Psychiatric Comorbidity in Pathological

Gambling: A Critical Review

David Neil Crockford, MD l , Nady el-Guebaly, MD2

Objective: To critically review the current literature on pathological gambling as regards the significant psychiatric
comorbidities associated with it.
Method: The authors synthesized information found via electronic searches (MEDLINE) and bibliographic-directed searches
in over 60 publications.
Results: Pathological gamblers frequently have comorbid substance use disorders. In addition, a subset appear to have
comorbid antisocial personality disorder, but they represent a minority when compared with those people who have acquired
their antisocial traits as a consequence oftheir gambling behaviour. A comorbidity with the mood disorders is probable, but
methodological concerns and inconsistencies with the data prevent further delineation ofthis. Emerging research for other
disorders possibly associated with pathological gambling is also reviewed.
Conclusion: Pathological gambling is associated with significant psychiatric comorbidity. Recommendations for future
research are described.

(Can J Psychiatry 1998;43:43-50)

Key Words: pathological gambling, comorbidity, psychiatric disorders, review

W ith the further legalization of gambling by govern-

ments as a means to enhance revenues has come an
increased awareness that individuals can develop an involve-
ment with gambling that is problematic. In 1980 the Ameri-
can Psychiatric Association (APA) formally recognized
pathological gambling as an Impulse Control Disorder Not
Elsewhere Classified. Current estimates suggest that approxi-
mately 1% to 3% of the population meet criteria for patho-
logical gambling using the South Oaks Gambling Screen
(SaGS) (1-7). As recent reviews have described, this disor-
der is ofparticular interest because it carries with it significant
legal, fmancial, vocational, and interpersonal difficulties, and
it is frequently associated with substance use, mood and
anxiety symptoms, and antisocial features (5,6,8-10). As
regards these observed associations, however, the question
Portions of this paper have been presented at the 45th Annual Meeting of the
Canadian Psychiatric Association in Victoria, British Columbia, on
September 20, 1995, and at the 7th Annual Meeting of the Canadian Medical
Society on Alcohol and Other Drugs in Banff, Alberta, October 14 to 16,
1995.
Manuscript received January 1997, revised and accepted May 1997.
'Psychiatry Resident, Department of Psychiatry, University of Calgary,
Calgary, Alberta.
2professor, Department of Psychiatry, University of Calgary, Calgary,
Alberta; Director, Addiction Centre, Foothills Hospital, Calgary, Alberta.
Address for correspondence: Dr DN Crockford, Department of Psychiatry,
Foothills Hospital, 1403 29th Street NW, Calgary, AB T2N 2T9
Can) Psychiatry, Vol 43, February 1998
43
remains as to what extent they are representative ofdiagnostic
overlap in symptoms or methodological problems, as op-
posed to being that of true psychiatric comorbidities-
defined as 2 or more psychiatric disorders present in a single
patient occurring independently of chance where each diag-
nostic entity has the characteristic phenomenology and etio-
logic basis typically found when each disorder is in isolation
(11). This is important to delineate because it may aid in the
development of better etiological, preventive, and treatment
models for this disorder in the future.
The aim ofthis paper is to review critically the empirical
data on the psychiatric comorbidity seen in pathological
gambling from community and clinical samples, with empha-
sis on its implications for diagnosis, treatment, and future
research. To this end, electronic (MEDLINE) and bibliog-
raphic-directed searches for literature relevant to the topic
from 1966 to February 1996 were carried out, resulting in
over 60 references being found.
Substance Use Disorders
Given that the settings in which alcohol use, drug use, and
gambling occur are much the same, it is of no surprise that
people with pathological gambling have a significantly in-
creased prevalence of the substance use disorders and vice
versa (Table 1). Heavy drinking and drinking problems are
associated with increased spending on gambling and greater
gambling problems, and many pathological gamblers use
substances while they gamble (12,13). Research using com-
44 The Canadian Journal of Psychiatry Vo143, No 1

