In gambling’s grip

The day that Marilyn Lancelot won the biggest jackpot of her life, she left the casino in Yuma, Ariz., with every penny of the $4,000 that had poured out of the slot machines. This time she knew that she would never gamble again.

She was right, although not for the reasons she thought. The next day, seven police cars appeared in her Phoenix driveway and she was taken out of her house in handcuffs. The 61-year-old grandmother had embezzled more than $300,000 from her employer to support her gambling addiction.

“I had something wrong with me,” says Lancelot, now 75 and living in a retirement community in Phoenix. “Some people can’t think that gambling is an illness but maybe it is. I know that I couldn’t stop. My head wouldn’t let me.”

Lancelot’s turn of phrase contains clinical truth. Researchers are learning that the heads — or to be more accurate, the brains — of pathological gamblers are biologically different from those of most of the estimated 73 million Americans who are able to play bingo, pull the arm of a slot machine or flip some aces and then simply stop. Not only does the research shed light on how this addiction is both similar and distinct from other addictive disorders, it also could contribute to new treatments.

The need is undeniable. With legalized gambling in 48 states, 40 states with lotteries and online gambling available in any home with Internet access and a credit card, the triumph of the occasional big win has been accompanied by a rich yield of individual lives in shambles.

About 1.6% of Americans have a full-blown gambling addiction and an additional 2% have a serious problem with gambling, says Jon Grant, assistant professor of psychiatry at Brown Medical School and author of “Stop Me Because I Can’t Stop Myself,” (McGraw Hill, 2003). By these estimates, nearly 4% of the population experiences a mild to severe gambling problem — and as the number of gamblers goes up, so does the number of those with a gambling problem.

In California, “We think that virtually everyone knows someone who has a problem,” says Bruce Roberts, executive director of the California Council on Problem Gambling, who has experienced the frightening trajectory of gambling addiction. Officially, about 1 million Californians are considered problem gamblers.

Now, with the aid of neuroimaging techniques and a greater understanding of neurotransmitters, researchers are discovering that the brain’s hard-wired reward system and frontal lobes have certain unique characteristics in these gamblers. Even some of their personalities and genes may be different from those without gambling problems.

“We are finding that pathological gambling is very definitely a brain disease,” says Timothy Fong, a psychiatrist and codirector of the UCLA Gambling Studies Program. “The central question is: Were pathological gamblers born that way or are the changes in their brains the results of excessive gambling? We are far from answering that question in a meaningful way.”

Pathological, or compulsive, gamblers simply cannot stop gambling, even when their losses cripple their lives. The narratives, though as unique as each life, have a similar trajectory: a fascination, then obsession with gambling, punctuated by a few wins and colossal losses often involving houses, jobs, personal relations and savings, finally resulting in a shattered life.

Nearly 20% of pathological gamblers have filed for bankruptcy protection, compared with 4.2% of non-gamblers. But perhaps a more telling, and certainly more tragic consequence, is that compulsive gamblers are nearly four times as likely to have attempted suicide than non-compulsive gamblers.

The disorder was officially categorized by the American Psychiatric Assn. as a diagnosable disorder in 1980, but was categorized as an “impulse control” disorder rather than an addiction like alcoholism.

As research during the last 25 years has revealed, however, it is both. The brain can become addicted to behaviors as well as substances, Grant says. “It can be addicted to anything that we find rewarding,” he says. “If we find it too rewarding, we will want to do it again and again. Even when they lose all their money and credit cards, they describe intense cravings much like people do for drugs.”

The explanation for why gambling is the drug of choice for one person, and for another it’s heroin is still unknown. But the key to most addictions can be found in the brain’s reward system, particularly a region called the ventral striatum. Neuroimaging studies of compulsive gamblers point to a different functioning in this neural system.

A study published in February in the journal Nature Neuroscience compared 12 pathological gamblers and 12 healthy people. While lying in a functional magnetic resonance imaging machine (fMRI), all were asked to choose a playing card by pressing a button. If the card was red, they won money; otherwise they lost money.

The task activated the ventral striatum, also known as the nucleus accumbens, an area of the brain that is primed for pleasure and reward-seeking behavior. But the experience of pleasure was far less pronounced for pathological gamblers. The more serious the gambling problem, the less activation of that region.

When the area is working normally, it responds appropriately to pleasure stimuli — such as winning money or getting a gift — filling us with a sense of happiness or satisfaction. When it is not working properly, as in cocaine addicts, this area seems almost indifferent. What would make a normal person react does nothing for people addicted to substances or behaviors. Even more stimuli, such as drugs, alcohol or gambling, are needed to feel the pleasure from a particular activity.

“You experience something very nice that gives you pleasure,” says UCLA’s Fong. “But then other parts of the brain seem to shut down and you need to have the reward so much that it takes over the rest of the brain.”

Marilyn Lancelot remembers the feeling of surrendering to the impulse of playing the slot machines. She couldn’t have cared less about horse races or bingo, but the slot machines mesmerized her.

“Gambling occupied everything in my mind,” she recalls. “When I sat at the slot machines, it was like a switch and they shut off everything real. The slots would become me and my dream world.”

Research presented at the American Academy of Neurology meeting in April found that executive function, the brain circuitry that underlies inhibition and self-control, was deeply impaired in pathological gamblers. These impairments made the gamblers unable to truly comprehend the trade-off between short-term reward and long-term negative consequences.

This loss of self-control in turn affects other important brain functions needed to step on the brakes when emotions spin out of control. Those who suffer from attention-deficit disorder experience difficulty with executive function, and researchers have found, not coincidentally, that a high percentage of pathological gamblers also have ADD.

