Monday, 17.05.2021

Peter R. Martin: Historical Vocabulary of Addiction

 

Gambling

           

       The noun gambling, according to the current electronic version of the Oxford English Dictionary (OED), is a derivative or variant of either the verb or noun game in combination with the suffix -ing.  The verb game itself was formed in English by conversion of the noun game, inherited from Germanic, as in “Middle Dutch (rare) game prank, mockery, Old Saxon gaman jollity, entertainment, amusement, Old High German gaman pleasure, amusement, something that causes laughter, joy, delight… Middle High German gamen fun, play.”  The verb game has many meanings in OED, including the first listed meaning in the English language of this word, which was in Old English (“intransitive. To amuse oneself; to play, sport, jest; [occasionally] to indulge in amorous or flirtatious play”).  The meaning of the verb game that is most relevant to addiction is defined in OED as: “To take part in an indoor game, of a kind on which stakes or wagers may be placed; especially to play games of chance for such stakes or wagers; to gamble.” 

       The definition of the noun game pertinent to addiction is: “An activity played for entertainment, according to rules, and related uses… An activity or diversion of the nature of or having the form of a contest or competition, governed by rules of play, according to which victory or success may be achieved through skill, strength, or good luck… in early use also chiefly restricted to indoor amusements, especially, those involving cards, dice, or playing-pieces, and to pastimes of a more or less light-hearted character.”  Accordingly, the noun gambling is defined in OED as: “The action, practice, or pastime of playing games for stakes, as cards, dice, etc., or betting money on the outcome of particular events, e.g. the result of a race or other sporting contest; (also occasionally) an instance or example of this.  Also more generally: the taking of risks in the hope of gaining some advantage, benefit, or success.”

       The first meaning listed in OED of the verb game appeared in a quotation in the Old English Hexateuch (Dodwell and  Clemoes 1974): “Þa wæs him geðuht swylce he gamenigende spræce.”  Although such texts are difficult to date, an approximation derives from the fact that this was a collaborative translation project during the late Anglo-Saxon period of the six books of the Hexateuch into Old English, presumably under the editorship of Ælfric of Eynsham (c950–c1010), a Benedictine abbot of Eynsham and scholar.  An example of the first use of the verb game in the English language as it pertains to addiction is found in The privy purse expenses of King Henry the Eighth by Sir Nicholas Harris Nicolas (1799–1848), an English antiquary (1827): “Item delivered to the kinges grace owne handes for to game therewt now at this tyme of Cristemas, C li.”  An example of the first use of the noun game as relevant to addiction is found in Old English glosses (Meritt 1945): “ [Turmasludi [participes et laboris consortes superans]: ga[menes].”  First use of the noun gambling in the English language is as found in the translation of The history of the renown’d Don Quixote de la Mancha by Peter Antoine Motteux (1663–1718), a French-born English author, playwright and translator (1700): “The Room where it stood was an old gambling Cock-loft [Spanish un camaranchón].” 

       Many quotations in OED reflect the stigma associated with gambling, especially as it relates to addiction, wantonness and crime: “The three glorious purposes of gluttony, drunkenness and gambling (Anonymous 1778)”; “She had an in-bred abhorrence of gambling” (Roberts 1792); and “Robberies are a natural consequence of universal gambling” (Darwin, Fitzroy and King 1839).  Additionally, there are expressed concerns about the harmful consequences of gambling for those who partake, but also gambling as a societal responsibility (Westcott 1897): “The State… must deal in some way with gambling.”  In fact, government legislation can pertain to gambling much as it does to other criminal activities or to drugs of abuse (Gover 1964): “The Senator gave the green light go-ahead for the recent crack down on gambling and prostitution.” The role of government regulation appears needed because engagement in gambling affects even those who do not have resources to waste and can be devastating to all social strata (Vaughan 1906): “This passion for gambling is not, I am sorry to say, confined to the Smart Set.”  Various of these quotations about gambling intimate shared features with addiction, a theme destined to appear as future studies elucidate the mechanistic underpinnings of these disorders (Potenza 2008). 

       A quotation by Richard Whately (1787–1863), an English academic, logician, economist and theologian, in his Introductory Lessons on Morals reflected on the role of gambling chance-taking) in human behavior.  He sensibly observed that gambling can be practiced without the exchange of valued objects or currency (Whately 1857):  “People may, and often do, play at games of chance without any stake at all.  And again, at billiards, which is altogether a game of skill, much gambling often takes place.”  Therefore, behaviors characteristic of gambling (chance-taking) should not per se be pathologized as there are many who engage in these activities for entertainment without negative consequences, much as those who drink alcohol in moderation. 