Table 1. Studies of comorbidity in pathological gambling-substance use disorders

Author and date
Dell and others (18)
Ramirez and others (14)
McConnick and others (15)
Lesieur and others (19)
Linden and others (24)
Roy and others (16)
Lesieur and others (20)
Lesieur and others (21)
Bland and others (17)
McConnick (22)
Elia and others (23)
Hewitt and others (25)
Spunt and others (13)
Smart and others (12)
Sample and design
N = 35, case series, retrospective
GA members
N = 51, case series, retrospective
Gambl ing treatment unit inpatients
N = 50, case series, retrospective
Gambling treatment unit inpatients
N = 458, case series, retrospective
Substance treatment unit inpatients
N = 25, case series, retrospective
GA members
N = 24, case series, retrospective
20 inpatient, 4 outpatient PG
N = 100, case series, retrospective
Therapeutic community residents
N = 105, case series, retrospective
Psychiatric unit inpatients
N = 7214 (30 lifetime PG)
Case-control, retrospective,
community survey
N = 2171, Case-control, retrospective
Substance treatment unit inpatients
N = 85 (53 white, 32 Native American)
Case-control, retrospective
Alcohol treatment unit patients
N = 149 (Native American gamblers)
Case series, retrospective
"Snowball sampling"
N = 117, case series, retrospective
Methadone maintenance patients
N = 2016
Retrospective community survey
Key instruments
• MCMI
• Demographic questionnaire
• SADS
• Autobiography
• Battery of psychological tests
• SADS
• Autobiography
• SOGS
• SCID (DSM-III version)
• Interview for DSM-III Axis II disorders
• Family history of psychiatric illness
• SADS-L, BDI, HDRS
• Family history of psychiatric illness
• SOGS and SOGS cross-check
• SOGS
• Clinical case records
• Diagnostic Interview Schedule version III
• SOGS, SUDDS, BDI
• Barratt Impulsivity Scale
• The NEO Personality Inventory
• SOGS
• Demographics from chart
• SOGS
• Texas Inventory of Grief
• Demographic survey
• Interview schedule (incl SOGS)
• Interview schedule for gambling, alcohol
and drug use
Key findings
• 11% drank excessively during abstinence from
gambling
• II % parental alcohol abuse; 9% sibling alcohol
abuse
• 39% alcohol or drug abuse in year prior to
admission
• 47% alcohol or drug abuse in lifetime
• 50% alcohol or drug abuse in one or both parents
• 36% alcohol or drug abuse in a sibling
• 36% alcohol or drug abuse
• 32% alcohol abuse; 4% drug abuse
• 9% PG; 10% problem gamblers
• 36% alcohol use disorder in first-degree relative
• 25% substance abuse
• 8.3% previously treated for alcoholism
• 25% alcohol use disorder in first-degree relative
• 14% PG; 14% problem gamblers
• 6.7%PG
• II % substance abusers with pathological gambling
• 63.3% substance use disorder in lifetime
• 63.3% alcohol use disorder in lifetime
• 23.3% substance use disorder in lifetime
• 13% PG
• Polysubstance abusers had more severe gambling
problems
• 13% PG
• 22% Native American PG
• 7.3% white PG
• 10% of substance abusers remained abstinent by
gambling
• 73% of problem gamblers smoked cigarettes
• 16% PG; 15% problem gamblers
• Alcohol abuse associated with gambling problems
• Heavy gambling associated with increased
nicotine use

See Table 3 for glossary of abbreviations.

munity and clinical samples has shown that between 25% and
63% of pathological gamblers meet criteria for a substance
use disorder in their lifetime (14-17). Correspondingly, 9%
to 16% ofpatients with a substance use disorder are also found
to be probable pathological gamblers (13,18-23). In addition,
the first-degree relatives of pathological gamblers have been
found to have an increased prevalence of substance use
disorders as compared with that seen in the community
(14,16,24).
The reported variations between studies of prevalences
appear to reflect the use of small sample sizes and the com-
parisons ofcommunity and treatment settings where different
instruments are used and the demographic variables, such as
age, ethnicity, and severity of gambling disorder, tend to be
inadequately described. Despite these methodologicallimita-
tions, the overall picture is consistent with a strong associa-
tion between these disorders.
Several specific findings should also be highlighted. Elia
and Jacobs found that Native American alcohol abusers have
rates of pathological gambling almost twice that found in
white alcohol abusers, which emphasizes the potential role
for ethnicity and culture to influence the prevalence ofpatho-
logical gambling (23). In all but 1 study, alcohol has been
found to be the most common substance of abuse when only
1 substance is used (15,17,19,22). With polysubstance abuse,
an increased prevalence and severity of pathological gam-
bling has been found when compared with those people who
abuse only 1 substance (22). High rates of nicotine use have
also been seen in pathological gamblers (12,25). The possible
switching of addictions has been suggested by Adler and
Goleman, but the literature to date in this regard is limited and
inconclusive (26). Two studies have found a limited degree
ofsymptom substitution, but 1 study has not (18,25,27). Only
1 study has attempted to look at the natural histories of
pathological gambling and the substance use disorders, with
February 1998 Psychiatric Comorbidity in Pathological Gambling 45

