Psychological experience of gambling and subtypes of pathological gamblers

Psychiatry Research 144 (2006) 17 – 27 www.elsevier.com/locate/psychres

Psychological experience of gambling and subtypes of pathological gamblers David M. Ledgerwood *, Nancy M. Petry Department of Psychiatry, School of Medicine, University of Connecticut Health Center, 263 Farmington Ave., Farmington, CT 06030-3944, United States Received 16 December 2004; received in revised form 8 August 2005; accepted 22 August 2005

Abstract Clinical experience and some empirical data suggest that different subtypes of gamblers may exist. This study examined psychometric properties of the Gambling Experience Measure (GEM) to establish support for differing subtypes of gamblers. In total, 149 treatment-seeking pathological gamblers completed the GEM and other instruments. A principal component analysis produced a three-factor solution that included gambling as a way to escape negative emotions (Escape), dissociating (Dissociation), and narcissism/seeking attention (Egotism). Multiple regression analyses revealed that being female and general dissociation was associated with Escape gambling. General dissociation was also related to the Dissociation factor. Male gender and impulsivity were associated with the Egotism factor. These data offer preliminary evidence of the validity and reliability of the GEM in distinguishing subgroups of gamblers. D 2005 Elsevier Ireland Ltd. All rights reserved. Keywords: Gambling; Dissociation; Egotism; Escape

1. Introduction In the past several years, substantial increases in opportunities for legalized gambling have taken place, along with a subsequent rise in gambling problems among the general population (National Gambling Impact Study Commission, 1999; Shaffer et al., 1999). A growing number of studies have explored motiva* Corresponding author. Tel.: +1 860 679 3239; fax: +1 860 679 1312. E-mail address: [email protected] (D.M. Ledgerwood).

tional and psychological correlates of gambling. These efforts may eventually distinguish different types of pathological gamblers. For example, research has identified the role of impulsiveness, sensation seeking, risk taking and antisocial personality in predicting patterns and correlates of pathological gambling (PG) (Vitaro et al., 1997; Coventry and Constable, 1999; Petry and Casarella, 1999; Petry, 2000). However, not all gamblers are primarily characterized by impulsiveness (Blaszczynski and Nower, 2002). Similarly, depression, loneliness and social isolation have been explored as motivators to gamble, especially in women gamblers, but are not universal (Trevorrow and Moore,

0165-1781/$ - see front matter D 2005 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.psychres.2005.08.017

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1998; Getty et al., 2000). Many pathological gamblers have also been shown to experience dissociation while gambling (Jacobs, 1988; Gupta and Derevensky, 1998; Diskin and Hodgins, 1999, 2001). People seem to gamble for different reasons and have diverse experiences while gambling, yet only a handful of studies have explored how one’s experience of gambling may affect the development or maintenance of gambling disorders. Recent theory emphasizes the heterogeneous nature of PG, noting subgroups of pathological gamblers may have differing underlying pathology (Blaszczynski and Nower, 2002). Some may experience neurological deficits that contribute to impulsiveness (Chambers and Potenza, 2003). For others, gambling may develop out of a need to cope with painful emotional experience, as is evident among individuals with depression and anxiety (Getty et al., 2000). Still others may develop gambling disorders through direct behavioral conditioning without any predisposing emotional or biological vulnerability (Blaszczynski and Nower, 2002). Blaszczynski and Nower (2002) suggested that there may be as many as three subtypes of gamblers. These include emotionally vulnerable gamblers who mainly gamble to escape from painful emotional experiences, antisocial/ impulsive gamblers who are driven primarily by impulsivity and sensation seeking traits, and behaviorally conditioned gamblers who gamble because of behavioral contingencies offered by the gambling activity rather than more severe psychological difficulties. Each group may exhibit unique psychological characteristics, and each may require a different treatment approach. However, no research to date has been conducted to validate these subgroups. The purposes of the current investigation were twofold. One was to evaluate the psychometric properties of a questionnaire for the measurement of psychological factors related to the gambling experience, called the Gambling Experience Measure (GEM). The second was to determine how the factor structure of this questionnaire might be represented among pathological gamblers with varying characteristics. Based on the factor structure and the variables created, we established hypotheses about how various groups would score on each newly created scale. The variables used to create specific hypotheses concerning each of the new factors included gender, preference for strategic versus non-strategic gambling, impulsivity, psychiatric symptom severity and dissociation experi-