       Seeking, engaging in and observing others in exciting activities can be thrilling and joyful even if the anticipation does not produce the hoped-for outcomes because they are due more or less to chance.  Such activities are present in the behavioral repertoire as play from an early stage of life (Hutt and Bhavnani 1972). They comprise the underpinnings of exploration, observation, experiencing and seeking to understand one’s world, which may underpin being a spectator at a sports event or betting on the outcome; playing hide-and-seek, cards or the stock market; and scientific discovery.  Risk/chance-taking is a normative aspect of personality and behavior (Chiu and Storm 2010) — it is the degree to which gambling is practiced and its consequences that can disrupt a normally balanced life that render it pathological. 

       Gambling was first considered to belong in the realm of anthropological studies of human interactions and their expression in forms of play (Roberts, Arth and Bush 1959).  Henry Lesieur, author of a classical description of the psychological and sociological aspects of compulsive gambling, The Chase: Career of the Compulsive Gambler (1977) wrote (1985): 

       “Archaeologists have found evidence of sheep ankle bones (called astragals) being used to cast lots, and anthropological field work with primitive cultures shows they cast lots to decide which way to hunt and whether a person was guilty of violating the rules of society.  The movement from casting lots to complex gambling games is a simple one.  Many tribal peoples (including American Indians) were avid gamblers.  Excavations of Egyptian, Chinese, and Indian sites have uncovered artifacts of gambling games as well as writings attempting to explain the origins of gambling and describing gods playing gambling games.  Historians have uncovered evidence that whether legal or not, gambling has persisted and so have problems associated with it.  Slaves, kingdoms, and fortunes have been won and lost using dice, cards, chariot races, horse races, and numerous other gambling events.”

       Subsequently, analyses of the mathematical properties of the games and how a person performed became a subject of scientific inquiry (Dale 1958): 

       “It is well known that subjective ideas of probability differ from predictions made using statistical laws.

       “It is also well known that persons in general like to gamble.  If they have the choice of a number of different courses of action which, on the average, will yield the same benefit, they will prefer to risk some loss in order to chance some gain, rather than to choose a course which has a certain outcome.  This preference has been shown in laboratory studies.

       “Did the more intelligent subjects have sophisticated ideas about subjective probability, or did they have the usual ideas but prefer to use the alternative, systematic, approach?  In order to throw light on this question the results of my subjective probability study were re-examined from the point of view of intelligence.  This showed that intelligence and subjective probability were not related.  It would seem, then, that intelligence determined not the hunches the man had, but whether he chose to be guided by them.”

       Descriptive studies of the phenomenology of games humans play and gambling behaviors eventually led to formulations of mathematical theories of probabilities of given outcomes as well as brain functions involved in decision-making, which, in turn, revolutionized many disciplines, including economics, psychology, neurology and psychiatry (Von Neumann and Morgenstern 1947; Bechara, Damasio, Tranel and Damasio 1997; Sanfey, Rilling, Aronson et al. 2003).  Moreover, new ways of considering decision-making in pathological gamblers has led to identification of similar dysfunctions in neuropsychological, psychophysiological, neuroimaging, neurochemical and genetic studies as those with alcohol and other drug use disorders (Goudriaan, Oosterlaan, de Beurs and Van den Brink 2004; Potenza 2008; Lawrence, Luty, Bogdan et al. 2009).  Consequently, despite the fact that gambling-related activities can be considered part of the normal behavioral repertoire, out-of-control and self-destructive gambling came to be considered a significant mental health concern (Martin, Weinberg and Bealer 2007): 

       “Partly as a consequence of [the] greatly expanded venues for gambling, it is estimated that 80 to 90 percent of adults gamble to some extent.  Gambling, then, affects a substantially greater proportion of the population than alcohol and drugs do.  In general, as the availability of gambling opportunities expands, so does the proportion of the population that develops problems associated with gambling.  Therefore, as gambling has spread, compulsive gambling has been on the rise.  It is now estimated that 1 to 2 percent of the adult population of the United States are compulsive or pathological gamblers...”