Table 2. Studies of comorbidity in pathological gambling-mood disorders

Author and date
Dell and others (18)
Ramirez and others ( 14)
Moravec and others (31)
McCormick and others ( 15)
Russo and others (39)
Linden and others (24)
Taber and others (32)
Taber and others (40)
Roy and others (16)
Roy and others (33)
Ramirez and others (43)
Blaszczynski and others (34)
Lesieur and others (21)
Bland and others (17)
McCormick (22)
Hewitt and others (25)
Sullivan and others (36)
Ladouceur and others (37)
Thorsen and others (44)
Blanco and others (42)
Sample and design
N = 35, case series, retrospective
GA members
N = 51, case series, retrospective
Gambling treatment unit inpatients
N = 23, case series
Gambling treatment unit inpatients
N = 50, case series, retrospective
Gambling treatment unit inpatients
N = 60, case series, l-year follow-up
Gambling treatment unit patients
N = 24, case series, retrospective
20 inpatient, 4 outpatient PG
N = 44, case series, retrospective
Gambling treatment unit inpatients
N = 57, case series, 6-month follow-up
Gambling treatment unit inpatients
N = 24, case series, retrospective
20 inpatient, 4 outpatient PG
Case-control (depressed PG N = 14,
versus normal controls N = 4 I)
N = 21, case series
Gambling treatment unit inpatients
N = 75, case series, retrospective
Gambling treatment unit inpatients
N = 105, case series, retrospective
Psychiatric unit inpatients
N = 7214 (30 lifetime PG)
Case-control, retrospective community
survey
N = 2171, case-control, retrospective
Substance treatment unit inpatients
N = 149 (Native American gamblers)
Case series, retrospective
"Snowball sampling"
N = 329, case series, retrospective
Gambling hotline callers (61% PG)
N = 1471 (college students)
Case-control, retrospective
N=400
Case-control, community survey
N = 27, case-control, male PG
Key instruments Key findings
• MCMI • 43% depression during abstinence from gambling
• Demographic questionnaire • Neurotic depression scores significantly lower
• SADS, Autobiography • 78% major depressive disorder
• Battery of psychological tests • Substance use related to depression
• WAIS, MMPI • Elevated MMPI depression (Scale 2) scores
• EPPS, POI
• SADS • 76% major depressive disorder
• Autobiography • 8% manic disorder; 38% hypomanic disorder
• 80% with suicidal ideation; 12% had made a
"lethal" attempt
• Depression preceded gambling problems in
minority
• Self-report survey • 71.9% with less depression; 17.5% with more on
follow-up
• Less depression with abstinence from gambling
• SCID (DSM-III version) • 7.2% major depressive episode
• Interview for DSM-III Axis II disorders • 52% recurrent major affective disorders
• Family history of psychiatric illness • 24% bipolar; 28% recurrent major depression
• 32% major affective disorder in first-degree relative
• Autobiographies • 90% severe life trauma preceded pathological
• MMPI, MCMI, SADS gambling
• High trauma patients more depressed
• Gamblers abusing substances more depressed
• Psychiatric status schedule • 32% major depression on admission
• Time line follow back • 18% depression persisted despite abstinence from
• Gambling Behaviour Survey gambling and improvement in work and family life
• SADS-L, BDI, HDRS • 75% affective disorder in lifetime (I6MOE,
• Family history of psychiatric illness 2 dysthymia, I hypomania); 58.3% current MOE
• 37.5% past treatment for depression
• 33.3% first-degree relative with affective disorder
• PG: HDRS, PRLEI • Mean HDRS = 17.8 ± 5.4
• Controls: SADS-L, PRLEI • More negative life events in PG but most of these
due to gambling
• BDI, MMPI, DST • All subjects normal suppressors on the DST
• SGHQ, SSTAI, BDI • Mean BDI = 18.89 ± 10.33
• 48% continued gambling because of depression
• SOGS ·6.7%PG
• Clinical case records • 2.6% with a mood disorder were PG
• DIS version III • 33.3% affective disorder (controls 14.2%)
• 20.0% dysthymia (controls 4.9%)
• SOGS, SOODS, BDI • In substance abusers with a gambling problem,
• Barratt Impulsivity Scale severity of gambling correlated to impulsivity and
• The NEO Personality Inventory negative affectivity
• SOGS • 75% recently experienced a death
• Texas Inventory of Grief • 18% still experiencing extreme grief over that death
• Demographic survey • 48% experienced some other significant loss
• SOGS • 92% PG contemplated suicide; 24% planned,
• Demographic survey 4% attempted
• SOGS • 26.8% PG attempted suicide versus 7.2% students
• Jacob's health survey without gambling problems
• CES-Depression Scale • No correlation between gambling (not PG) and
depression
• Demographic survey • Significantly lower platelet MAO activity in PG
• Platelet MAO activity

