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Introduction
Several authors have suggested
that the need to escape negative emotional states partially explains the
motivation for persistent gambling in a proportion of participants (Blaszczynski
& McConaghy, 1989; Jacobs, 1989; Wynne, 1994). The central concept
underlying this view is that gambling is capable of producing sufficient
arousal to induce a state of narrowed attention, or an altered state of
consciousness characterised by amnesic episodes, trance and dissociation.
It is argued that this state of consciousness permits a person who is
gambling to temporarily 'switch off' from stressful thoughts, reduce boredom
(Blaszczynski, McConaghy & Frankova, 1990), escape emotionally from
their current situation or cope with feelings of inadequacy or rejection.
Although imprecisely defined, the phenomenon of dissociation, the cornerstone
of Jacobs' General Theory of Addictions (1989), is claimed to mediate
this process.
Studies demonstrate that gambling
is associated with subjective and physiological indices of arousal (Anderson
& Brown, 1984; Leary & Dickerson, 1985; Dickerson & Adcock,
1987; Roby & Lumley, 1995) and high scores on measures of dissociation
(Kuley & Jacobs, 1988; Brown, 1997; Gupta & Derevensky, 1998).
Empirical data offered by Diskin and Hodgins (1999) demonstrate the ability
of gambling to engross participants during play. The authors demonstrated
that reaction time in response to visual stimuli during a laboratory session
of gambling was slower and scores on a dissociative scale higher among
12 people with pathological gambling problems who played video lottery
compared to 11 occasional players.
We present an interesting case
of a male for whom arousal associated with gambling invoked a dissociative-like
state (or level of distraction) that induced analgesia for chronic back
pain. His gambling rapidly escalated as it was an effective strategy that
distracted him from his chronic back pain. According to principles of
operant conditioning, removal of pain negatively reinforced gambling and
led to the development of a gambling habit. However, consistent with the
behaviour completion mechanism model (McConaghy, 1980; McConaghy, Armstrong,
Blaszczynski & Allcock, 1983), once his gambling became a habit, he
acknowledged that he played independently of pain. He enjoyed gambling
for the excitement it generated, and in response to urges triggered by
stresses of any nature or source.
Case history
Mr. S.M. was a 48-year-old
married, self-employed businessman. He referred himself for treatment
because, for one year, he played slot machines and roulette excessively.
He reported a mean net expenditure of AUD $500 to $800 per session (on
infrequent occasions, more than AUD $1,000), frequently playing twice
a week for two hours. He endorsed seven of 10 DSM-IV criteria and obtained
a South Oaks Gambling Screen (Lesieur & Blume, 1987) score of 11.
Mr. S.M. produced bank statements verifying recurrent withdrawals of AUD
$200 from gambling venues.
Mr. S.M. consented to publication
of this case study.
Personal details
Mr. S.M., second youngest of
four boys, was born in Germany in 1950, went to school, and then migrated
to Australia with his family at age 20. His father, a cabinetmaker, died
20 years ago from a heart condition and his mother lives near his residence.
His developmental milestones were normal and his childhood unremarkable.
The family was close and he maintains irregular contact with his brothers.
In Australia, he commenced
but did not complete a diploma in chemistry. He was employed as a technical
assistant in a painting and printing research and development laboratory.
He subsequently embarked on a relatively successful career as a self-employed
businessman, importing goods and earning approximately AUD $240,000 per
annum. He is a gregarious and talkative person.
At age 21, he married a nurse
and they had three children. He described the relationship as "good."
In 1984, because they both worked long hours, they experienced marital
difficulties, which resulted in a two-month separation.
Mr. S.M. denied the presence
of a family or premorbid history of psychiatric illness, alcohol dependency
or illicit drug use. He consumed alcohol socially; less than two standard
drinks per day on average; although, because of a car accident, he drank
more when he experienced severe pain. There was no evidence suggesting
a personality disorder, thought disorder, antisocial or conduct-behavioural
problem, nor was there evidence of any significant medical illness prior
to the injuries sustained in the accident.
History of physical injuries
In June 1997, Mr. S.M. was
involved in a motor vehicle accident and sustained severe bruising, soft
tissue whiplash injuries and a fractured spine and sternum but did not
lose consciousness. He continued to suffer significant back pain and psychological
changes characterised by increased irritability, anger and depression.
His back pain was located in the lumbar regions L1 and L2 and upper neck
and shoulder area. He described it as severe fluctuating episodes lasting
a day or two with continual moderate pain. Using the McGill Pain Questionnaire
(Melzack, 1975), his pain was rated at a score of three; which is distressing
because of its intensity. Using the rank value method, the following pain
scale scores were obtained: sensory, 6; affective, 16; evaluative, 10;
and miscellaneous, 13; giving an overall total Pain Rating Index of 45.
He stated that he was unable to stand or sit for any length of time and
said this had hampered his ability to function at work.
Taking analgesic medication
such as Panadeine Forte and Efexor (300 mL) daily temporarily alleviated
pain but did not eliminate it completely. When the pain was severe, he
would consume several glasses of alcohol over a few hours.