Many studies suggest that compulsive gamblers may have reduced frontal lobe activity, which may in turn be triggered by decreased activity in the basal ganglia, a deeper part of the forebrain that generates two important neurotransmitters called dopamine and norepinephrine.

The feel-good neurotransmitter dopamine, in particular, has intrigued those studying compulsive gamblers. Several studies have looked at a dopamine receptor gene and have found real differences in the structure of that gene between gamblers and non-gamblers.

That genetic predisposition has direct consequences on brain chemistry. The dopamine receptor sites in the midbrain that are driven by anticipation, but uncertain of the rewards, are especially sensitive. They require more and more dopamine to create the rush of happiness and satisfaction. When gambling is the trigger for the dopamine rush, a vicious cycle is created.

A study in the Archives of Neurology last month looked at 11 patients with Parkinson’s disease who were taking an artificial dopamine, nine of them took pramipexole and two others took a similar drug called ropinirole. Eventually they all became compulsive gamblers, and seven of them did so within three months

A 53-year-old registered nurse, who had gambled only once in five years, began going to casinos once a week. A 54-year-old minister who had gambled only an occasional $20 at a local casino began to gamble almost daily and over several months lost more than $2,500. And a 52-year-old married man who had never had a problem lost more than $100,000 gambling. He also developed a voracious appetite for food and sex, gaining 50 pounds and engaging in extramarital affairs.

Although the research focused on medication side effects for those with Parkinson’s disease, the study also shed light on both dopamine and compulsive gambling.

“This research makes us more sensitive to the idea that there are deficits in certain brain areas of gamblers,” says Leann Dodd, a psychiatrist at the Mayo Clinic and lead researcher in the study. “It adds to the evidence that gamblers might have a decreased capacity to get stimulation from their pleasure system and they need extra stimulus to get there.”

Roberts, of the California Council on Problem Gambling, whose costly “drug of choice” was poker, experienced the physical and behavioral rush of gambling.

He made his last bet Dec. 12, 1989, and realized that he had “to get help or die.” He had refinanced his home nine times to support his compulsive gambling and had lied about nearly everything to his wife.

“Even today I may be flipping through channels and see poker on TV,” he says. “It may be someone I played with years ago and I stop to take a look. I can feel my insides changing. It is kind of like a little adrenaline rush, the way you feel when you come close to having an accident on the freeway. You feel your body coming alive to the stimulus.”

And yet, some people can feel the same excitement and gamble within their means, enjoying the game, while others are completely out of control. Perhaps it is also a question of personality.

In a paper last month in the Archives of General Psychiatry, researchers looked at the personality and temperament of 939 men and women, all born in 1972 or 1973, to see if they could discern some personality traits that compulsive gamblers all shared. They also wanted to find out if these traits related to those in substance abusers.

All the participants were given a personality test when they were 18, and then at 21 they were screened to see if problem behaviors such as compulsive gambling, drug and alcohol abuse or nicotine dependence, had emerged. The researchers found that the problem gamblers shared many personality traits with others with addictive disorders: risk taking and impulsivity.

Until now, treatment has consisted primarily of cognitive behavioral therapy, which can help gamblers control impulses. But increasing understanding of the neurobiology of the disorder may result in new and more effective treatments.

One promising treatment is the drug naltrexone, an opioid receptor antagonist. In several preliminary studies, the drug reduced the urge to gamble and when gambling did occur, there was much less enjoyment or enthusiasm for it. Side effects can be unpleasant, and the drug can be toxic to the liver.

Antidepressants and mood stabilizers have also been used to treat gamblers, but they have had only mixed success.

But, writes Richard Rosenthal, the director of the UCLA Gambling Studies Program, “Medication should be thought of as an adjunct to the treatment of pathological gambling. Most gamblers can be treated successfully without it.”

Both Marilyn Lancelot and Bruce Roberts credit their recoveries with a treatment program, not with drugs. They changed their behavior and simply stopped gambling. For other people, more intensive supportive therapy is necessary, or even placement in a residential treatment facility where each hour of the day is scheduled.

Roberts’ life is financially stable and he now organizes educational programs on the human costs of gambling addiction.

Lancelot now boasts a triple-A credit rating, works part time and is saving money. In January she will celebrate 15 years of being free from gambling. “I’ll bet that the next 15 will be even better,” she says. “But I don’t bet.”

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Signs of trouble

Pathological gambling is classified not under addictions in the Diagnostic and Statistical Manual of Mental Disorders, or DSM IV — the diagnostic bible of the American Psychiatric Assn. — but rather with kleptomania and pyromania as an “impulse control” disorder. A person must demonstrate five or more of the following 10 characteristics to be considered pathological, although some experts say that possessing several of these characteristics can point to signs of trouble. Signs of being a pathological gambler include:

• Preoccupation with gambling, reliving past gambling experiences or thinking of ways to get money with which to gamble.

• A need to gamble with increasing amounts of money to achieve the desired excitement.

• Repeated and unsuccessful attempts to control, cut back or stop gambling.

• Restlessness or irritability when attempting to cut down or stop gambling;

• Gambling as a way to escape from problems or relieve a depressed or unhappy mood.

• After losing money, returning another day to get even or “chase” one’s losses.

• Lying to family members, therapists or others to conceal the extent of involvement in gambling.

• Committing illegal acts such as forgery, fraud, theft or embezzlement to finance gambling.

• Jeopardizing or losing a significant relationship, job or educational or career opportunity because of gambling.

• Reliance on others to provide money to relieve a desperate financial situation caused by gambling.

— Marianne Szegedy-Maszak