Pathological Gambling and Switching Addictions: Report of a Case Sheila B. Blume, M . D . South Oaks Hospital, Amityville, New York
T h e p h e n o m e n o n of "switching addictions," defined as a substitution of one chemical or behavioral addiction pattern for another, has been observed in clinical practices for some time. This case study describes a patient who, in attaining abstinence from alcohol and other drug dependence, became a pathological gambler. T h e complexities of personal history, medical history and psychiatric history are described as well problems in treatment.
During the past several decades, an addiction model of pathological gambling has gained increasing acceptance among clinicians (Orford, 1985; Blume, 1988). The many parallels between pathological gambling and alcohol/drug dependence in their course and symptomatology, and the utility of addiction model treatment (Lesieur and Blume, 1991), have both supported the concept of pathological gambling as a behavioral addiction. In addition, the frequent cooccurrence of chemical dependence and pathological gambling in the same individuals (Lesieur, Blume and Zoppa 1986, Ramirez, et al, 1984; Lesieur and Heineman, 1988) provides further evidence of a relationship between the two. In clinical practice, the interrelationship between various chemical dependencies is complex and difficult to
Send reprint requests to Sheila B. Blume, M.D., South Oaks Hospital, 400 Sunrise Highway, AmityviUe, NY 11701.
Journal of Gambling Studies Vol. 10(1), Spring 1994 9 1994 Human Sciences Press, Inc.
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describe in simple terms. Drugs are most often used in various combinations to enhance their mood elevation and to balance undesired side effects, one of another. However, in some patients, the phenomenon of "switching addictions" is observed. Switching addictions may be defined as a substitution of one drug of choice or one set of addictive behaviors for another, while continuing a pattern of addiction. At South Oaks hospital, which runs a program for pathological gamblers in an addiction setting (Blume, 1989; Blume, 1986), we have encountered a number of abstinent alcoholics and addicts who have developed pathological gambling. The switch to gambling most often occurs in a treated alcoholic or addict who has a past history of either heavy gambling, a strong interest in gambling or some gambling problems. This history is not recognized or addressed during the individual's addiction treatment. The alcoholic/addict becomes abstinent from alcohol and other drugs but increases his or her gambling and eventually experiences symptoms which meet criteria for pathological gambling. Subjectively, the individual sustains abstinence from chemicals by substituting the "high" from being "in action" for that of the previous drug of choice, rather than developing more adaptive patterns of handling life problems. Similar patterns are sometimes seen in switching to other addiction-like behaviors, such as compulsive overeating or compulsive shopping. The patient described here sought treatment for cocaine dependence and a severe gambling problem. A review of her history revealed multiple addictive behaviors, with a recent and rapid switch to a gambling addiction. Like most patients who reach treatment, her problems were not limited to addictions. However, her addictive behavior history presents both a therapeutic challenge and a lesson for addiction treatment specialists. The patient adopted the pseudonym of M a r y Alice for the purpose of this case study and has reviewed the manuscript for accuracy. It is submitted with her consent.
PRESENTING PROBLEM
M a r y Alice was referred for inpatient treatment by the employee assistance program at her workplace, a health-related facility. After three previous inpatient rehabilitation treatments for alcohol and cocaine dependence and one for drug detoxification and depression, she
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had again relapsed, but this time a compulsive pattern of gambling had been added to her complaints. She had left her last inpatient rehabilitation program 36 months earlier, determined to remain abstinent from alcohol and other drugs. After breaking off a somewhat stormy love relationship 20 months into her alcohol/drug abstinence, she had experienced a bout of colitis, with intestinal bleeding, for which she was hospitalized. To distract herself while recuperating she took a trip to Atlantic City, New Jersey, a resort known for casino gambling. Her first deposit of a one dollar coin into a slot machine had an immediate effect on her mood. "I felt h i g h . . , it was w o n d e r f u l . . , like cocaine but without the drug." Thereafter and until the week before her present admission, she spent all of her free time at casinos, catching as much sleep as she could on the bus to and from Atlantic City, or spending a few hours in a casino hotel room. She had returned to work, but her job performance suffered. One month before her present admission she relapsed into free base cocaine use, and was hospitalized for detoxification and psychiatric treatment of severe depression. She was then referred for rehabilitation. By the time of her last hospitalization she was about $30,000 in debt, mostly through her compulsive slot machine use, but also to some degree due to overspending on clothing she neither needed nor wore.
