use (24.1%) dis- nificance. Although limited data reached statistical sig- orders the most common. From group to group, however, nificance using the Bonferroni correction, we highlight we found no significant differences in comorbidity.
statistical differences at the 0.05 α level as findings with potential clinical significance.
Past studies that examined gambling preference did so as a secondary component of an analysis, with the primary focus on age39 or sex.40 This study is the first to examine Four hundred and forty adults with PG (54.1% females; a large group of treatment-seeking individuals with PG mean age 47.7 ± 11.4) were included in the study. Of exclusively with respect to gambling preference. For these, 200 (45.5%; 95% confidence interval [CI]: 40.8% to this, we used a broad range of self-report and clinician- 50.2%) reported a preference for nonstrategic games, 56 based measures. Using a larger sample than prior studies Annals of Clinical Psychiatry Vol. 23 No. 2 May 2011 strAtegiC vs nonstrAtegiC gAmbling TABLE 3
Current rates of psychiatric comorbidity in 440 pathological gamblers based
on preferred type of gambling behavior
Strategic
P value
Any depressive disorderb Any anxiety disorderc Any substance use disorderd Daily nicotine use aStatistic for type of gambling factor: Multinomial regressions (SPSS NOMREG). Statistic shown is χ2 with df = 2 for Likelihood Ratio Tests.
bAny depressive disorder = major depressive disorder and depressive disorder not otherwise specified (NOS).
cAny anxiety disorder = posttraumatic stress disorder, panic disorder, obsessive-compulsive disorder, social phobia, generalized anxiety disorder, and anxiety disorder NOS.
dAny substance use disorder = alcohol use disorder and drug use disorders.
All variables are n (%). allowed us to more completely assess gambling-related how preferred forms of gambling differ between women thoughts and behaviors and identify between-group and men may aid in the development of different pre- differences related to gambling preference.
vention and treatment strategies based on sex and gam- Consistent with our first hypothesis, nonstrate- bling preference. gic gambling was more common in women with PG. Contrary to our second hypothesis, gamblers Sociability of certain forms of gambling has been who lacked a preference for a particular form of gam- reported as a factor influencing women to choose bling did not report more severe gambling symptoms. nonstrategic gambling forms.41 Strategic games such Gambling preference has been associated with faster as poker may be more socially or culturally acceptable progression to problematic gambling46 and with dif- among men, with the result that women gravitate to ferences between problem gambling compared to rec- more nonstrategic gambling forms. The nonstrategic reational gambling.47,48 Our findings, however, suggest gambling group also was significantly older than the that among pathological gamblers the preferred form of strategic group (mean age 50.4 vs 43.8 respectively, gambling is not associated with greater severity of the which is consistent with previous research examining disorder. One possible explanation is that the range of gambling preference and age.39 Thus, whether the sex gambling symptom severity in this sample is too narrow issues associated with nonstrategic gambling apply to detect these differences. Another explanation might equally to younger cohorts awaits further examination.
