To the Editor: Concurrent with the increased availability of legalized gambling has been a growing appreciation for pathological gambling. Many psychiatric populations have high rates of pathological gambling, including those with mood or substance use disorders (1). The extent to which individuals with schizophrenia exhibit the symptoms of pathological gambling has not been adequately investigated.
Ms. A was a 31-year-old divorced woman with schizophrenia, nicotine dependence, and pathological gambling. Her symptoms of paranoia and disorganized thought began at age 19, prompting hospitalization. Since then she had been treated primarily with oral haloperidol, 5–10 mg/day. Her parents were gamblers who had frequented casinos and held poker games since her childhood. Ms. A had attended bingo games with her mother since age 8 and had continued playing throughout adulthood. She first played lottery "scratch-off" games at age 12 and continued playing into her 20s, spending up to $20 per week. After the opening of a major local casino when Ms. A was in her mid-20s, she began playing slot machines and table games, losing up to $500 a day on multiple occasions. Repeatedly, her gambling losses required her to borrow money from friends and family members in order to afford rent and food.
Ms. A reported gambling to be pleasurable; when under stress, she said, she gambled to escape or feel excitement. During an unplanned pregnancy, she increased her gambling, losing approximately $2,000 at casinos and more than $150 on lottery tickets. Four months after giving birth, she was hospitalized with paranoia and disorganized behavior. She had stopped taking haloperidol for a month because of an inability to afford her medications because of her gambling losses. She could not afford rent, food, or child care, prompting evaluation by child protective services. After her hospitalization, her antipsychotic treatment was changed to oral olanzapine, 10 mg every night at bedtime; it gave her good control of her psychotic symptoms. She has not gambled since her hospital discharge. She recently scored 14 on the South Oaks Gambling Screen and 10 (lifetime) and 5 (past year) on the National Opinion Research Center (NORC) DSM-IV Screen for Gambling Problems (5 or more on either corresponds to pathological gambling).
Given this report and data suggesting higher rates of pathological gambling in schizophrenic populations (2), screening individuals with schizophrenia regarding their gambling behaviors seems warranted. Individuals with either schizophrenia or pathological gambling exhibit motivational and reward-directed behavioral disturbances that are thought to be related to abnormal dopaminergic function (3, 4). Serotonin dysfunction has been implicated independently in schizophrenia and pathological gambling (4). It is of interest that the patient’s psychotic and gambling disorders have appeared to be controlled with the serotonin/dopamine antagonist olanzapine and pathological gambling-targeted psychosocial intervention. Further characterization of possible interactions between pathological gambling and schizophrenic symptom profiles or treatment modalities is indicated to inform better treatments for this group of patients.