PERSONAL HISTORY M a r y Alice is a 44 year old married African-American woman with one grown daughter who is married and living on her own. Her childhood was one of hard work, deprivation and abuse. She was born out-of-wedlock in a small southern town, and raised initially by her maternal grandmother who was loving and a "good person." However, when she was about 7 years old, her mother married and sent for her. She thereafter lived on a farm, where she was responsible for housekeeping and caring for her mother's 7 additional children. She compares her early life of domestic work to that of Cinderella. In addition, however, she was required to do farm work, and in doing so was left unprotected, and sexually assaulted by other farm workers. She hid this fact from her mother because her mother was ill and troubled. However she feels that this experience made her distrustful of men and confused about her own sexuality. She was a bright student and a hard worker. In high school she took a job after school to help her family.
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This also provided her first experience of handling some of her own money, which she greatly enjoyed. At age 18 she left home to join relatives in the north, got a job and was introduced to a new way of life. Brought up in a strict Southern Baptist culture, she had never smoked, used alcohol or drugs, gambled or dated young men. Although she feared all of these activities she was gradually coaxed into trying them by accusations that she appeared to be acting superior to others by not joining in. She married at age 19 and has one child, born when she was 20. The marriage was prompted by her pregnancy and has not been happy. H e r husband is an alcoholic who enables her alcohol and drug use. She has had two extramarital affairs and expresses confusion about sexuality, feeling that a relationship with an older woman over a prolonged period has an addictive quality to it at times. MEDICAL HISTORY M a r y Alice was a strong and healthy child, and had no serious illness until she developed colitis at age 42. Since then, she has suffered from occasional bouts of severe abdominal pain and bleeding. Exploratory surgery was performed at age 43 for adhesions between the uterus and colon.
FAMILY HISTORY M a r y Alice knows little about her natural father or his family. Three maternal uncles are alcoholics. One half-brother is an alcoholic and one half-sister is a compulsive gambler. She is unaware of any other addiction or mental illness in the family.
ADDICTIVE BEHAVIOR Alcohol M a r y Alice first tried alcohol on the urging of friends after coming north at about age 19. She preferred sweet drinks at first, but after she married she drank scotch whisky in increasing amounts. H e r first alcohol problems occurred at about age 22 and she was soon bringing whisky to work so that she could drink throughout the day. She experienced blackouts, morning shakes, severe hangovers and, toward
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Figure 1 Life Diagram of Addictive Behaviors
ALCOHOL
-i
:=
PILLS
I
COCAINE GAMBLING SHOPPING AGE IN YEARS
15 16 17 I8 1 9 2 0 2 1 2 2 2 3 2 4 2 5 2 6 2 7 2 8 2 9 3 0 3 1 3 2 3 3 3 4 3 5 3 6 3 7 3 8 3 9 4 0 4 1 4 2 4 3 4 4 4 5 4 6 4 7 4 8 4 9 5 0 A
B
USE OF ALCOHOIJ DRUG. GAMBLING OR SHOPP[NG
CD
EF
LIFE EVENTS: A = LEAVING HOME B.C.D = REHABILITATION TREATMENT
g ~ IN PATIENT DE'TOXAND P~YCHL~TRIC EXCESSIVE OR PROBLEMATIC USE OR BEHAVIOR
TREATMENT
g : PRESENT I ,D M I ~ O N A L C O H O L O R D R U G D E P E N D E N C E O R PATHOLOGICAL G~BUN~
(DSM I~l.R c R r r ~ L ~
the end of her drinking, abdominal pains. She considers alcohol her "drug of choice" until age 37 when she "discovered" free base cocaine. Thereafter she used alcohol only to modulate the effects of cocaine. The only exception was a period of 6 months between her first rehabilitation treatment and first cocaine relapse. At that time she drank in hiding 4 or 5 days a week, but did not consume enough alcohol to become physically dependent. M a r y Alice feels that she became dependent on alcohol initially as a help in dealing with her disappointment in an unhappy marriage and an unsatisfying sexual relationship. Later on she drank to ward off withdrawal symptoms, and found herself unable to stop. "Pills" M a r y Alice's work in the health industry gave her access to a variety of prescription sedatives and analgesics which she used primarily as an adjunct to alcohol and to treat hangovers. In addition, she was given codeine for colitis pain about 6 months before her final hospital-