See Table 3 for glossary of abbreviations.

the most common pattern being that the onset ofthe substance
use predates the onset of the gambling problems (14).
Generally, the current literature suggests that a statistically
significant comorbidity is present between the substance use
disorders and pathological gambling. The extent of the co-
morbidity, however, varies depending on the sample charac-
teristics and the instruments used. Future research needs to
expand on the limited data in regards to the nicotine use
disorders and use prospective designs to elucidate the natural
histories of these disorders. For example, does one disorder
predispose to the development ofthe other? Is the severity of
one disorder related to the other? Is comorbidity associated
with a significantly worse prognosis for both disorders?
46 The Canadian Journal of Psychiatry
Mood Disorders
Early reports found a relationship between the mood dis-
orders and pathological gambling based upon clinical case
observations (28-30). Since then, there has been a substantial
proliferation of literature that suggests these disorders are
likely comorbid, but there are also inconsistencies which are
currently unexplained (Table 2).
Research using psychological tests and evaluations of
significant life events, the frequency of suicide, suicide at-
tempts, and suicidal ideation, and family histories has pro-
vided support for the possibility that pathological gambling
and mood disorders are comorbid. Pathological gamblers
have been consistently found to score significantly higher
than control populations on psychological tests evaluating
depression (16,18,22,31-35). They have also been shown to
experience a greater number of significant life events as
compared with controls, both prior to the onset of their
gambling becoming "compulsive" and the onset of a major
depressive episode via retrospective analysis (32,33). Inter-
estingly, however, the majority of these life events were
attributable to their gambling. Very high rates of suicidal
ideation and suicide attempts have also been reported in
pathological gamblers (15,36,37). Moreover, 2 studies have
reported that approximately one-third of pathological gam-
blers have a first-degree relative with a mood disorder, and
high prevalences of pathological gambling have been de-
scribed in families of bipolar probands, which suggests the
possibility ofa familial link between the disorders (16,24,38).
Attempts to find some of the neurobiological abnormali-
ties associated with major depressive disorder have produced
results that neither support nor disprove any association be-
tween the mood disorders and pathological gambling. Al-
though a recent study by Blanco and others found
significantly decreased platelet monoamine oxidase (MAO)
activity in abstinent inpatient gamblers as compared with
controls, it did not report on the presence or absence ofmood
disorders in the study population (42). Roy and others found
that pathological gamblers had a significantly higher cen-
trally produced fraction of cerebral spinal fluid (CSF) 3-
methoxy-4-hydroxyphenylglycol (MHPG) and significantly
greater urinary outputs of norepinephrine when compared
with controls (16). These noradrenergic differences were not
seen, however, when depressed gamblers were compared
with nondepressed gamblers, and there was no difference
between these 2 groups on any other indices ofnoradrenergic
function or urine-free cortisol measured in the study. Low
CSF 5-hydroxyindoleacetic acid (5-HIAA) levels were also
not found in gamblers compared with controls. Furthermore,
Ramirez and others found all pathological gamblers to be
normal suppressors of the dexamethasone suppression test
(DST) (43). Overall, no consistent neurobiological abnor-
malities have been found.
The greatest support for a possible comorbidity comes
from the significantly increased prevalence ofmood disorders
that has been reported in 4 studies. In all but 1 study, approxi-
Vol 43, No 1
mately 75% of pathological gamblers in an inpatient treat-
ment setting were found to meet criteria for a major depres-
sive disorder (14,15,24,40). Elevated rates ofhypomanic and
manic episodes suggestive of a bipolar disorder have also
been found (15,24). One study also reported that 52% of
pathological gamblers had recurrent affective disorders and
that 28% had recurrent major depressive disorders (24). These
recurrent episodes may be secondary to continued gambling,
however, because Russo and others found that pathological
gamblers who continued to gamble 1 year after inpatient
treatment had higher rates of depression than those who
abstained from gambling (39). Consistent with this is the
finding that only a minority ofpathological gamblers felt their
depressive symptoms preceded the onset of their gambling
problems (15). Probably a better representation of the true
comorbidity rate is found in the follow-up study ofTaber and
others, in which it was noted that significant continued de-
pression occurred in 18% of their original sample, despite
abstinence from gambling and improvement in their work and
family lives-a percentage of depressive disorders similar to
that seen in patients with substance use disorders (40,41).
Thus the bulk of clinically related findings points toward
an association between mood disorders and pathological
gambling. There are, however, some potential problems with
the data: study sample sizes were small, and most studies used
a one-time retrospective method to evaluate symptoms after
the patient sought treatment. This makes the findings prone
to sampling bias because it is well recognized that patients
with more than 1 psychiatric disorder are more likely to be
found in treatment settings (11). In addition, the data may be
confounded by mood syndromes attributable to life crises
surrounding entry into treatment and the presence of comor-
bid substance use disorders (41). The latter point is supported
by 2 studies that identified a close relationship between
depressive symptoms and substance abuse in pathological
gamblers (14,32). A period ofabstinence from substances and
gambling is necessary to allow better evaluation of any con-
current mood symptomatology.
The only study using a community sample found that
pathological gamblers, when compared with controls, had a
significantly higher lifetime prevalence of dysthymia but not
major depressive episodes or manic episodes (17). This could
suggest that the increased prevalence of the major mood
disorders found in the previous treatment samples may, in
part, reflect a sampling bias rather than a true comorbidity.
Moreover, patients treated for a mood disorder have not
been found to have a higher prevalence of pathological gam-
bling as would be expected if the 2 disorders were truly
comorbid (21). Gambling in general, not necessarily patho-
logical gambling, has not been found to be associated with
the mood disorders as would be expected ifindeed life events,
negative affectivity, and depression predispose an individual
to gamble and potentially develop a gambling disorder (44).
Thus despite the clinical observations and research find-
ings that suggest pathological gambling and mood disorders
February 1998 Psychiatric Comorbidity in Pathological Gambling 47

