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• W2004192105 abstract "We welcome the comments of our distinguished colleagues, Jim Orford, Nancy Petry and Richard Rosenthal, concerning the methods, analyses and conclusions of our paper proposing a hierarchy of gambling disorders (Toce-Gerstein et al. 2003). Extreme or persistent gambling losses have long been identified as a source of personal distress, social disturbance and even class ruin. Nevertheless, pathological gambling is a relative latecomer to the family of recognized psychiatric disorders as codified, for example, in the DSM-IV scheme of the American Psychiatric Association (APA), where it sits cheek-by-jowl with trichotillomania and other impulse control disorders not elsewhere classified (see APA 1994). The commentators for our paper identify several of the central nosological and psychometric issues posed by this disorder. From a clinical perspective, one first wants to determine whether a patient is sick or well in order to decide whether any intervention is called for; and then one seeks a differential diagnosis if there is a reason to do so, such as needing to choose the best treatment course among alternatives. Even if one has only a single course to offer for a particular diagnosis, such issues as the search for etiology (an interest in prevention rather than cure) or heterogeneity in observed responses to treatment may push one toward identifying degrees or kinds of an illness. All three commentators wonder whether the definitions of problem and pathological gambling that we employ in the paper, or that lie within the DSM, place exactly the right boundaries between normality and disorder. Dr Rosenthal, one of the prime architects of the DSM-IV definition of pathological gambling, reminds us that the DSM is intended as a guidebook rather than a cookbook. He endorses the addition of a clinical ‘problem gambling’ concept, but argues that ‘distress or impairment’ remains the sine qua non of any clinical designation. We favor this point in general, but note that many unquestionably pathological physical and mental processes can progress quite far without the afflicted person presenting or perceiving any but the subtlest signs of distress or impairment. The specific implication of his argument seems to be that certain DSM criteria—particularly the ‘fantasy’ elements of preoccupation, escape, and lying about gambling—fall short on this test and thus may tend to overdiagnose clinical conditions. We have not performed a definitive analysis to resolve this concern, and the NORC data may well be inadequate to resolve it. We do intend to explore further the relationship of this particular constellation of items to behavioral indicators of distress, such as suicide attempts and divorce, and indicators of impairment, such as unemployment and incarceration. These are all items that we found generally elevated among problem and pathological gamblers as defined here (Gerstein et al. 1999; Volberg 2002, 2003). Petry joins Rosenthal on this issue, but implicitly questions a different set of criteria, and indeed to the opposite effect. She points out that the DSM-IV does not recognize such common signs of gambling-related distress and impairment as (1) borrowing money to pay gambling debts (presumably a less stringent test than the ‘desperate situation’ specified in the bailout criterion), (2) regrets about amounts wagered (in contrast to difficulties when trying to bet less, as in loss of control or withdrawal, or a drive to bet more, as in tolerance) and (3) receiving criticism of one's gambling (an appreciably lower threshold than risking relationships or the potential consequences of illegal acts). In all these senses, her concern is that the DSM-IV criteria may underdiagnose this clinical condition. Rosenthal further holds that the ‘chasing’ criterion (as acknowledged in our recital of limitations) may be too loosely specified in the NODS, failing on the overdiagnosis side by not distinguishing malignant (persistent and maladaptive) chasing from benignly acute eruptions of this behavior. On this matter he is joined by Orford, but in a somewhat contrary direction; Orford holds that the chasing concept in the DSM-IV is actually too narrow and should be broadened to include other cognitions and behaviors. We think Rosenthal's point is sounder, on balance, and we refer readers to a further analysis (Toce-Gerstein & Gerstein 2004) where we have grappled with the question of the persistence of the DSM-IV conception of chasing. A related issue is temporal. Both Petry and Orford (with opposite evaluations) consider that our proposed hierarchy of disorders necessarily entails progressive developmental stages. However, we state clearly that our cross-sectional analysis, which simply represents individuals grouped ordinally by a cumulative life-time measure, does not and cannot stake this claim. We acknowledge in our concluding discussion that a hierarchy is consistent with and may reflect a developmental sequence (including oscillations between relapse and remission in the late stages of the disorder), but the data we present can neither confirm nor deny these very interesting speculations. Finally, there is a general question whether a typological approach to nosology can ever serve as a useful path to understanding. Orford offers up a number of homilies on the hazards of psychiatric typologizing (his examples are bulimia, depression and substance use disorders). He concludes that a two-dimensional vector, as described in Orford et al. (2003) (a publication not available to us when this paper was submitted), may be preferable. On this matter, we believe that readers should examine the respective arguments and take their own counsel. Several remarks in Orford's comments may reflect time pressures under which the comments were submitted. He expresses dismay that a ‘rather important detail’, specifically use of a life-time rather than a past-year measure of gambling problems, is ‘strangely…not clear until quite late on’. However, we stipulate this detail plainly in the Abstract of the paper and in the Methods section. Orford also refers to ‘controversial features’ of our data, namely (1) the ‘complex’ weighting scheme, (2) variance of our prevalence results from individual state-level surveys and (3) the ‘rather small’ sample size. We are aware of no technical review of the NORC survey that controverts any of these matters, nor does Orford cite any. Moreover (1) as our Methods section makes clear, we use no weights in the present paper, (2) most state-level surveys have used the DSM-III-based South Oaks Gambling Screen (SOGS), which is known to generate higher estimates of pathological gambling prevalence than DSM-IV based instruments (Rönnberg et al. 1999; Sproston et al. 2000; Welte et al. 2001; Volberg 2002, 2003) and (3) typical state and national prevalence surveys in the United States—including the national surveys performed by Welte et al. (2001; n= 2638), whom Orford cites, and Kallick et al. (1976; n= 1736), whom he does not—are usually comparable in size with the NORC study (n = 2917), which took statistical guidance into account with respect to sampling efficiency. However, we appreciate the additional precision potentially achievable through the larger sample taken in the British Gambling Prevalence Survey (BGPS) (Sproston et al. 2000; n= 7680). We look forward in turn to reporting the results from an even larger sample we have obtained by merging all of the US national and state level surveys that use the NODS. We note in closing that we agree strongly with Petry regarding the need for prospective research to investigate how the severity of gambling problems may vary within persons over time, as well as across the population as a whole. Less than a handful of published articles constitutes the entire research literature on this matter. We also agree with Petry concerning the importance of more closely examining the relationship of gambling disorder scales to measures of gambling participation, such as the quantity and frequency of betting and the specific games played. The NORC dataset has extensive measures of participation, and we have explored some of these relationships in other studies (Gerstein et al. 1999; Volberg, Toce & Gerstein 1999). We hope others are doing so as well; in fact, the NORC dataset has been downloaded more than 2300 times since it was first posted on the internet in 1999 (http://www.icpsr.umich.edu:8080/SAMHDA-STUDY/02778.xml). We would like to thank the editors of Addiction for selecting our paper for this forum, as well as the commentators and reviewers who so thoughtfully read our paper and agreed to share their comments and insights with us and our readers." @default.
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• W2004192105 title "Where to draw the line? Response to comments on ‘A hierarchy of gambling disorders in the community’" @default.
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