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ization for detoxification (age 43). At that time she reports that she gradually increased her use, found herself asking her physician for extra prescriptions, and used the codeine capsules for sleep. Cocaine
M a r y Alice was introduced to intranasal cocaine at age 32. She reports that she did not particularly like the feeling and did not seek out cocaine until, at age 37, she was offered a "hit" of freebase by a friend. She reports, "I felt like m y head rose up to the ceiling. I said to myself, Aha[ I have finally found my drug[ I lost all interest in alcohol. I started using freebase after work, but was soon using it all the time." After about 6 months she experienced an overdose which led to a "minor stroke," from which she recovered completely, and which did not interrupt her freebasing. Both work problems and financial problems quickly developed. She sent her daughter to live with relatives. She became paranoid and often hid in a closet. H e r employer referred her to a hospital where she underwent her first rehabilitation treatment. She remained cocaine free for 11/2 years but resumed drinking after about a year, and then resumed cocaine use. H e r cocaine dependence was immediately reestablished, and she again needed hospital care. However, she left treatment prematurely (second rehabilitation). Following discharge there was an immediate relapse to freebase cocaine use, and a return to the inpatient program (third rehabilitation). This was followed by 3 years of abstinence, until the events leading up to the present admission.
Gambling M a r y Alice was not exposed to gambling during childhood. After moving away from home, at about age 19, she began to play poker with friends and to bet on numbers. She enjoyed playing cards and became a very good player. She and her husband also ran a poker game in their home. She often won at gambling and considered herself lucky. She did not lose control of her gambling and did not chase losses at this time. However, she did lie to her husband about her losses and hid betting slips from him. When she began to use freebase cocaine at age 37 she abruptly lost interest in gambling and did not gamble again until her trip to Atlantic City at age 42.
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H e r gambling on slot machines became compulsive very rapidly. She became preoccupied with these machines, began to chase her losses, often missed her bus home and had to stay overnight, missed work, went increasingly into debt and had interpersonal problems. As her desperation increased she became depressed and considered suicide. She finally decided to return to cocaine as a means of escape from unbearable pressure. She went on a 4 day cocaine binge, became depressed and tearful and was brought to a psychiatric unit of a general hospital by family members.
Shopping Perhaps because of her childhood poverty, M a r y Alice always found that having money to spend made her feel good. She states "I always loved money but I spent it." When her daughter was still young she began to buy her gifts, and was thought by others to be spoiling her by purchasing "nothing but the best." She acquired the nickname "Rockefeller" during her drinking years because of her taste for good clothes, but she did not go into serious debt at that time. When she began her addiction to freebase cocaine she stopped shopping to excess, but she began again during her period of drug abstinence (age 41). When she began to gamble compulsively on slot machines, the only other activity she recalls was leaving the casino occasionally to buy pairs of shoes or articles of clothing on her credit cards, increasing her indebtedness. She feels that she is now in danger of uncontrolled shopping if she is successful in stopping her other addictive behaviors.
CLINICAL EVALUATION By the time she reached the present rehabilitation program, Mary Alice was detoxified and her depression had partially abated. She showed no psychotic traits nor any residual organic symptoms from the "minor stroke" 6 years earlier. There was no history of psychiatric disorder, other than outlined above. She was well dressed and well groomed, and presented herself as a warm outgoing person who cares deeply for others. Her insight and motivation have been good, and she has participated fully in her treatment program.