ences. These variables were chosen because of their conceptual and empirical relevance to gamblingrelated experiences in pathological gamblers. Studies of gender differences in gambling disorders, for example, reveal that men score higher on measures of sensation-seeking than women (Vitaro et al., 1997; Coventry and Constable, 1999). Men are also more likely than women to engage in strategic forms of gambling, commit illegal acts, and have substance use problems (Ladd and Petry, 2002). These latter factors are associated with greater impulsivity (Blaszczynski et al., 1997; Potenza et al., 2001). Women, on the other hand, may be more likely than men to use gambling as a way of escaping problems (Brown and Coventry, 1997). Another variable that has evidenced significant relationships in the literature is strategic versus nonstrategic gambling style. The primary problematic gambling behavior type engaged in by pathological gamblers correlates with such factors as age, gender, psychiatric difficulties, gambling severity and alcohol use (Petry, 2003). Some have likened strategic gambling to bface-to-faceQ gambling, as opposed to nonstrategic, bless interpersonally interactiveQ gambling styles (Potenza et al., 2001). Additional evidence suggests that some forms of non-strategic machine gambling are associated with lower sensation-seeking and arousal (Coventry and Constable, 1999). Impulsivity is elevated among individuals with gambling disorders (Petry, 2001). Among pathological gamblers, greater impulsivity is associated with greater gambling disorder severity (Steel and Blaszczynski, 1998) and co-occurrence with substance use problems (Vitaro et al., 1998). The concept of the bantisocial– impulsivistQ has been proposed as a PG sub-group that encompasses such characteristics as impulsivity, disinhibition and sensation-seeking (Blaszczynski and Steel, 1998; Steel and Blaszczynski, 1998). Impulsivity is related to antisocial personality, disinhibition, and exhibitionism in pathological gamblers (Blaszczynski et al., 1997; Blaszczynski and Steel, 1998; Vitaro et al., 1999). Exhibitionism and disinhibition are essential features of impulsiveness among gamblers. Pathological gamblers also experience high rates of psychiatric problems (McCormick et al., 1984; Black and Moyer, 1998; Cunningham-Williams et al., 1998). Pathological gamblers often report alienation from others (Trevorrow and Moore, 1998), loneliness and

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isolation (Brown and Coventry, 1997). Depression in pathological gamblers has been linked to a desire to escape from problems (Brown and Coventry, 1997; Getty et al., 2000). Researchers have identified gambling as a means of escaping from the reality of home life, noting that gamblers often report greater feelings of safety and belonging while gambling (Brown and Coventry, 1997). Thus, escape when gambling may be associated with psychiatric and interpersonal distress (Brown and Coventry, 1997; Getty et al., 2000). Dissociation during gambling has also been proposed as an important factor in the study of differing subtypes of pathological gamblers (Kuley and Jacobs, 1988; Kofoed et al., 1997). Increases in the severity of gambling problems are associated with greater dissociation while gambling (Gupta and Derevensky, 1998). One study revealed that generalized dissociation is associated with gambling-related dissociation (Diskin and Hodgins, 1999), but another found general dissociation did not differ between problem and nonproblem gamblers (Diskin and Hodgins, 2001). As mentioned above, we conducted a principal component analyses on the GEM to determine factors that may explain some of the psychological experiences in gamblers. Following the principal component analysis, we made a number of specific hypotheses concerning the convergent and discriminant validity of the three GEM factors. We expected that female gender and higher scores on measures of psychiatric symptom severity (GSI) and general dissociation would each account for a significant proportion of the variance in gambling-related escape, while strategic gambling style and impulsivity would be unrelated to this factor. We hypothesized that general dissociation and possibly other psychiatric symptoms would predict gambling-related dissociation. Finally, we hypothesized that male gender, strategic gambling style and impulsivity would associate with egotism.

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or group psychotherapy and/or Gambler’s Anonymous. Participants were recruited through posters at the sites and word of mouth. The participants were also included in a prior analysis of suicidality among pathological gamblers (Ledgerwood and Petry, 2004). Eligibility requirements included that the participant was at least 18 years old and had been in gambling treatment for at least 2 weeks. Exclusion criteria included uncontrolled, severe, acute psychiatric disorders (e.g., severe acute suicidality, acute substance withdrawal or intoxication, psychosis, or manic episode). Inclusion criteria were intentionally broad to increase generalizability of results, and no known eligible participants were excluded. Participants completed a series of self-report questionnaires. The study was approved by the University of Connecticut Health Center Institutional Review Board (IRB), and by local IRBs at study sites if applicable. Each participant provided informed consent to participate in the study and received a $25 gift certificate to a local department store for participating. 2.2. Measures 2.2.1. Demographics A number of demographic questions were included, such as gender, age, race, employment status, income and level of education.

