Letters to the Editor
Reply: Pathological Gambling and Cross-Addiction
Dear Editor: Dr Procopio read the editorial and 2 articles (1–3) published in the August 2004 issue of the CJP on pathological gambling with enthusiasm; however, he ultimately felt somewhat disappointed. He believes that some important issues were left out and that some comments may not adequately reflect our understanding of this disorder. In the following comments, we address the main issues raised by Dr Procopio.
Dr Procopio criticizes the editorial as follows:
The editorial by Dr Ladouceur attempts to explain problem gambling in terms of a pure cognitive model (1), according to which pathological gambling stems from the sufferer’s inability to understand the independent randomness of chance events, confirmed by the fact that most individuals will hold nonscientific, false beliefs if exposed to gambling.
Ladouceur’s editorial goal was not to present an exhaustive critical review of the literature on the causes of pathological gambling or to explain its etiology. The editorial described a central attribute associated with the experience of pathological gambling—the hope to win money. Contrary to Dr Procopio’s statement, the cognitive theory was not focused on the etiology of pathological gambling. Rather, “The central consequence, and possibly the core factor in causing gambling problems, are the financial losses” (1, p 501).
A careful reading of Dr Shaffer and others’ article reveals that they do support a syndromal approach to addiction—exactly the view espoused by Dr Procopio. Shaffer and others refer to a syndrome approach in the paper, but perhaps not sufficiently, because the paper’s primary purpose was to focus on epidemiology. For example, Shaffer and others note that
Although the DSM-IV currently classifies pathological gambling as an impulse control disorder, many clinicians consider it to be an addiction, a label not yet included in the APA nomenclature. Indeed, the DSM criteria for gambling disorders closely parallel the signs and symptoms of substance use disorders, which are commonly considered addictions
(2, p 505–6).
Similarly,
Many aspects of problem behaviours emerge during adolescence.
Compared with adults or those younger, adolescents are more likely to take drugs, act delinquently, and commit serious crimes . . . Jessor and Jessor have posited a ‘problem behaviour syndrome’ to explain this multifaceted increase. Some researchers
. . . suspect that gambling may be another facet of this syndrome, implying that the prevalence of gambling-related problems in adolescents may be similarly inflated. Indeed, prevalence studies have consistently shown that adolescents evidence higher rates of problem and pathological gambling than adults (2, p 509).
We encourage readers interested in a syndrome approach to gambling and other addictions to read Shaffer and others’ publication, in which they review addiction as a syndrome (4).
Concerning the treatment paper (3), self-help groups were not included because Dr Toneatto only examined controlled studies, and he could find none that evaluated 12-step approaches. This paper’s objective was not to review treatments per se, but rather, empirically supported treatments.
Regarding the comment about substitute addictions, Dr Procopio is making assumptions. In our experience, many individuals recover from an addiction and do not transfer their addictive tendency to another behaviour. Certainly, this does happen, but of course, it may not be true for everyone.
The comments about cognitive distortions are not clear. The point seems to be that the key to understanding gamblers is to look also at other addictive behaviours. Again, this statement is not supported by empirical data.
References
1. Ladouceur R. Gambling: the hidden addiction [guest editorial]. Can J Psychiatry 2004;49:501–3.
2. Shaffer HJ, LaBrie RA, LaPlante DA, Nelson SA, Stanton MV. The road less travelled: moving from distribution to determinants in the study of gambling epidemiology. Can J Psychiatry 2004;49:504–16.
3. Toneatto T, Millar G. Assessing and treating problem gambling: empirical status and promising trends. Can J Psychiatry 2004;49:517–25.
4. Shaffer HJ, LaPlante DA, LaBrie RA, Kidman RC, Donato AN, Stanton MV. Toward a syndrome model of addiction: multiple expressions, common etiology. Harv Rev Psychiatry 2004;12:367–74.
Howard Shaffer, PhD
Boston, Massachusetts
Tony Toneatto, PhD
Toronto, Ontario
Robert Ladouceur, PhD
Quebec, Quebec
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