PATHOLOGICAL GAMBLING DURING ADOLESCENCE
Pathological gambling manifests by a persistent and recurrent gambling behavior, characterized by an impulse decontrol, havingas a result the disadjustment in terms of personal, family, school or professional life. This article presents the case of a 17-year oldteenager who came to our hospital of his own accord asking for specialized help in order to solve this issue he had been dealingwith for about one year.
The beginning of pathological gambling generally occurs during adolescence with men and later on in their adult life with women. According to the international classifications in use, the pathological gambling is currently included in the category of Impulse Control Disorders (DSM-IV-TR) and the Habits and Impulses Disorders (ICD-10). But the recent approaches debate upon the conceptualization of pathological gambling as a non-pharmacological addiction or as an obsessive-compulsive disorder. The essential feature of the pathological gambler is the growing persistence to gamble, despite the negative consequences of it, namely great financial problems, deterioration of the relationship with the rest of the family and with friends, the affectation of the personal life. Presently, there is no unanimously accepted pattern of the gambler, but Blaszczynski and colab., 2002 (quoted by Lupu 2008) suggest the division of gamblers into three behavioral groups:
- pathological gamblers with behavior disorders;
- pathological gamblers with emotional disorders;
- pathological antisocial gamblers with impulsivity problems.
“Catalin”, aged 17, coming from a rural environment, came to our hospital of his own accord for a clinical examination related to the fact that he had spent great amounts of money on gambling; he manifested difficulties in controlling his behavior, irritability, difficulties about falling asleep, terrifying nightmares.
The boy comes from a disorganized family, his mother being away to work abroad for one year and his step-sister being taken care of by some neighbors.
Within the family case history, we mention his maternal grandfather – chronic potatory and his mother suffering from a psychiatric disease under treatment. Upon hospitalization, the boy was living in his parent’s house all by himself. The school results were very good during primary school, they lowered in the fifth grade due to inappropriate peer group and to lack of attendance and in the ninth grade he quit school. He has several adult friends. Starting with the age of 16, he took up gambling in casinos (roulette and slot machines), but all this time he only won one time. He lost bigger and bigger amounts of money, the biggest being 2500 euro in one day. This is why he had to borrow money and sell his personal assets and eventually he started making money illegally. He gambled in casinos in different counties and the most time he has spent in a casino was 48 hours. He started neglecting his personal hygiene, his alimentation and took up drinking alcohol. He has lost 20 kg in the past year due to inappropriate life rhythm. After he had lost the above-mentioned amount, the patient had an autolysis attempt by pills ingestion. After that, he started wishing to quit gambling and he had not been in a casino for approximately 2 weeks before hospitalization. Yet, he kept playing roulette on the computer for several hours a day. He related the sleeping disorders (difficulties in falling asleep and terrifying nightmares) to the fact that he was very concerned about his deeds, as a result of gambling and possibly of psychoactive substances consumption – caffeine, energizers.
Psychiatric and psychological examination have revealed as follows: cognitive development appropriate to chronological age, IQ=92 (RAVEN test), good, intermittent cognitive capacity due to the difficulty of establishing a thinking strategy, unstable, fatigable attention focused on gambling activities, low self-esteem (he thought he was a “loser” and a “parasite”), low tolerance to minor frustration, irritability, irascibility, emotional immaturity, fear for the possible consequences of his deeds, defense instinct slightly diminished, hyperactivity, impulsivity, non-observance of rules, inconsistency in making decisions, truth misrepresentation, theft, roulette gambling on bigger and bigger amounts of money, alteration of the relationship with his grandparents, his sister and his neighbors (due to his behavior), trouble with the police, toxic substances consumption: tobacco since 12 years old, about 30 cigarettes a day, alcohol 2-3 times/month (up to now he suffered 2-3 acute alcoholic intoxications), 5-6 cups of coffee plus 1-2 energizers a day; insomnias, terrifying nightmares 2-3 times/week, sleep talking, structuring, disharmonic personality with emotional unstable elements.
The Biorad toxicological multi-drug urine test carried out upon hospitalization was negative. The electrocardiogram has revealed a track without modifications, but he refuses blood collection for the laboratory tests, explaining he simply does not want to.
HADS test has been carried out, which has shown high anxiety scores (16 points, above 10 being pathologic) and a score within normal limits for depression.
Also, he has been asked the 20 Questions of the Anonymous Gamblers in the USA to which he gave 16 positive answers related to pathological gambling, when a positive diagnosis requires 7 positive answers.