2.1. Participants

2.2.2. NORC DSM Screen for gambling problems (NODS) The NODS is based on DSM-IV criteria for PG (APA, 1994; Gerstein et al., 1999). The NODS consists of two sections, one for lifetime PG and one for pastyear PG. Each form consists of 17 items (Gerstein et al., 1999), with some criteria assessed two different ways. Participants may obtain a maximum score of 10 on the measure, and scores of five or greater on the NODS reflect a DSM-IV diagnosis for PG. The validity and reliability of the NODS has been reported elsewhere (Gerstein et al., 1999). The lifetime and pastyear versions of the NODS were used in the current study as descriptive measures of gambling pathology.

Participants included 149 individuals from gambling treatment sites located in Arizona, Connecticut, Indiana, Massachusetts, Nevada, Pennsylvania, and Windsor, Ontario. Treatment included individualized

2.2.3. Gambling Experience Measure (GEM) Participants responded to a number of items reflecting their own experience while gambling. The 18 items were adapted and reworded from prior

2. Methods

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investigations (Jacobs, 1988; Lesieur, 2001). Each was answered on a five-point Likert scale. Four items were adapted from Jacobs’s (1988; Kuley and Jacobs, 1988) measure of gambling-related dissociation. Other items were adapted from the Escape and Narcissism/Power portions of the Gambling SelfReport Inventory (Lesieur, 2001); these items reflected gambling-related escape, relief of painful emotion, relationship problems, narcissism, shyness, attention-seeking, coping with stress and additional gambling-related problems. The response choices for the items are presented in Table 1. The items compiled for this measure were the focus of the principal component analysis reported below, and they were selected because they ask about the experience of the participant while gambling. For half of the questionnaire items, higher scores signified greater endorsement of the item. However, nine items were scaled such that greater endorsement of the item received a lower score. These items were reverse-coded to obtain consistency with other items before all analyses. 2.2.4. Gambling preference Participants were asked, bPlease indicate which form of gambling you have had the most troubles with.Q Participants wrote the gambling type verbatim. The investigators coded each gambling type as either strategic or non-strategic. Consistent with other studies

(Potenza et al., 2000), strategic gambling types (in order of popularity) included video poker, dog and horse racing, cards, sports betting, poker, black jack, craps/dice games, roulette and dominos. Non-strategic gambling forms included slots, lottery, keno and bingo. 2.2.5. Brief Symptom Inventory (BSI) The BSI is a self-report measure of recent psychiatric symptoms along nine separate dimensions (Derogatis and Melisaratos, 1983; Derogatis and Savitz, 1999). It is based on the longer SCL-90 and consists of 53 self-report items. The validity and reliability of the BSI has been studied extensively in prior investigations (see Derogatis and Savitz, 1999, for review). The General Severity Index (GSI) is a general composite of the BSI, and is a global measure of the number of distressful symptoms and the intensity of the distress the individual is experiencing. The GSI was used as a general measure of psychiatric distress. The GSI has achieved test–retest reliability of 0.90, and the validity of the BSI is established (Derogatis and Savitz, 1999). 2.2.6. Dissociative Experiences Scale (DES) The DES is a measure of lifetime dissociative experiences (Bernstein and Putnam, 1986). The measure consists of 28 self-report items that are scored on a scale of 1 to 10, ranging from bNeverQ to bVery

Table 1 Principal components analysis with Varimax rotation Item

Factor 1

To cope with stress (–) (c) To deal with painful or difficult feelings (–) (c) To forget about things like guilt and shame (–) (c) So wouldn’t feel empty (–) (c) To forget about problems gambling caused (–) (c) Wanted to numb feelings (–) (c) Forgot all problems (–) (c) Gambling helped you feel like a bigshot (b) Felt like royalty or like a god (–) (c) When winning, made sure people found out; used winnings to impress people (–) (c) Felt shy around people and gambling helped to be more social (b) Felt like you were boutside yourselfQ — watching yourself gamble (a) Felt like you had been in a trance while gambling (a) Felt like a different person while you were gambling (a) Experienced a memory blackout for a period when gambling (a)

0.87 0.86 0.84 0.79 0.77 0.77 0.63 0.02 0.01 0.08 0.16 0.05 0.17 0.10 0.05

Factor 2

Factor 3

0.00 0.01 0.13 0.08 0.23 0.02 0.06 0.85 0.83 0.80 0.62 0.08 0.01 0.19 0.17

0.07 0.13 0.15 0.07 0.04 0.19 0.07 0.07 0.24 0.05 0.08 0.82 0.81 0.74 0.70

(–) indicates that items were reversed-scored. a. Response choices were bstrongly agree,Q bagree,Q bneutral,Q bdisagree,Q and bstrongly disagree.Q b. Response choices were bnever,Q boccasionally,Q bsometimes,Q boften,Q and balmost all of the time.Q c. Response choices were bnever or not sure,Q bonce or twice,Q b3–5 times,Q b6–10 timesQ and b11 times or more.Q