Mr. S.M. became depressed due
to the pain, which interfered with his capacity to work and restricted
his quality of life. He consulted a psychiatrist for counselling and a
hypnotist for pain management and he initiated compensation because of
his injuries.
Gambling history
Mr. S.M. commenced gambling
at 17, infrequently betting AUD $5 on horse races at off-track betting
venues. He also began playing slot machines socially, and infrequently
attended a casino with friends and or his wife. There was no reported
loss of control over the 15-year period prior to 1998.
In March 1998, Mr. S.M. attended
a casino with his wife and won AUD $4,500. Significantly, he noted that
gambling (and winning) produced a state of excitement — powerful
enough to act as an effective analgesic for his pain. The excitement altered
his mood and self-confidence: "Nothing but happy thoughts, I'm on cloud
nine."
As a result, Mr. S.M.'s gambling
escalated rapidly over the following three months after learning that
gambling was effective in reducing his chronic back pain. Whenever the
pain increased, he gambled to reduce its intensity. All other concerns
and physical sensations were excluded from conscious awareness:
"…the concentration
on the gambling is so intense that I don't feel anything. I talk with
people at the roulette table and become very happy and relaxed. The
concentration is on the gambling. Very important, when gambling just
small amounts it becomes boring and the pain becomes noticeable. To
chase gives full concentration. The pain disappears. This does not
work without real [meaning substantial amounts] money."
On the Jacobs (1989) four-item
dissociative scale, he failed to endorse depersonalization ("…ever
felt like you were outside yourself watching…") and reported only
occasional memory lapses. The remaining two items were rated as frequently:
"I'm really into it [gambling], everybody is a shadow when I am playing" and "I feel totally
happy, invincible."
The negative reinforcing effects
of gambling led to a cycle where gambling represented a costly approach
to pain management. He lost substantial amounts and, given his restricted
capacity to earn money, was forced to sell investment properties to cover
expenses. He began to chase losses and developed erroneous beliefs about
his skills and probability of winning. Over three months, he lost approximately
AUD $20,000 and made repeated, unsuccessful efforts to cease gambling.
Between March and September,
Mr. S.M. was offered imaginal desensitisation (McConaghy et al., 1983)
and cognitive therapy designed to correct erroneous perceptions. He reported
an estimated improvement of 60 to 90 per cent (as assessed by frequency
and amount used to gamble).
Chiropractic manipulation partly
contributed to this positive outcome of pain reduction, and his back pain
stabilised to tolerable limits. In September 1998, he reported that he
gambled less frequently, reduced the amount substantially, and that current
gambling sessions were not motivated by the need to induce analgesia.
His gambling patterns changed significantly and he often gambled within
controlled limits motivated by social enjoyment. He made the conscious
decision to play for excitement in weekly one-hour sessions with a net
expenditure of $100. However, there were additional binge episodes that
were triggered by a range of stresses or depressed moods related to worries
over his compensation proceedings and inability to work. At these times,
he spent more than intended, losing up to AUD $250 to $350 per session.
At his October 1999 follow-up,
he reported continued improvement of approximately 80 per cent from pre-treatment
levels of amount and frequency of gambling. However, he still had intermittent
lapses during the intervening 12 months in which he lost up to $400 (amounts
significantly less than those lost in earlier binge episodes). On one
occasion, he was under considerable pressure and decided to gamble despite
the efforts of his friends to contain him. He acknowledged awareness of
his actions but felt the need to release pent-up stresses and the overwhelming
drive to gamble. In another episode, conflict with barristers and anxiety
associated with the preparation of compensation reports provoked a serious
episode where he gambled AUD $1,000 but aborted the session despite having
access to money.
When last seen, in December
1999, he reported no subsequent episodes of excessive gambling. On several
occasions he entered gambling premises with his wife, but either did not
gamble or limited his gambling to a small amount with no difficulty, deciding
to cease despite having AUD $2,000 or more in cash. He acknowledged a
persistent underlying urge to gamble but claimed it was controllable.
Given his fluctuating pattern of improvement, his prognosis was regarded
as positive, but uncertain in the longer term. Cognitive therapy and counselling
continued to be offered.
Discussion
It makes intuitive sense to
argue that gambling represents an exciting activity capable of generating
sufficient levels of arousal. Gambling offers an opportunity for emotional
escapism by narrowing a player's attention, and altering his or her state
of consciousness and sense of disconnection from self and environment.
From a behavioural learning perspective, the reduction in aversive mood
states is a negative reinforcer. Once immersed in gambling, all extraneous
aspects of a person's life can be excluded from conscious thought, while
attention and concentration are directed at the single task of winning,
anticipating the next outcome and the powerful, ego-boosting fantasy associated
with winning.
A number of authors have underscored
the desire to escape stressful situations, memories and aversive mood
states as a primary motivation for continued participation in gambling.
Anderson and Brown (1984) first hypothesised that the physiological arousal
and subjective excitement associated with gambling could sufficiently
narrow attention to allow participants to escape from their current state
of emotional distress.
Jacobs (1989; 1998) incorporated
this concept as a central feature of his General Theory of Addictions,
arguing that such arousal was comparable to dissociative-like phenomena.