DSM-IV-MR-J scale has also been applied (the items for Diagnostic Statistical Manual-IV-Multiple Response-Adapted for Juveniles) with 8 positive answers out of 9 questions, when a problem gambler is defined if he gives 4 positive answers. As a result of the tests, investigations and surveys applied have been established the positive diagnoses of Pathological Gambling, Social Behavior Disorder, Non-Organic Sleep Disorder (Insomnia. Nightmare dreams) Psychoactive substances consumption (tobacco, caffeine, alcohol) damaging for the health and Unusual family situation. There has also been the possibility of the existence of Hyperkinetic Disorder, but the hetero anamnesis data are missing. We excluded the hidden depression by behavior disorder, but also the existence of a maniacal episode when the pathological gambling could have occurred.
The aims for treating this case have been as follows: self-esteem improvement, improvement of the sleeping condition and the establishment of a lifestyle appropriate for his age (sleep schedule, regular meals, personal hygiene, reduction of the time spent in front of the computer and TV, reasonable spending of money), renunciation of gambling, reduction or interruption of the toxic substances consumption, social care with the purpose of re-registration in school and family.
The intervention methods have been the pills cure, psychological/psychiatric counseling, cognitive and behavioral psychotherapy techniques and social intervention. We have started by informing the patient about his current condition and drew up a list of good news (his wish for help, the fact that he is in a specialized institution, that he has not gambled in a casino for 2 weeks, that he has changed his telephone number so that he cannot be contacted by his former friends) and a list of bad news (the absence of his family along the therapeutic process, the toxic consumption since an early age, the deeds he committed in order to get money could have repercussions, the fact that he is still gambling on the roulette on the Internet for many hours a day – harm reduction).
The medicamentous treatment consisted of hypno induction treatment with zolpydem, mood stabilizer with carbamazepine (600mg/day, namely 10mg/kg body/day) and substitution with nicotine plaster – Nicorette. Within counseling and psychotherapy, we and the patient drew up a list of the negative and positive effects of gambling on life in order to highlight the inclination of the balance for one of the two, the longest list being the one with negative effects. He received informative materials in order to read about gambling (including cases of people who gave it up) and about the damaging effect of alcohol and tobacco consumption. We have identified the irrational cognitions relating to profit. We have worked on his self esteem, he was taught the relaxation breathing technique in three times. He was offered counseling related to the continuation of studies given his cognitive potential. He has been involved in occupational group activities therapy and in sports activities. The hospital social worker assessing the case has also been involved and he required a social inquiry from the residence City Hall and tried to find a school so that he could go on with his education, but the patient showed disinterest in going to a public school because there he should study in order to take his exams. During the psychotherapy sessions, there were times when “Catalin” did not want to continue, with no reason and so he showed his inconsistency in his decision of being helped.
We have assessed the results of the intervention after the first hospitalization (14 days) and they consisted of sleep condition improvement, reduction of irascibility and irritability, reduction of anxiety (with HADS: A=8 points in comparison with the 8 points upon hospitalization), persistence of his wish to give up gambling to which was added the desire to give up smoking, and the improvement of his psychic condition on a scale from 1 to 10 was assessed by the patient with 7, in comparison with 1 upon hospitalization.
The reassessment a month after he got out the hospital showed that the teenager did not gambled in a casino, but that he keeps playing computer games.
Catalin moved back to his maternal grandparents and is trying to improve his relationship with them. He has not decided to take up school again. HADS test maintained within normal score in terms of anxiety and depression.
The particularity of this case lies in the fact the patient came to our institution of his own accord in order to get specialized help, given the fact that pathological gambling is a ego-syntonic disorder. On a long term, the previsions for this case are still reserved due to the lack of family and social support, to the difficulties in attending counseling and psychotherapy sessions due to the fact that he resides in a rural environment, he took up toxic substances and gambling at an early age, he committed infractions in order to get money and he has a disharmonic personality.
- Lupu V. 2008. Pathological gambling at adolescents. Ed. Risoprint, Cluj-Napoca.
- Lupu V. 2009. Introduction in the hypnoterapy and in the cognitive-behavioral psychotherapy of child and the adolescent. Ed. ASCR, Cluj-Napoca.
- Diagnostic statistical of mental diseases manual (DSM). 2003. Fourth ed. revised. The Free Psychiatrists Association of Romania, Bucharest. First publishing by American Psychiatric Association, Washington DC and London. 2000
- World Health Organization. 1998. Classification of the mental and behavioral diseases. Ed. All Educational, Bucharest.