Pathological gambling: Risk factors, prevalence, pathophysiology, and treatment outcomes

Pathological gambling (PG) is characterized by failure to resist the urge to gamble despite dire consequences on personal and family life. It is estimated to affect 0.4-2% of the general adult population in the US, and the prevalence varies with different cultures and countries. The etiology is multifactorial, involving biological, psychological and social factors. These include male gender, younger age, greater novelty-seeking personality, greater impulsivity, smoking history, family history of gambling, personal/family history of alcoholism or other psychiatric comorbidities. Certain medications may provoke PG: notably dopamine agonists, used for treatment of Parkinson’s disease and restless legs syndrome; and aripiprazole, an atypical antipsychotic. A genetic predisposition to PG is proposed, and PG has been associated with dopamine, serotonin, and glutamate gene polymorphisms. It is postulated that gene-environment interactions result in susceptibility to PG. In addition, dopamine agonists have selective affinity for the D3 receptor, which is primarily localized in the limbic system, and could explain medication modulation of reward and motivated behavior. Treatment of PG is challenging. Increased awareness in at-risk populations could help prevent PG. Behavioral interventions such as Gamblers Anonymous, support groups, computer firewalls, and limitation of credit cards, have been shown to limit PG. Cognitive behavioral therapy has been shown to be effective in a randomized control trial. Education of patients and their families prescribed dopamine agonists, and follow-up screening, can identify new emerging PG behavior. Reducing the dose or stopping dopamine agonists improves or eliminates PG. A black-box warning for dopamine agonists and aripiprazole has been suggested by the FDA. Additional approaches include off-label medication trials of mood stabilizers, anticonvulsants, or atypical antipsychotics. As PG causes significant psychosocial impact on affected individuals and their families, further research to prevent and treat this disorder is of significant importance.