He has produced convincing empirical data to show that people who gamble
experience blurred reality, shift in persona, depersonalisation and amnesia
for events occurring during gambling (Jacobs, 1998). According to Jacobs,
addiction is defined as "a dependent state acquired over time by a predisposed
person in an attempt to relieve a chronic stress condition" (Jacobs, 1989,
p. 35). Addiction to gambling specifically arises from an interaction
of two predisposing variables: an abnormal state of physiological hyper-
or hypo-arousal and negative childhood experiences invoking rejection,
inadequacy and low self-esteem.
In this model, the potential
to induce a dissociative-like state that diverts attention from chronic
aversive arousal states, deflects thoughts of self-perceived inadequacies
from consciousness and fosters the emergence of wish-fulfilling fantasies
that give gambling its "addictive" qualities. Gambling represents a problem-solving
method that permits psychological escape through mechanisms of dissociation.
"[It is a] normal…defence
we all use against distractions in everyday life. We also use dissociation
as a defense when high levels of psychological distress, physical
pain, or sense of helplessness caused by a traumatic incident or a
continuing aversive condition overwhelms a person's resources for
coping with the stress it engenders" (Jacobs, 1998, p. 4).
That people who gamble obtain
elevated scores on measures of dissociation has been found repeatedly;
(Gupta & Derevensky, 1998; Kuley & Jacobs, 1988) although with
some contrary results. For example, Diskin and Hodgins (1999) found that
a small sample of people diagnosed with pathological gambling problems
had higher dissociative scores than people who gambled occasionally, but
neither differed from normative scores.
However, dissociation is a
complex concept that lacks a single framework. It is variously conceptualised
as a non-integrated mental module or system, an alteration in consciousness
resulting in a disconnection from self or environment, or a psychological
defence mechanism (Cardena, 1994). In Jacobs' model, dissociation is used
with various meanings with no attempt made to distinguish it from altered
states that emerge as correlates of ordinary "distraction." As Cardena
(1994) cautions, labelling any simple disconnection between self and perceptions,
or emotions and thought as dissociative weakens the utility of the construct.
The term should be retained for circumstances where there is a qualitative
disconnection from ordinary modes of experience. We are suggesting that
there are many normal activities that engross the participant wherein
they become so focused they lose perceptions of external and internal
stimuli. These activities are enjoyable and participation is sought recurrently.
Examples are sporting contests, computer play, reading and board games.
Gambling can be conceptualised in the same vein without recourse to more
complicated concepts of dissociation.
In the present case study,
Mr. S.M. was so engrossed in gambling that he was distracted from pain,
which led directly to increased participation. It should be noted that
distraction is used effectively in pain management strategies without
recourse to dissociation as an explanatory process. Once the habit was
established, other factors superseded the analgesic effects as the primary
reasons for participation, notably, excitement and erroneous perceptions
surrounding the likelihood of winning.
Blaszczynski and McConaghy
(1989) adopted a similar position. They argued that gamblers experiencing
anxiety selected low-skill games, while dysphoric gamblers chose high-skill
games to modulate mood states and achieve optimal levels of physiological
arousal (Zuckerman, 1979). However, adopting a neo-Pavlovian, behaviour
completion mechanism model, McConaghy and his colleagues (McConaghy, 1980;
McConaghy et al., 1983) did not consider dissociation or negative childhood
experiences a necessary component of the aetiological process. Rather,
a wide range of current external or internal stresses was considered sufficient
to trigger the drive to gamble once a gambling habit was established.
This behaviour completion mechanism would drive the person to engage in
and complete the sequence of behaviours underlying the urge. The person
would experience this as a persistent preoccupation and urge to engage
in the behaviour and to carry it through until satisfactorily completed.
Attempts to impede this process would lead to an aversive state of increased
tension and continued drive to complete the behavioural sequence.
In addition to the operant
reinforcing qualities of the excitement of winning, the reduction in aversive
arousal associated with the urge to carry out a habitual behaviour to
completion and aversive emotional state were seen to represent important
negative reinforcers. In the case of Mr. S.M., when the physical pain
overwhelmed his coping resources, he gambled as a means of temporarily
reducing pain through distraction. Once this became a habitual pattern,
this strategy was applied to escape negative emotional states.
This client
case presentation was peer-reviewed.
Submitted:
July 17, 2000
Accepted: September 13, 2000
Correspondence:
Alexander Blaszczynski,
PhD
School of Psychiatry
Psychiatry Research and Teaching Unit
Level 4, Health Services Building
Liverpool Hospital
Liverpool, NSW 2170, Australia.
E-mail: a.blaszczynski@unsw.edu.au
Fax: +61
(2) 9828 4910
By Durand F. Jacobs, PhD,
ABPP
Clinical Professor
of Medicine (Psychiatry and Behavioral Sciences)
Loma Linda University Medical Center, California, USA
By Rina Gupta
Youth Gambling
Research and Treatment Clinic
McGill University, Montreal, Quebec, Canada
By David Hodgins
Coordinator,
Program Development and Research
Foothills Medical Centre, Calgary, Alberta, Canada
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