The clinical evaluation and assessment of Gambling Disorder has changed since the DSM-III. Now in the DSM 5, Gambling Disorder has been updated for clinical interface with a new demographic and new modes of online gambling and online sports betting.

Gambling disorder is regarded as a complex and multifaceted condition (and set of behaviors) that has been a subject of significant attention in psychiatric classification systems. Since the legalization of online gambling and sports betting in 2018, further attention has been devoted to ensuring the clinical qualifications for gambling disorder are updated. The Diagnostic and Statistical Manual of Mental Disorders (DSM), published by the American Psychiatric Association, is amongst the primary references used by providers both nationally and internationally. The DSM has a long and varied history and aims to provide a standardized framework for diagnosing mental and behavioral health disorders. Here, our team examines the evolution of gambling disorder across the DSM-III, DSM-IV, and DSM-5 and explores the changes in diagnostic criteria and understanding of this specific condition.

DSM-III Categorization

DSM-III: In the third edition of the DSM (DSM-III), published in 1980, gambling disorder was not explicitly designated as a distinct clinical entity. Instead, it was categorized under "Impulse Control Disorders Not Elsewhere Classified." Despite its inclusion, this classification reflected a limited understanding of gambling and sports betting-related behaviors, the problems that may arise, and their underlying mechanisms. The diagnostic criteria primarily focused on impulse control issues and lacked a comprehensive characterization of gambling disorder.

Updates Between DSM-III and DSM-IV

DSM-IV: In the fourth edition (DSM-IV), published in 1994, gambling disorder took a significant step forward in terms of both recognition and classification. The DSM-IV introduced the diagnostic category of "Pathological Gambling" and included it within the category of "Impulse Control Disorders." This update from the DSM-III highlighted the problematic nature of gambling, and in turn, went about emphasizing the psychological and behavioral aspects of the disorder.

The DSM-IV diagnostic criteria for pathological gambling consisted of the following five criteria:

1. Preoccupation: Frequent thoughts about gambling experiences.

2. Tolerance: Needing to increase the amount of money wagered to achieve the desired excitement.

3. Withdrawal: Restlessness or irritability when attempting to cut down or stop gambling.

4. Escape: Gambling as a way to escape problems or negative feelings.

5. Chasing: Repeated unsuccessful efforts to control, cut back, or stop gambling.

These criteria represented a significant step forward in recognizing gambling disorder as a distinct clinical condition. However, the DSM-IV criteria were criticized for primarily focusing on the behavioral aspects of gambling, neglecting the underlying psychological mechanisms involved.

How was Gambling Disorder changed for the DSM-5?

DSM-5: With the release of the fifth edition of the DSM (DSM-5), published in 2013, further revisions were made to enhance the diagnostic accuracy and clinical utility of gambling disorder. In turn, this empowered clinicians to better understand and diagnose gambling disorder. Among the updates to the DSM-5, gambling disorder was taken out of “Impulse Control Disorders" as a category and instead was  included in a novel classification entitled "Substance-Related and Addictive Disorders."

The diagnostic criteria for gambling disorder in DSM-5 expanded upon the previous edition and incorporated new elements. Crucial criteria to inform a diagnosis include:

1. Persistent and recurrent problematic gambling behavior leading to clinically significant impairment or distress.

2. Increasing need to gamble with larger amounts of money to achieve the desired excitement.

3. Restlessness or irritability when attempting to cut down or stop gambling.

4. Repeated unsuccessful attempts to control, cut back, or stop gambling.

5. Preoccupation with gambling (e.g., reliving prior gambling experiences and at-risk gambling behavior, planning the next or ongoing gambling ventures).

6. Gambling to escape or relieve negative emotions.

7. Chasing losses (i.e., trying to win back previous gambling losses through further gambling).

8. Deception regarding the extent of gambling involvement.

9. Jeopardizing or losing significant relationships, job, educational or career opportunities due to gambling.

10. Relying on others for financial assistance due to gambling losses.

11. The diagnosis is not made if gambling behavior is better accounted for by a manic episode.

DSM-5 also introduced a severity specifier for gambling disorder, allowing clinicians to gauge the level of impairment associated with the condition. The severity levels are classified as mild, moderate, or severe, based on the number of diagnostic criteria met.

What’s Next for Further Classifications of Gambling Disorder?

The evolving understanding of gambling disorder across DSM-III, DSM-IV, and DSM-5 highlights the progressive recognition of this condition as a significant mental health issue. The transition from impulse control disorders to substance-related and addictive disorders reflects a growing understanding of the underlying psychological and neurobiological mechanisms involved in gambling disorder.

Throughout the changes made over the past 33+ years, the diagnostic criteria for gambling disorder in DSM-5 have become more comprehensive. As a result, the criteria now capturies a broader range of symptoms and their impact on individuals' lives. Additionally, the inclusion of a severity specifier enhances diagnostic accuracy, and aids clinicians in personalized treatment planning for gambling disorder. However as with all clinical criteria, ongoing clinical research and evidence-based clinical practice are necessary to continue refining the diagnostic criteria and improve the assessment and management of gambling disorder as well as how to recognize behaviors in individuals struggling with gambling and sports betting.

Clinical References:

1. American Psychiatric Association. (1980). Diagnostic and statistical manual of mental disorders (3rd ed.). American Psychiatric Publishing.

2. American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). American Psychiatric Publishing.

3. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). American Psychiatric Publishing.

4. Petry, N. M., Blanco, C., Auriacombe, M., Borges, G., Bucholz, K., Crowley, T. J., ... & Grant, B. F. (2014). An overview of and rationale for changes proposed for pathological gambling in DSM-5. Journal of Gambling Studies, 30(2), 493-502.

5. Dowling, N. A., Cowlishaw, S., Jackson, A. C., Merkouris, S. S., Francis, K. L., & Christensen, D. R. (2015). Prevalence of psychiatric co-morbidity in treatment-seeking problem gamblers: A systematic review and meta-analysis. Australian and New Zealand Journal of Psychiatry, 49(6), 519-539.