Evaluating Gambling Disorders: Screening, Assessment and Diagnosis: Column by Debi LaPlante, Ph.D., and Howard J. Shaffer, Ph.D., C.A.S.
In my previous Responsible Gaming Quarterly article (Shaffer, 2002), I reviewed the nature of gambling problems and how these difficulties can become an addiction. In this article, Dr. LaPlante and I review the evaluation of disordered gambling. We consider evaluation one of the most important steps toward recovery from disordered gambling because it leads to a multidimensional set of events including, but not limited to, developing alliances with patients, providing a blueprint for treatment planning and establishing a reference point for treatment monitoring and aftercare. Also, evaluation has the power to change the attitudes, emotions and behaviors of problem gamblers. The tools of evaluation should be used with care.
The first step in recovering from gambling-related disorders is determining whether a problem actually exists. Although many people assume that all evaluations are alike, the evaluation of disordered gambling includes three primary forms: (1) screening, (2) assessment and (3) diagnosis. These different aspects of evaluation are distinct, and the purposes of these efforts are intended for very specific settings.
The most common type of evaluation, screening, is an informal check that can be administered without the aid of a clinician or other health professional. Many screening devices can be found on the Internet, and they often are quite brief. For example, the Gamblers Anonymous (GA) 20 questions screen can be found at the GA Web site. Screening tools provide gamblers who are not in treatment with information that will help them decide whether they should seek a more thorough evaluation.
Another type of evaluation, assessment, is slightly more formal. Assessment tools are frequently used by clinicians to determine whether treatment seekers need more extensive diagnostic evaluation or how to match patients' current problems with treatment plans. One example of an assessment tool is the South Oaks Gambling Screen (SOGS, Lesieur & Blume, 1987). The SOGS was designed to be used in a clinical setting; its popularity has extended from the treatment setting as an assessment device to the general population as a screening tool. This shift in application has led some investigators to suggest that the SOGS often overestimates the likelihood that an individual has a problem with gambling (Dickerson, 1994; Volberg & Boles, 1995; Walker & Dickerson, 1996). It is impossible to determine if the SOGS over- or underestimates gambling problems since currently there is no "gold standard" to evaluate the accuracy of the SOGS. From a clinical perspective, overestimating is preferred to underestimating since this allows individuals to be identified for further evaluation more readily.
The most formal type of evaluation, diagnosis, is used by trained mental health professionals. This aspect of evaluation involves a more detailed understanding of the problem and its causes. Diagnosis also helps to guide treatment strategies. There are two primary sets of criteria to guide the formal diagnosis of gambling disorders: theDiagnostic and Statistical Manual of Mental Disorders, published by the American Psychiatric Association (American Psychiatric Association, 1994), and theInternational Classification of Diseases, published by the World Health Organization (1992). Table 1 summarizes the DSM-IV criteria for pathological gambling.
In a cautionary note, the DSM-IV states: "… inclusion here, for clinical and research purposes, of a diagnostic category such as Pathological Gambling or Pedophilia does not imply that the condition meets legal or other non-medical criteria for what constitutes mental disease, mental disorder, or mental disability. The clinical and scientific considerations involved in categorization of these conditions as mental disorders may not be wholly relevant to legal judgments, for example, that take into account such issues as individual responsibility, disability determination, and competency (American Psychiatric Association, 1994, p.xxvii). By merely mentioning3 pathological gambling in this cautionary note, the editors of DSM-IV purposely or inadvertently have removed the full standing of this problem as a psychiatric disorder–rightly or wrongly–with all of its exculpatory power. Nevertheless, by suggesting that pathological gambling may not be "wholly relevant" to legal judgments, the DSM-IV also implies that gambling disorders might be partly relevant. Determining how relevant is a complicated legal and regulatory matter.
Unfortunately, evaluation tools must be interpreted, and clinicians can misuse these instruments. For example, screens are often used to assess and assessment tools to screen. Further, clinicians' judgments do not always agree, and their considered opinions are not as reliable as we would like. This can have unfortunate consequences, such as leading treatment seekers to believe that they have a problem when they do not or, even worse, leading individuals to believe that they do not have a problem when they actually do. Evaluation is a thorny and difficult activity. It is a clinical art as much as a science. However, evaluation will continue to be a key treatment component. Treatment begins with evaluation and repeats the evaluative process throughout the course of care. Our next column will discuss treatment and self-help options that are often spawned from evaluation.
Please direct any electronic correspondence regarding this article to debi_laplante@hms.harvard.edu orhoward_shaffer@hms.harvard.edu. Regular mail can be sent to either author at the Division on Addictions, Harvard Medical School, 350 Longwood Avenue, Suite 200, Boston, MA 02155.
1(American Psychiatric Association, 2000).
2Readers also might consider the social and public policy impact of having only one conceptual counterpart, pedophilia, included in this cautionary note.
REFERENCES
American Psychiatric Association. (1994). DSM-IV:Diagnostic and statistical manual of mental disorders(Fourth ed.). Washington, D.C.: American Psychiatric Association.
American Psychiatric Association. (2000). Diagnostic and Statistical Manual of Mental Disorders-Text Revision (Fourth ed.). Washington, D.C.: American Psychiatric Association.
Dickerson, M. (1994, June). Alternative approaches to the measurement of the prevalence of pathological gambling. Paper presented at the Ninth National Conference on Gambling and Risk-Taking, Las Vegas.
Lesieur, H. R. & Blume, S. B. (1987). The South Oaks Gambling Screen (SOGS): A new instrument for the identification of pathological gamblers. American Journal of Psychiatry, 144, 1184-1188.
Shaffer, H. J. (2002). Gambling and disordered gambling.Responsible Gaming Quarterly, 1(1), 6-7.
Volberg, R. A. & Boles, J. (1995). Gambling and problem gambling in Georgia (Report to the Georgia Department of Human Resources). Roaring Spring, Penn.: Gemini Research.
Walker, M. B. & Dickerson, M. G. (1996). The prevalence of problem and pathological gambling: a critical analysis.Journal of Gambling Studies, 12(2), 233-249.
World Health Organization. (1992). The ICD-10 classification of mental and behavioral disorders: clinical descriptions and diagnostic guidelines. Geneva: World Health Organization.
