As gambling becomes available to more and more individuals in this country, the problem of compulsive or pathological gambling (PG) will also increase. As with other forms of addiction, both environmental and genetic factors are involved in PG. Identification of the genes that play a role in increasing a person's risk for PG will lead to a better understanding of the disorder and to more rational and effective treatment. Although studies of the molecular genetics of PG are just beginning, a number of interesting observations have been made and are reviewed in this article. As with other addictive behaviors, abnormalities in dopaminergic reward pathways a likely to be involved. Consistent with this, we have observed a significant association between PG and the D1, D2, D3, and D4 dopamine receptor genes. The fact that each these genes has an effect is consistent with a polygenic inheritance of a susceptibility to PG The involvement of multiple dopamine genes consistent with the “reward deficiency syndrome,” which suggests that addictive impulsive disorders are due, at least in part, to genetic abnormalities of the dopamine reward pathways. On the basis of this hypothesis, we describe other genes also likely to play a role in a person's susceptibility to PG.

Research on pathological gambling has begun to demonstrate the significant pathophysiologic role of several neurotransmitter systems in this disorder. Challenge studies with various pharmacologic agents have suggested the importance of potential dysregulation of the serotonergic system in pathological gambling, as this system is linked to dysfunction in behavioral initiation and inhibition. In addition, the noradrenergic system has been associated with mediation of arousal, increases of which are manifested by pathological gamblers. The interactions between these and other neurotransmitter systems, as well as the similarities between pathological gambling and other behavioral disorders, may provide important clues for pharmacologic intervention.

The growth of gambling across the United States over the past decade has created significant difficulties for pathological gamblers. The rise in problem gambling, coupled with an increasing strain on social and health care services for treatment of gamblers and their families, has resulted in an urgent need for innovative interventions that target patients, health care providers, educational institutions, government, media, and the gambling industry. This article describes the impact of gambling from a consumer-protection perspective, and offers approaches to promoting public awareness of compulsive gambling as a pervasive problem that affects multiple areas of society.

This article describes a new approach to the understanding and treatment of pathological gambling (PG). In order to foster an understanding of the pathological variations of gambling, gambling as a “normal,” widespread behavior that spans cultures and centuries is briefly reviewed, as is the current socioeconomic impact of gambling on society. PG is interpreted as an excessive exaggeration of a normal behavior (a behavioral excess disorder, or BED), similar to exaggerations of cleaning, grooming, loving, working, or shopping.

Particular developmental deficits in certain individuals and their resulting vulnerabilities make these persons prone to “getting lost” in excessive gambling activities. PG fulfills three important functions that serve to maintain these behaviors. Most frequently, it serves the intraindividual function of distraction from a cognitive, emotional, or physiologic negative state (NEST). A second, much less frequent intraindividual function is that of fast socioeconomic self-destruction in persons who develop presuicidal depression before they start gambling. In the worst disease course of this subtype, patients enter a dramatic “last game”; when they lose, “fate has decided” that they should kill themselves immediately thereafter. A third function fulfilled by PG is interactional, ie, in the “I can't be with or without you” type of relationship.

These gambling-related vulnerabilities are discussed against the background of recent studies from: (1) cognitive psychological and animal experiments regarding the prediction of future events; (2) functional brain imaging studies in obsessive-compulsive disorder; and (3) gambling experiments (prediction of future events) in patients with specific lesions in the orbitofrontal cortex. This article outlines the basics of strategic-systemic behavior therapy for these conditions, and summarizes results of the first outcome and follow-up studies.

Pathological gambling is an understudied disorder that causes significant distress to sufferers, their families, and society. Despite its prevalence among the general population, the impact of pathological gambling remains largely unrecognized by many health care providers. Although a discrete entity, pathological gambling shares salient characteristics with addiction and obsessive-compulsive disoders, and is comorbid with these and other conditions such as attention-deficit hyperactivity disorder in a large number of cases. Recognizing these similarities has significant implications for treatment, as pharmacologic therapies used for these disorders, including serotonergic and mood-stabilizing agents, have shown some degree of efficacy in pathological gambling.