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.