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Wednesday, February 27, 2008


The article in this month's wager on problem gambling and other psychiatric comorbidity is interesting.

Is problem gambling perhaps a good indicator of an underlying psychiatric disorder?

Could pathological gambling (PG) be like having a high temperature, i.e., not a cause but a side effect?

Could problem gambling be a side effect which is readily recognised and could therefore be used as an early warning device for detecting psychiatric disorders?


Dear Ms. O:

Thank you for your comment about the WAGER volume 13(2) – Chickens, Eggs, and Psychiatric Comorbidity among PGs.

Based on the current evidence, we think that pathological gambling is a psychiatric disorder, and it seems to be a proxy for the presence of additional psychiatric disorders, among other things. In addition, PG might indicate that those with this diagnosis qualified for other disorders during their lifetime, but not currently.

Comparing PG to a high body temperature (fever) is an interesting analogy that we also have used. The National Comorbidity Study Replication (NCS-R) reveals the sequence of disorders, and shows that other problems typically precede and potentially stimulate gambling problems. The NCS-R, however, is designed so that it can only measure associations. Although we can determine that there is a relationship between PG and other disorders, we only can infer the nature of this relationship and the factors that mediate the association. This means designating psychiatric disorders as a cause for PG or PG as a side effect of a psychiatric disorder is beyond the scope of the NCS-R. This is a subject area that needs and deserves more prospective research.

PG could be a warning device for detecting psychiatric disorders, much as smoking tobacco in the United States is now. The social context of these phenomena is important to consider. Finally, prevention programs look for opportunities to identify the “proxy” that reliably predicts other problems as early in the sequence of events as possible and then tries to change them. If we can make life worth living, fewer people need to attenuate or escape their lives. Of course we still need to permit that some people – the minority – have problems with gambling or other objects of addiction without any preceding psychopathology. However, this group is few in number.

Faculty at the Division on Addiction have promulgated a Syndrome Model of Addiction. Your questions allude to some parts of this model. A complete description of the model might help connect your questions into a more comprehensive understanding of addiction, including pathological gambling as one expression of addiction, and how various expressions of addiction can relate to psychiatric disorders. You can find original syndrome model paper in the following publication:
Shaffer, H. J., LaPlante, D. A., LaBrie, R. A., Kidman, R. C., Donato, A. N., & Stanton, M. V. (2004). Toward a syndrome model of addiction: Multiple expressions, common etiology. Harvard Review of Psychiatry, 12, 367-374.

Some BASIS articles briefly describe and discuss the Syndrome Model. Links to those articles are below:

Thank you again for your questions and feedback.

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The BASIS is a product of the Division on Addiction, Cambridge Health Alliance, a Harvard Medical School teaching hospital. The Division is an entirely self-funded academic organization that relies on grants, contracts, and gifts in order to produce The BASIS and our other high-quality work.