Gambling as a recreational activity is on the rise. This is Super Bowl weekend, and it is expected to be one of the largest sports betting events in U.S. history, with tens of millions of Americans predicted to wager billions of dollars on this event. Gambling disorder is also now a recognized part of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). Gambling as a medical condition is categorized with substance-related disorder (addictive disorder), and this categorization is related to the similarities between gambling disorder and addictive disorders in their clinical expression, brain origin, comorbidities, and treatment.
More than 35 states have legalized sports betting markets, and the American Gaming Association estimates that more than 65 million adults will place more than 20 billion dollars in wagers on this year’s Super Bowl. Gambling options beyond sports betting are now available 24/7, transforming gambling from an activity that was once in the shadows into a commonplace and embedded part of American life. The options for gambling and betting are unlimited, and with the advent of artificial intelligence and big gambling data, numerous types of bets can be placed before or even during a game in real time. This wider variety seems to appeal to a large swath of Americans with different gambling preferences.
Most recently, Thomas Goldstein, a highly respected attorney who cofounded SCOTUSblog in 2003, was indicted on tax fraud charges, including misreporting, filing, and paying obligations related to his gambling habits. The story was quite salacious, and his involvement in gambling and extensive spending on romantic relationships resulted in a 22-count tax indictment by the Department of Justice. Mr. Goldstein was once a highly revered attorney who pioneered resources for covering the Supreme Court and was, for a while, a lecturer at Harvard Law School and Stanford Law School. Now, he navigates the legal system as a criminal defendant due to his gambling habits.
The reputation of gambling as a gritty activity has been replaced with glamour and mesmerism. It used to be that if one enjoyed gambling, they were viewed as a person of vice and sin. This has completely changed, as gambling is now more mainstream, accepted, and normalized. Among individuals between the ages of 21 and 35, it is even more normalized—if you don’t gamble, people may ask, What’s wrong with you? Cultural icons like Dana White, the president of the UFC (Ultimate Fighting Championship), have numerous YouTube videos detailing his gambling habits and how he was banned from different casinos due to his gambling activities.
To meet the DSM-5 criteria for gambling disorder, patients must exhibit at least four or more concerning behaviors in the last 12 months. These concerning behaviors include preoccupation with gambling and the need to gamble more. Furthermore, individuals with a gambling disorder are unsuccessful in their attempts to stop and become restless and irritable when they try to stop gambling. They gamble to escape, chase losses, and lie to hide the extent of their gambling. The behavior of individuals with gambling disorder leads to lost opportunities and reliance on others to relieve the financial problems caused by gambling. Notably, gambling disorder was moved from the impulse control disorder section in DSM-5 to the substance-related and addiction disorder section, recognizing gambling as a behavioral addiction.
It is important for primary care doctors to recognize gambling disorder, as people afflicted with this condition will easily confide in their physicians. Gambling disorder is also comorbid with depression, anxiety, and substance use disorders, so individuals with any mental health issues should be screened for gambling disorder. It is well established that there is a genetic component, as individuals with a family history of gambling are more likely to develop gambling issues. Gambling disorder is a brain disease, and many physicians struggle to understand the attraction to gambling, asking, How can a person be addicted to a behavior? Why can’t they just stop? The urge to gamble is so strong that individuals often can’t think of anything else. Early Pavlovian experiments revealed that stimuli with an intermittent reinforcement schedule—like slot machines—are the most difficult to extinguish. Slot machines also use sounds, lights, and colors to attract gamblers, who report that the euphoric state they experience after gambling is similar to the highs produced by some drugs.
Treatment for problematic gambling disorder is available. Psychotherapy is very helpful, and one of the goals of treatment is harm reduction by minimizing the damage related to gambling. It is important to identify the gambling activities that are most problematic. Gamblers Anonymous has been a successful treatment approach. Additionally, effective treatment of other mental health issues, such as depression and anxiety, can be helpful. Self-care, along with establishing and strengthening relationships with others at home and in the community, is important and can help patients focus on aspects of life beyond gambling.
Gambling is part of the human experience, and taking risks and learning to deal with losses is a normative part of life. Recreational gambling does not create harmful consequences for the individual; it becomes problematic when unpleasant consequences start to affect the individual, their family, or the community. A useful guideline for keeping gambling within the social and recreational category is to ask: Is gambling making my quality of life better or worse?
There are resources available for anyone struggling with gambling or for those who have family members experiencing gambling-related issues. Call 1-800-GAMBLER for help. Most states have gaming commissions where individuals experiencing problematic gambling behavior can self-ban from casinos or gambling platforms.
Muhamad Aly Rifai is a practicing internist and psychiatrist in the Greater Lehigh Valley, Pennsylvania. He is the CEO, chief psychiatrist and internist of Blue Mountain Psychiatry. He holds the Lehigh Valley Endowed Chair of Addiction Medicine. Dr. Rifai is board-certified in internal medicine, psychiatry, addiction medicine, and psychosomatic medicine. He is a fellow of the American College of Physicians, the Academy of Psychosomatic Medicine, and the American Psychiatric Association. He is the former president of the Lehigh Valley Psychiatric Society.
He can be reached on LinkedIn, Facebook, X @muhamadalyrifai, YouTube, and his website. You can also read his Wikipedia entry and publications.