Table 3. Studies of comorbidity in pathological gambling-anxiety disorders

Author and date
Linden and others (24)
Roy and others (16)
Blaszczynski and others (34)
Bland and others (17)
Black and others (47)
Sample and design
N = 25, case series, retrospective
GA members
N = 24, case series, retrospective
20 inpatient, 4 outpatient PG
N = 75, case series, retrospective
Gambling treatment unit inpatients
N = 7214 (30 lifetime PG)
case-control, retrospective community
survey
N = 120 probands ofOCD patients
Case-control, family prevalence
Key instruments Key findings
• SCID (DSM-III version) • 28% symptoms of panic disorder, agoraphobia, or
• Interview for DSM-III Axis II disorders OCD continuing after gambling ceased
• Family history of psychiatric illness
• SADS-L, BDI, HDRS • 12.5% simple phobia or generalized anxiety
• Family history of psychiatric illness disorder
• SGHQ, SSTAI, BDI • State and trait anxiety scores not significantly
different from normative sample
• DIS version III • 26.7% an anxiety disorder (nongamblers 9.2%)
• 13.3% agoraphobia (nongamblers 2.4%)
• 16.7% OCD (nongamblers 2.3%)
• SADS, DIS version III • No relatives with PG
• Interview for DSM-III Axis II disorders

Glossary of abbreviations:
BDI = Beck Depression Inventory
CES = Center For Epidemiologic Studies
DIS = Diagnostic Interview Schedule
DST = Dexamethasone Suppression Test
EPPS = Edwards Personal Preference Schedule
HDRS = Hamilton Depression Rating Scale
MCMI = Millon Clinical Multiaxial Inventory
MOE = Major Depressive Episode SCID = Structured Clinical Interview for DSM-III
MMPI = Minnesota Multiphasic Personality Inventory SGHQ = Structured Gambling History Questionnaire
NEO Personality Inventory = Neuroticism Extraversion SOGS = South Oaks Gambling Screen
and Openness Personality Inventory SSTAI = Speilberger's State-Trait Anxiety Inventory
PG = Pathological Gambler(s) SUDDS = Substance Use Disorders Diagnostic Schedule
POI = Personal Orientation Inventory WAIS = Wechsler Adult Intelligence Scale.
PRLEI = Paykel 64-ltem Recent Life Event Interview
SADS = Schedule For Affective Disorders and Schizophrenia