be that preferred form of gambling plays a larger role Sex differences in PG may be particularly important in the development of a gambling problem and not in in terms of prevention and treatment. Although women maintenance of the disorder. in general gamble less than men, female gamblers have Contrary to our third hypothesis, PG patients shown poorer measures of mental health when com- who preferred nonstrategic gambling were not signifi- pared with male gamblers.40,42 Additionally, the asso- cantly more likely to have a depressive disorder. Many ciation between gambling problems and co-occurring individuals with PG gamble secondary to dysphoria, psychiatric conditions generally is stronger for women and dysphoria or depression often is associated with than men.42 Although the observed sex difference in a desire for social isolation.49-51 Nonstrategic gambling gambling choice may be primarily biologic,43 previous allows a person to escape feeling sad or depressed while investigations indicate significant social and cultural not interacting directly with others, and pathologi- influences.44 Some researchers have speculated that the cal gamblers with depressive symptoms have reported rapid action of slot machine gambling, for example, may choosing forms of gambling that promoted this isola- contribute to the faster onset of gambling in women.20 tion.49,50,52 Although depressive disorders affected one- Because women tend to progress from an initial gam- fourth to one-third of PG patients in this study, these bling experience to a pathologic form of gambling rates were not significantly associated with any particu- addiction more quickly than men,20,45 understanding lar form of gambling. One possible explanation is that May 2011 Vol. 23 No. 2 Annals of Clinical Psychiatry AnnAls of CliniCAl PsyChiAtry gambling behavior may be linked to a primary depres- these various settings. Although this methodology may sive disorder rather than a reflection of a primary per- have introduced some bias, heterogeneity of place and sonality feature (eg, lower risk-taking), and any form of time may reflect "real world" gambling pathology. Fifth, gambling activity functions as an escape or mood ele- the low rates of certain co-occurring disorders limit our vating behavior. ability to investigate the relationships between preferred Strategic gambling was not associated with higher form of gambling and psychiatric comorbidities. Sixth, rates of substance use disorders. Previous research on because certain information relied upon subjective recall strategic gambling with psychophysiologic measures has (eg, amount of income lost gambling) certain data may shown increased risk-taking behavior and overall defi- over- or under-estimate actual amounts. Seventh, the ciencies in decision-making behaviors associated with study excluded individuals with lifetime bipolar disorder. strategic forms of gambling.53 Previous research also has Because gambling may occur during manic episodes this found that sensation-seeking gamblers had higher rates study fails to capture a comorbidity that may relate to pre- of substance or alcohol abuse or dependence25,54 and ferred form of gambling. Finally, almost 4 times as many that engaging in either gambling or substance abuse patients endorsed nonstrategic compared with strategic because of negative mood states is common.55 The idea forms of gambling, which may have biased our results. of an impulsive/sensation-seeking gambler who enjoys Despite the limitations the study has multiple strengths, the risk-taking associated with strategic gambling and including the large sample of treatment-seeking patho- substance use, however, was not endorsed by our data. logical gamblers and the use of both self-report and cli- In fact, higher rates of daily nicotine use trended toward nician-administered measures with strong psychometric significance in the nonstrategic group (P = .023), a find- properties and established norms.
ing consistent with prior research.56 This difference seems largely attributable to slot machine and bingo gambling. These forms of gambling typically occur in casinos, halls, or other venues in which groups congre-gate. Public health concerns related to first- and second- Our results suggest that age and sex affect pathologi- hand smoke have led to recent restrictions on smok- cal gamblers' preferred forms of gambling, but severity ing within some but not all such venues. The potential of gambling symptoms and psychiatric comorbidities impact that such restrictions have on gambling behav- do not. Pathological gamblers might have such high iors warrants investigation. gambling symptom severity and rates of co-occurring disorders that subtyping based on gambling preference limitations and future directions
provides little information in this group. Future research This study has several limitations. First, no standard could investigate whether subtyping based on gambling exists for subtyping methods of pathological gambling. preference has more utility in predicting outcomes in Thus, our subtyping criteria were based on reported recreational and problem gamblers as opposed to patho- gambling preference and whether the person could logical gamblers. ■ potentially influence the game's outcome through choice or the outcome was left to chance (as in slot play). Future ACKNOWLEDGEMENTS: This research was supported in part
studies could explore our criteria and the Blaszcynski by a Career Development Award by the National Institute and Nower (2002) pathways model, which suggests 3 of Mental Health (K23 MH069754-01A1) (J.E.G.). subgroups of pathological gamblers based on emo-tional, biologic, and ecologic factors.57 Second, because DISCLOSURES: Dr. Grant has received research grants
a treatment-seeking sample was used the results might from Forest Pharmaceuticals, GlaxoSmithKline, and or might not apply to nontreatment-seeking individu- Somaxon Pharmaceuticals. Dr. Grant has also been a als with PG. Third, lack of ethnic/racial diversity in our consultant to Somaxon Pharmaceuticals and for law sample may suggest that these findings will not apply to offices as an expert in pathological gambling. Mr. Odlaug members of different ethnic and cultural groups. Fourth, and Drs. Marsh and Kim report no financial relationship the patients were recruited over several years from a vari- with any company whose products are mentioned in this ety of venues without control groups being taken from article or with manufacturers of competing products.
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