Sachio Matsushita: Deepening the Understanding of Gambling Addiction

Gambling issues have occasionally attracted social attention, such as when the waste of funds at casinos was found behind a breach of trust case involving a major corporation executive, or more recently, when a Major Leaguer's interpreter committed criminal acts through illegal gambling. Until now, there has been little focus even among medical professionals specializing in addiction, and a situation where treatment was provided by only a small handful of practitioners continued for a long time. This situation changed completely with the legalization of casinos in Japan under the Act on Promotion of Development of Specified Integrated Resort (IR) Districts. Because of concerns regarding an increase in gambling problems due to the lifting of the ban on casinos as a new form of gambling, the Basic Act on Countermeasures against Gambling Addiction (hereinafter referred to as the "Basic Act") was enacted in 2018, leading to increased social attention.

Furthermore, with the enactment of the Basic Act, the national and local governments began to address gambling issues. The Basic Plan for Promoting Measures against Addiction was formulated and approved by the Cabinet on March 25, 2022.

The term "gambling addiction" has become well-known due to the influence of casinos. However, it seems that understanding of it as a disease has not progressed. What is called gambling addiction was first defined as "Pathological Gambling" in the DSM-III, a diagnostic criterion created by the American Psychiatric Association in 1880 and used worldwide; it was categorized as an impulse control disorder. Other diseases in the same category included trichotillomania and kleptomania, and it was not considered an addiction.

However, because it shares many points in common with other addictions such as alcohol and drug addiction, the name was changed to "Gambling Disorder" in the 5th edition revised in 2013, and it was included in addictive disorders. While addiction to alcohol or addictive drugs is called substance addiction, addiction to behaviors such as gambling, internet gaming, and—though not yet formally included in diagnostic criteria—shopping, theft, and sex, is called behavioral addiction. Currently, the formal medical names are gambling disorder or gambling behavior disorder, but here we will refer to it as "gambling addiction."

Common symptoms of gambling addiction include lying to hide the fact that one is gambling or the extent of their involvement, trying to win back money lost through gambling (chasing losses), borrowing money to gamble, and failing in attempts to stop or reduce gambling. According to recent surveys, the prevalence of gambling addiction is estimated at 2.8% for adult men and 0.5% for adult women. However, the number of people who have a family member or loved one with a gambling problem reaches 14% of the adult population, making gambling issues a familiar problem for Japanese people.

People with gambling addiction may enjoy gambling for a while after starting, but as problems such as debt grow larger, the purpose becomes earning money and they can no longer enjoy it. When economic problems or personal health issues arise due to gambling, related problems such as depression, anxiety, suicide, and crime occur. The impact on the family also becomes significant, as trust is broken and economic problems arise, placing a heavy burden on family members.

The Pathway Model has been proposed as a cause of gambling addiction. This model classifies gambling disorder into three types: 1) Behaviorally Conditioned, 2) Emotionally Vulnerable, and 3) Antisocial/Impulsive. The behaviorally conditioned type is one where a person gradually gets hooked while repeating gambling behaviors. For the emotionally vulnerable group, the motivation is to gamble to escape from negative moods, which can be described as self-medicating gambling. The antisocial/impulsive group is characterized by high impulsivity, which is a risk factor for gambling addiction, and the motivation is seeking stimulation and excitement from gambling.

As a characteristic of gambling addiction, there are unique ways of thinking about gambling, and the following are known:

A. Superstition—Believing that holding specific items like charms increases the probability of winning, etc.

B. Interpretive Bias—1) Overestimating gambling skills or abilities while underestimating luck and probability, 2) Believing that a win is near after a series of losses, 3) Believing that the only way to recover economic losses is to continue gambling.

C. Selective Memory—Selectively remembering only wins and having difficulty remembering losses.

D. Predictive Skill—Making decisions based on subjectively meaningful clues about gambling. Clues include internal ones (physical sensations, intuition, etc.) and external ones (weather phenomena, coincidental events, etc.).