are comorbid, the inconsistencies in the data defy this asser-
tion from being made more definitively. In all likelihood,
there is at least a subpopulation ofpathological gamblers who
have a comorbid mood disorder, which may playa role in
perpetuating their gambling behaviour (34,40). This stands to
reason because there have been similar findings in popula-
tions with substance use disorders (41). To confirm this,
future work will have to control for comorbid substance use
disorders, use prospective designs to distinguish primary
symptoms from secondary symptoms, assess patients after a
period of abstinence, and further assess community samples.
It will also have to take into account the recent changes to the
diagnostic criterion for pathological gambling in DSM-IV,
where behaviour better explained by a manic episode is an
exclusion criteria, as this will undoubtedly further affect the
comorbidity rates (45).
Anxiety Disorders
Relatively little data are published on the possible associa-
tion of anxiety disorders with pathological gambling. Pres-
ently, 3 studies have reported an increased prevalence of
anxiety disorders in this population (Table 3), but each has
found different prevalences of the various anxiety disorders
with no consistent pattern (16,17,24).
The results partly seem counterintuitive as it would be
unusual for a person with an anxiety disorder to seek out an
anxiety-provoking stimulus. Their interpretation is also
fraught with difficulties. The potential confounding produced
by concomitant substance use, such as combining nicotine
and caffeine, is not controlled, which may account for the
increased prevalences found in the 3 studies (46). In addition,
extremely small sample sizes, poorly described demograph-
ics and the use of different instruments in each study further
complicate the interpretation of the positive results. If all
these factors are considered with the results from 1 study, in
which psychological testing did not reveal anxiety scores
significantly different from the normative sample and another
study, in which the familial aggregation that would be ex-
pected to occur with the anxiety disorders was not found, then
the possibility of a comorbidity being present seems less
likely (34,47).
Thus despite an increased prevalence being reported in 3
studies, there would appear to be insufficient data to support
the theory that anxiety disorders are comorbid with pathologi-
cal gambling. In particular, there is little support for a comor-
bidity with obsessive--eompulsive disorder (OCD). The lack
of evidence for a comorbidity and the egosyntonic nature of
the pathological gambler's behaviour (as opposed to the
egocystonic nature of compulsive phenomena) then further
emphasizes that the term "compulsive gambling" is a misno-
mer (60). Future work will require that the possible confound-
ing due to concomitant substance use be controlled for, that
more adequate samples be used, and that prospective designs
be developed to determine the natural histories of these
disorders. For example, the question "Is anxiety a cause or a
consequence of gambling?" must be addressed.
Personality Disorders
Crime and gambling are frequent bedfellows, so it is no
surprise that pathological gamblers are often found to have
antisocial features (48,49). Minnesota Multiphasic Personal-
ity Inventory (MMPI) data have consistently shown that
pathological gamblers score significantly higher than con-
trols on the Psychopathic Deviate Scale (Scale 4) (31,32).
Correspondingly, Lesieur found that approximately two-
thirds of Gamblers Anonymous (GA) members admitted to
illegal activities to support their gambling, and it has been
reported that up to one-third of American prisoners may
suffer from pathological gambling (50,51,52).
Are these antisocial features symptomatic of pathological
gambling, or are they representative of an idiopathic antiso-
48 The Canadian Journal of Psychiatry
cial personality disorder? Only 2 studies to date have at-
tempted to address these questions. In their community sur-
vey using the Diagnostic Interview Schedule version III,
Bland and others found a 40% lifetime prevalence of antiso-
cial personality disorder in the pathological gamblers identi-
fied (17). When Blaszczynski and others studied 109
pathological gamblers who were seeking treatment or in GA,
however, they found that only 14.6% ofthe subjects qualified
for a diagnosis ofantisocial personality disorder (a difference
that may relate to individuals with antisocial personality
disorder being less likely to seek treatment) (53). Those
subjects more frequently committed both gambling-related
and nongambling-related offences. The majority of patho-
logical gamblers with antisocial features, however, especially
those reporting offences only related to gambling, appeared
to develop their traits as a consequence of their gambling
behaviour. This would be expected since the diagnostic cri-
teria for these disorders overlap.
Thus despite limited data, it would appear that a small but
significant subset of pathological gamblers probably have a
comorbid antisocial personality disorder. Replication ofthese
findings and expansion upon them would be useful because
individuals with this comorbidity may have a different course
and prognosis, as has been found with the substance use
disorders (54).
As regards the other personality disorders, reference has
been made only to the narcissism of pathological gamblers,
but at present no studies formally evaluate a possible comor-