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She scored 43 on the Michigan Alcohol Screening Test (MAST), scoring on all but questions n u m b e r 12, 18, 19, 24 and 25 (a M A S T score of 5 or more is considered indicative of alcoholism) (Selzer 1971). She scored 26 on the Drug Abuse Screening Test (DAST), scoring on all but questions n u m b e r 6 and 10, (a DAST score of 5 or more is considered indicative of drug dependence) (Skinner 1982). O n the South Oaks Gambling Screen (SOGS) Mary Alice scored 17, scoring on all but questions number 16e, g and i (a SOGS score of 5 or more is considered indicative of probable pathological gambling) (Lesieur and Blume 1987). M a r y Alice met D S M - I I I - R diagnostic criteria for alcohol dependence, cocaine dependence, pathological gambling and polysubstance abuse (American Psychiatric Association, 1987).
DISCUSSION
M a r y Alice has a history of multiple addictive behaviors. However, it would not be correct to conclude that she is addicted to "everything and anything." She tried smoking both tobacco and marijuana on multiple occasions but did not find either sensation attractive. She remains a non-smoker. Likewise, she was given various stimulants (amphetamines, anorectics) and did not use them because they made her feel tense. She has never used heroin nor any drug via intravenous injection. Her life history does document the complex interaction of both chemical and behavioral addictions. M a r y Alice became addicted to alcohol during her 20's. At the same time her gambling and shopping were both inappropriate and excessive in her view, but not beyond her control. She experienced a clear shift of addiction to freebase cocaine at age 37. Later, following three inpatient rehabilitation stays, she established chemical abstinence but became rapidly addicted to slot machine gambling once she was introduced to this activity. H e r history also illustrates the fact that behavioral addiction can be a factor in relapse to chemical addiction. W h e n her pathological gambling reached its desperation stage, she relapsed into binge use of cocaine and alcohol, as a perceived alternative to suicide, to escape from an unbearable situation.
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This case also illustrates the importance of anticipating the possibility of switching addictions, which should be a routine part of chemical dependency treatment. At the time of her first rehabilitation treatment, she already had a history of regular gambling (poker and numbers), with an intense interest in numbers, to the extent that she hid the amount of her betting from her husband and denied the extent of her losses. However, she did not chase losses, was not in debt due to gambling, and did not meet criteria for a D S M - I I I or D S M - I I I - R diagnosis of pathological gambling. Although the S O G S was not yet available at the time of her first rehabilitation treatment, had it been so M a r y Alice would have scored 4 (positive on questions number 5, 7, 8 and 11), indicating some gambling problem. Thus, a careful gambling history and/or SOGS screening test would have identified her as a patient at risk for a switch to pathological gambling. H a d this identification been made, it could have triggered preventive counseling which might possibly have averted the patient's disastrous experience with slot machines. Unfortunately, M a r y Alice denies ever being asked about or educated about gambling during her previous treatment experiences. This description of switching addiction also raises the question of her problems with shopping. M a r y Alice clearly states that she feels "high" when buying beautiful things. She herself expresses fears of switching from compulsive gambling to compulsive shopping. H e r current treatment includes an exploration of her shopping behavior and an introduction to Debtors Anonymous as a long term resource, along with Alcoholics Anonymous, Narcotics Anonymous and Gamblers Anonymous. She is also encouraged to set up a realistic budget which will not allow her to handle large amounts of money, to write checks or to buy on credit. Finally, M a r y Alice identifies some addictive quality in her previous relationship with an older woman. In exploring this aspect of her life, she described more ambivalence than addiction, combined with uncertainty about her "true" sexual orientation. However, her plans for the future do not include resuming this relationship. M a r y Alice has many strengths which can be utilized in the service of recovery. She is a hard working, enthusiastic person who throws herself into activities in which she has an interest. In the past several years she has embraced the Buddhist religion, which attracted her with its message of peace. She has related well to the 12-steps of the
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various self help groups she attends, which she considers her lifeline for survival. She also hopes she can learn to help others suffering from addictive disorders to find their way out of the complex of problems she has experienced. Finally, Mary Alice hopes that bringing her history of switching addictions to the attention of the treatment community will encourage better prevention efforts on the part of those who treat addictions.
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