E. The illusion that one can control luck.

F. Linking gambling results to specific situations or believing in causal relationships—For example, 1) Noticing that one often wins at night, 2) Noticing that one often wins on specific days of the week, etc.

Such ways of thinking might seem pathological, but some of them can be explained by Prospect Theory. Prospect Theory is a theory of behavioral economics, a study that won the Nobel Prize in Economics in 2002. Also called loss aversion, it refers to the tendency of people to overvalue losses, meaning that actual gains and losses do not match psychological gains and losses. For example, it explains that investors tend to sell early when there is a profit to avoid loss, but conversely, when a loss has occurred, a psychology works to try to recover the loss even if it means taking risks.

Taking risks in a situation where losses are occurring may seem like a contradictory way of thinking at first glance. However, this is said to be a thought process that occurs because humans have a strong tendency to be stability-oriented when they are at an advantage and risk-oriented when they are at a disadvantage. Part of the reason for continuing to gamble while taking risks even in a situation where debt has been created by gambling can be explained by such a theory, don't you think?

Furthermore, according to a study using fMRI comparing people with gambling addiction and those without, it has been reported that cravings triggered by gambling stimuli from gambling-related images are proportional to the activity of the bilateral insula. It has been pointed out that changes are seen in brain function, and brain science research suggests a link between changes in brain function and clinical features seen in gambling addiction, such as sensitivity to rewards and excitement, chasing losses, and stress dysregulation.

Gambling addiction is a disease that is difficult to detect early. Recently, gambling using the internet has become common, making it easy to gamble in secret. Sometimes debt swells without the family even knowing.

If a gambling problem is discovered, it is important to have an attitude of discussing it calmly without blaming or becoming emotional. It is best to convey that you are worried and consult with medical institutions or public consultation desks such as Mental Health and Welfare Centers. Even if the individual does not agree to a consultation or visit, these centers will respond to consultations from family members alone. You can also consult with self-help groups for families (such as Gam-Anon or the Association of Families of Gambling Addicts).

There are no therapeutic drugs for the treatment of gambling addiction. Psychosocial treatment and participation in self-help groups are the core of treatment. Support for family members who are strongly affected by gambling problems is also important. Cognitive Behavioral Therapy, which combines cognitive therapy to correct unique ways of thinking and behavioral therapy to make it easier to stay away from gambling by changing daily life and actions, is the standard treatment. Simply enduring gambling through sheer willpower will not last long, but by helping the patient understand the disease well, they can continue to stop for longer, and this effect has been scientifically proven.

Additionally, participating in a self-help group called Gamblers Anonymous (GA) also leads to recovery. GA began in Los Angeles in 1957 and is held all over the world. For details, please refer to the GA website. Support for the family is also important. Some hospitals hold family meetings for families, and there are consultation desks such as Gam-Anon, the National Association of Families of Gambling Addicts, and the Society for Considering Gambling Addiction Issues. Family members can also gain a good understanding of the disease called gambling disorder and receive specific advice on how to interact with the person concerned and points to watch out for as a family.

Sometimes people suffering secretly from debt due to gambling addiction consult their families, but you should avoid paying off the debt on their behalf. If you pay it off, they will become unable to face the gambling problem themselves. Tell them that while you cannot provide economic support, you will provide support for recovery, and encourage them to visit a specialized medical institution. There are medical institutions and consultation agencies serving as bases for gambling addiction nationwide. For details, please search the National Center for Addiction Services Administration website.

Gambling addiction is a disease that is generally not yet well understood. The inability to stop gambling is often considered a problem of one's personality or weakness of will, and it is rarely viewed as a symptom of a disease. Patients themselves often think so too, which is one reason they hesitate to seek treatment or support. It is hoped that as society's understanding of gambling addiction progresses, more individuals will be able to seek treatment and support, leading to further recovery.