       Only relatively recently has gambling found acceptance in the realm of medicine, as a psychopathological construct and a psychiatric disorder in its own right (American Psychiatric Association 1980).  A distinct syndrome, the pathological expression of chance-taking activities that comprise gambling and its consequences, are now included in the Diagnostic and Statistical Manual of the American Psychiatric Association (DSM-5) as an addictive disorder termed gambling disorder (2013).  Gambling disorder includes features which strongly resemble alcohol and drug use disorders: preoccupation with and the persistent urge to gamble with dysphoria when unable to gamble or trying to stop (withdrawal); loss-of-control over gambling and forgoing other activities that comprise a balanced life; the need to progressively increase the money that is put at risk (tolerance); denial about the extent of gambling and losses; using gambling to ease depressed mood or tension and anxiety (self-medication); and loss of relationships, job or a significant career opportunity.  In addition, there are rather specific aspects of gambling disorder, namely, repeatedly attempting to win back gambling losses and relying on others for money to deal with financial problems caused by gambling (American Psychiatric Association 2013).  Gambling means the willingness to risk something of value in the hope of getting something of even greater value with little objective likelihood of success.  Therefore, gambling disorder is rightfully considered an addictive disorder, the uncontrollable urge to keep gambling (loss-of control) despite the toll it takes on one’s life (self-destructive). 

       The epistomologic evolution of our understanding of the pathophysiology of gambling disorder has resembled the course, but not the more measured progression, of alcoholism and other drug use disorders prior to acceptance as bone fide mental disorders (Martin 2019).  The centuries required for emergence of alcoholism as a psychiatric disorder have seemed for gambling to have been telescoped into about a half century of human historyThe devestation of gambling behaviors have been part of our literary heritage (Dostoevsky 1964) and were considered in psychoanalytic thinking as expression of a neurotic form of development (Lindner 1950), but the leap into public awareness as a disease is perhaps related to accelerating development of communication media (McLuhan 1964) which have provided ideal venues for expression of pathological gambling behaviors (Fauth-Bühler and Mann 2017).  In parallel was the emergence of the disease concept of pathological gambling; founding of Gamblers Anonymous in Los Angeles in 1957 by Jim Willis (Jim W.), an alcoholic who applied his experience in Alcoholics Anonymous in the new self-help mutual support (12-step) program; and implementation of pioneering treatment in the medical milieu by Dr. Robert L. Custer (1927-1990) at Brecksville, Ohio Veterans Administration Hospital (Lesieur 1985).  The first scientific journal devoted to pathological gambling (Journal of Gambling Behavior) was not founded until 1985, consistent with the relatively late arrival of gambling in the realm of biomedicine.  

       It is of both historical and nosological significance that when the pathological complement of gambling behaviors was first recognized as a psychiatric disorder by the American Psychiatric Association in DSM-III (1980), it was classified as a disorder of impulse control rather than an addiction (Lesieur and Rosenthal 1991; Clark 2014).  Internet gaming disorder, a recent arrival to psychopathologic and nosologic debates, was considered a “condition for further study” in DSM-5, although current evidence suggests that internet gaming disorder shares very similar neurobiological substrates with gambling disorder (Fauth-Bühler and Mann 2017).  In particular, both disorders have as their neurobiological underpinnings impulsivity, compulsivity and sensitivity to reward and punishment.  As discussed above, the phenomenology of gambling disorder has much in common with that of addiction and neurobiological research continues to support this nosological decision by the American Psychiatric Association (Reuter, Raedler, Rose et al. 2005; Potenza 2008).  All the same, the debate about whether inclusion of gambling disorder as a mental disorder is justified has continued (Martin and Petry 2005). 

       The issue of nosology is at the heart of diagnosis and treatment.  However, inclusion of gambling disorder as an addictive disorder becomes a moot point unless it can also be demonstrated that the neurobiological findings are consistent with those of addiction.  Potenza (2008) reviewed data on the neurobiology of pathological gambling and considered its conceptualization as a behavioral addiction.  He found impulsivity as an underlying construct for both drug and behavioral addictions and presented brain imaging findings investigating the neural correlates of craving states in pathological gambling which compared to those for cocaine use disorder.  Blanco, Hanania, Petry et al. (2015) employed a statistical model, originally developed for contributory factors in major depression, to model the development of pathological gambling.  After statistically adjusting for recognized risk factors, nicotine dependence and independent stressful life events predicted life‐time pathological gambling.  Additionally, despite the large proportion of variance accounted for by life‐time history of pathological gambling, past‐year nicotine dependence and personality disorders were also associated significantly with 12‐month pathological gambling.  This supports parallels between gambling and drug use disorders and, in particular,  abuse of drugs with psychostimulant effects.  The relevance of alterations in frontoparietal, salience, default mode neural circuits have recently been demonstrated for individuals with bothe cocaine use disorders (Yip, Scheinost, Potenza and Carroll  2019) and those with internet gaming disorder (Liu, Potenza, Lacadie et al. 2020).  Finally, treatment of gambling and internet use disorders have many parallel strategies to those employed for alcohol/drug use disorders and continue to be equally challenging and important to pursue due to their prevalence and significant negative consequences for mental health (Petry 2003; Koo, Wati, Lee and Oh  2011; King, Wölfling and Potenza 2020).

 

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February 18, 2021