Book Review

Pathological Gambling: The making of a medical problem

N Engl J Med 2000; 343:1050-1051October 5, 2000

Article

Pathological Gambling: The making of a medical problem
By Brian Castellani. 222 pp. Albany, State University of New York Press, 2000. $18.95. ISBN: 0-7914-4522-4

Gambling has always existed, but only recently has it taken on the colorful and highly accessible forms we know today. Essentially, gambling stakes something valuable — usually money — on the outcome of an entirely unpredictable event. In other words, gambling is governed by events that occur by chance — hence the term, “games of chance.” A gambler's main task is to use any information available to predict the outcome of the game (although it is, of course, unpredictable). We might wonder why anyone would risk his or her financial security on such a dubious venture. But most gamblers behave as though the outcome of their gambling depended on their personal skills and on the exercise of those skills at the appropriate moments. In the gambler's world, skill can influence chance. In reality, however, chance has the last word.

More than two thirds of adults gamble on a regular basis. For most of these people, gambling is a relaxing activity and has no negative consequences. For others, however, gambling becomes a disorder, characterized by an irrepressible urge to wager money. It ultimately dominates the gambler's life and has a multitude of negative consequences for the gamblers themselves and their friends, families, and employers. Experts agree that the social costs of pathologic gambling are enormous.

It is estimated that 1.5 percent of the adult population gambles excessively. Given that the prevalence of gambling is related to the accessibility of gambling activities and that new forms of gambling are constantly being legalized throughout the United States and in most other Western countries, this figure is expected to rise. Pathologic gambling is currently one of the fastest-growing mental health problems in these parts of the world.

Surprisingly, it was only two decades ago that pathologic gambling was first recognized as a mental disorder. Some may wonder why acknowledgment of the psychiatric aspect of this disorder was so long delayed; others, however, may wonder whether gambling merits recognition as a disorder at all. In many ways, gambling seems fairly harmless. In fact, it is not the act of gambling itself that is harmful but, rather, the vicious cycle that is set into motion by gamblers' attempts to recuperate their losses. This cycle begins when a gambler wagers money he or she cannot afford to lose and then, through a fault of logic, continues to gamble in order to recuperate the loss. The gambler fails to understand that gambling is governed solely by random events. He or she attempts to control the outcome of the game by concocting strategies to “beat the game.”

Pathological Gambling: The Making of a Medical Problem, which is divided into 14 chapters, presents a unique and refreshing perspective on its subject. Castellani begins by tracing the history of pathologic gambling and proceeds with an articulate, integrated, and complete description of the first formal treatment unit, created by the late Dr. Robert Custer. Castellani goes on to describe some of the sticky social controversies surrounding the legalization of gambling. In particular, he criticizes the dual role adopted by government, which attempts to protect the public by regulating gambling while simultaneously encouraging this lucrative activity. Castellani concludes, “We cannot continue to have government and business working hand-in-hand. Government needs to re-establish its role as government and initiate regulations that will protect the public.”

Castellani also describes and appraises the pioneering work of eminent scientists and clinicians (such as Lesieur, Lorenz, Rosenthal, and Taber) who made substantial contributions to the recognition of pathologic gambling as an independent disorder. More important, Castellani provides convincing evidence that pathologic gambling is a complex disease with numerous causes. Indeed, in order to have a comprehensive and comprehensible body of knowledge about gambling, we must look to many disciplines, including sociology, psychology, psychiatry, economics, and social work, while also remembering moral, political, and legal issues. Castellani has provided us with just such a broad, comprehensive view of gambling in his brilliant, elegantly written book.

This book is an indispensable resource for both advocates and opponents of the biologic and psychosocial perspectives it discusses. It presents readers with new perspectives on the important social problems posed by pathologic gambling. Experts and laypeople alike will find food for thought in this book. The epilogue alone makes the book worth reading; it contains more than 30 recommendations that, according to the author, must be implemented if we are to move beyond current limitations of thinking about and caring for persons affected by pathologic gambling. As Castellani eloquently states, “The lives of those we care for — from pathological gamblers and their families to the communities in which we live — are at stake.”

Robert Ladouceur, Ph.D.
Université Laval, Quebec, QC G1K 7P4, Canada