bidity with narcissistic personality disorder (55,56).
Other Disorders
Attention Deficit Hyperactivity Disorder (ADHD)
Research into a possible association between pathological
gambling and ADHD is based upon subtle electroencephalo-
gram (EEG) deficits found in pathological gamblers, such as
deficits in task-appropriate hemispheric differentiation,
which seem to parallel those found in children with ADHD
(57,58). Carlton and others obtained retrospective self-report
data concerning childhood behaviours from 14 pathological
gamblers and 16 controls that found a strong correlation
between pathological gambling and childhood behaviours
related to ADHD, which persisted when substance abuse was
controlled for (35). Carlton and Manowitz replicated their
previous findings in another study, but did not find that
pathological gamblers showed any consistent deficit in a test
of behavioural restraint (59). Rugle and Melamed compared
33 nonsubstance-abusing pathological gamblers with 33
nonaddicted controls and found that the pathological gam-
blers did significantly worse on measures of higher order
attention and reported more childhood behaviours related to
ADHD, which was confirmed by collateral data (60).
The preliminary nature of this work, however, cannot be
overemphasized. It is retrospective, the sample sizes are very
small, treatment samples that tend to include the most se-
verely disordered pathological gamblers are used, and the
Vol 43, No 1
relationship between current neuropsychological functioning
and childhood behaviour is uncertain at best. Without pro-
spective work, there would appear to be minimal justification
to find ADHD and pathological gambling to be comorbid
disorders.
Eating Disorders
Literature to support an association between pathological
gambling and the eating disorders comes from self-report
questionnaires that have positively correlated SaGS scores
with nonspecific questions about the respondents' eating
habits, such as if they felt they were compulsive overeaters
or if they had an eating disorder (37,61). Similar methods
have also been used to suggest that there is some overlap with
so-called sexual addictions (6). Certainly the predictive value
for the diagnosis of an eating disorder or a sexual addiction
from such self-report data seems dubious at best. This con-
clusion is at least partly supported by Bland and others' study,
which found that none ofthe pathological gamblers identified
in their community survey had a lifetime prevalence of ano-
rexia (17). It could be possible that any association between
these disorders reflects their comorbidity with the substance
use disorders rather than a true association, but there is no data
to allow further comment upon this speculation.
Dissociative Disorders
Although dissociative-like symptoms have been described
in pathological gamblers while they are gambling, and com-
mon dissociative states have been theorized as a means to link
the addictions, no studies have evaluated the presence of a
comorbid dissociative disorder in pathological gamblers
(6,62). It would seem highly unlikely that this would be
probable, particularly in light of the negative findings de-
scribed in this regard for the substance use disorders (63).
Conclusion
The research on psychiatric comorbidity in pathological
gambling is still very much in its infancy. While an overlap
of symptoms belonging to a variety ofdiagnostic disorders is
common, a more systematic analysis of comorbidity, based
on studies of natural histories, life events, results of psycho-
logical and biological tests, and prevalences among first-de-
gree relatives, reveals a much more tentative picture.
There are relatively few studies published to date with
methodologically strong designs including structured diag-
nostic interview schedules to both define the study population
of pathological gamblers, instead of using scores on the
SaGS, and to classify comorbid psychiatric symptomatol-
ogy. The likely presence ofmultiple comorbities in pathologi-
cal gamblers, particularly substance use disorders, may have
confounded many of the findings, making the interpretation
of discrete associations problematic. Nevertheless, the fol-
lowing conclusions can be made: 1) pathological gambling is
frequently comorbid with substance use disorders; 2) a subset
of pathological gamblers would appear to have a comorbid
antisocial personality disorder, but this population is in the
February 1998 PsycWatric Comorbidity in Pathological Gambling
minority compared with those who have acquired antisocial
traits secondary to their gambling behaviour; 3) acomorbidity
with the mood disorders is likely, but there are some meth-
odological concerns and inconsistencies with the data that
prevent further delineation; 4) although anxiety symptoms
have been described frequently in pathological gamblers,
there is no clear consensus about whether or not they repre-
sent a discrete comorbidity; and 5) research into other possi-
ble comorbid disorders is either preliminary in nature or has
not been done, thereby disallowing any conclusions to be
made.
It has been postulated that pathological gambling may
represent a form of an "affective spectrum disorder" because
it may share the same potential underlying physiological
abnormalities as other proposed disorders in this novel class,
such as the other impulse control disorders, OCD, panic
disorder, bulimia nervosa, and ADHD, as suggested by their
high rates of mood disorders, findings of serotonin and no-
repinephrine abnormalities, and response to thymoleptics (9).
Although this is an appealing hypothesis because the thera-
peutic modalities we presently have to treat the mood disor-
ders are generally more effective than those we have to treat
pathological gambling, the data reviewed in this paper do not
necessarily support it. There would appear to be a comorbid-
ity with the mood disorders, but the proposed common bio-
logical abnormalities remain poorly delineated in
pathological gambling, and the thymoleptic agents have not
been effective in its treatment, unless a specific comorbid
disorder has been present that is known to respond to these
agents (16,44,45,51). In addition to these major deficits, the
hypothesis does not go on to explain the tolerance seen in
some pathological gamblers, the presence of withdrawal
symptoms reported upon abrupt cessation of gambling, the
association with antisocial personality disorder, and the de-
velopment of impulsivity seen in pathological gambling in
response to partial reinforcement schedules (53,64-66). A
subpopulation of pathological gamblers may fit into the con-
cept of an "affective spectrum disorder," but it would not
appear to be the case for the majority of pathological gam-
blers. Conversely, since the patterns of comorbidity seem to
follow those found with the substance use disorders, it may
be more appropriate to view pathological gambling in terms
of an addictive disorder.
Future research, if it is to further clarify how best to
conceptualize pathological gambling and address the ques-
tions left by previous work, will need to take into account
study design problems identified earlier in this paper. A major
consideration would be attempting to control for the potential
confounding created by the presence of comorbid substance
use disorders, because the potential for these disorders to
produce transient symptoms that mimic the symptoms of
another psychiatric disorder are well known (11,41). Other
considerations include the use oflarger sample sizes in com-
munity settings to help avoid the potential for sampling bias
to which treatment samples are prone (individuals are more
likely to seek treatment if they have 2 or more psychiatric
49
conditions) and the greater attention to demographic vari-
ables, such as age, sex, and ethnicity, as previous research has
tended to underrepresent minorities and women (67). The use
of retrospective designs, which are prone to subjective bias,
including mistaken memory or misrepresentation, are also
potentially problematic. More work using prospective de-
signs is crucial so that the potential demographic impacts,
shared etiologies, and natural courses of these disorders can
be more fully elucidated.
A final consideration concerns the possible significance of
any described comorbidity on clinical management. Pres-
ently, there are little if any data showing that pathological
gambling being comorbid with another disorder impacts ad-
versely on the clinical course or optimal treatment of either
disorder, even though this would appear probable. This is of
particular interest in light of the advent of newer and poten-
tially more specific therapeutic modalities, such as naltrex-
one, which may further aid in the amelioration of one or both
disorders.
This review of pathological gambling demonstrates both
the promises and limitations that are inherent in the study of
comorbidities and the assessment of their treatment implica-
tions. Hopefully, future research will answer the many ques-
tions that remain so that a greater understanding of
pathological gambling and its associated psychiatric comor-
bidities can be better determined.
Clinical Implications
• Pathological gambling is a disorder of growing importance
because of the increased availability of gambling in Canadian
society.
• Patients with pathological gambling frequently have comorbid
substance use disorders and, to a lesser extent, antisocial per-
sonality disorder and major mood disorder upon presenting for
treatment.
• Pathological gambling is best conceptualized as an addiction
based on its similarity to the substance use disorders in their
patterns of comorbidity.
Limitation
• This review further identifies the limitations inherent in the
study of comorbidities.
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Resume

Objectif: Proceder a l'examen critique de la litterature actuelle sur Ie jeu pathologique a l'egard des comorbidites
psychiatriques liees ace trouble,

Methode: Les auteurs ont realise la synthese de renseignements recueillis au moyen de recherches electroniques (MEDLINE)
et bibliographiques dans plus de 60 publications,

Resultats : Les joueurs pathologiques sont frequemment atteints de troubles comorbides lies a l'utilisation de substances
psycho-actives, En outre, un sous-ensemble de ces joueurs semble dote d'une personnalite antisociale comorbide, mais if
represente une minorite par comparaison avec lespersonnes ayant acquis leurs traits antisociaux dufait de leur comportement
de joueur. Une comorbidite avec les troubles de I'humeur est probable, mais des preoccupations quant ala methodologie et
des incoherences touchant les donnees nous empechent de mieux delimiter cet aspect, On traite aussi de recherches
avant-gardistes sur d'autres troubles pouvant etre associes aujeu pathologique.

Conclusion: Le jeu pathologique est associe a une comorbidite psychiatrique importante. Des recommandations en vue de
recherches ulterieures font I'objet d 'une description.