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Frequently.Q The DES has demonstrated test–retest reliability, internal consistency, and construct, discriminant and convergent validity (Bernstein and Putnam, 1986). The initial test–retest reliability coefficient reported by Bernstein and Putnam (1986) was 0.84. The DES has been used in many investigations, and a meta-analysis has confirmed the reliability and concurrent validity of the DES (Van Ijzendoorn and Schuengel, 1996). 2.2.7. Eysenck Impulsivity Scale The Eysenck Impulsivity Scale is a 54-item selfreport questionnaire used to measure impulsivity (Eysenck and Eysenck, 1978; Eysenck and McGurk, 1980). The measure is composed of three separate scales: Impulsiveness, which assesses failure to evaluate risk; Venturesomeness, which measures perception and acceptance of risk in behaviors; and Empathy, which was added to the measure for item variety. In the current study, only the Impulsiveness scale was used, based on the specific hypothesis tested.

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3. Results 3.1. Sample characteristics Each site provided between 5 and 35 participants and roughly equivalent numbers of men and women (F 2). Mean age was 47.7 (S.D. 11.1) years, 51.7% of participants were women, 91.9% were Caucasian, and 4.1% were African American. Participants had 14.0 (S.D. 2.4) years of education on average, 68.5% were employed full time, and they had a mean income of $37,306 (S.D. $21,992) per year. On average, the sample first gambled at age 20.2 (S.D. 12.1), began gambling regularly (once per week or more) at age 31.4 (S.D. 14.2), and gambled regularly for 13.6 (S.D. 11.7) years before seeking treatment. Median time in treatment (excluding GA) was 1 month (interquartile range = 5). Based on the NODS, the average number of lifetime DSM-IV PG diagnostic criteria met by the participants in the current study was 8.6 (S.D. 1.7). The average number of DSM-IV PG symptoms in the past year was 4.8 (S.D. 4.1).

2.3. Analysis 3.2. Principal components analysis First, GEM items were included in a principal components analysis to reduce the items to a smaller number of variables. Varimax rotation was used to maximize the loading variance within factors and across variables, thereby simplifying interpretation (Tabachnick and Fidell, 1989). Second, Cronbach alpha coefficients were calculated as an index of internal reliability for each GEM factor. Following the principal components analysis, specific hypotheses were made concerning the convergent and discriminant validity of the factors. To test the convergent validity hypotheses, three standard multiple regression analyses using forward entry were performed with each of the three factors of the GEM as dependent variables (DV). The five independent variables (IVs) included gender, strategic versus non-strategic gambling preference, general dissociation (DES), GSI and impulsivity. DES was transformed using a square root transformation because raw scores were skewed. Spearman correlation coefficients were also calculated using nontransformed data to show the direction of raw correlations between IVs and DVs.

The 18 items of the GEM were entered into a principal components analysis. Some GEM data were missing from three participants (1 woman and 2 men). The data of these participants were not included, leaving a total sample of 146. The principal components analysis extracted four factors with eigen values N1. However, examination of the scree plot suggested that a three-factor solution better fit the data, and the analysis was re-run allowing only for three factors. A cutoff factor loading of 0.40 was used to include variables on a factor. Examination of the Varimax principal components matrix identified three items that each loaded roughly equally on two factors. These included items reflecting the use of gambling to escape problems, to relieve feelings of helplessness, and to not think about relationship problems. These three items were removed to avoid ambiguity in the interpretation of the factors (Tabachnick and Fidell, 1989). The principal components analysis with Varimax rotation was conducted again using 15 items, and the rotated principal components matrix is presented in

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Table 1. The three factors retained accounted for 63.9% of the overall variance in GEM item scores, with four to seven items loading on each factor. The overall solution had a simple structure (Thurstone, 1947). The first factor accounted for 33.3% of the variance in item scores. Variables that loaded onto the first factor mainly reflected a conscious effort to escape from problems, stress, guilt, shame, anxiety and painful feelings. Thus, this factor constitutes gambling as a means of escape from problems and painful feelings. This factor was named Escape. The second factor accounted for 18.2% of the variance in item scores. Items that loaded highly on the second factor reflected dissociation experiences, such as being in a trance, feeling boutsideQ oneself, having a bmemory blackout,Q and feeling like a different person. This factor was labeled Dissociation. The third factor accounted for an additional 12.4% of the variance. This final factor reflected desire for attention and included such items as feeling like a big shot, feeling less shy, feeling like royalty or like a god, and using winnings to impress others. This factor was labeled the Egotism factor. 3.3. Internal consistency Cronbach alpha coefficients were calculated for each of the three factors. The first factor, Escape, yielded an alpha coefficient of 0.86. The second factor, Dissociation, obtained an alpha coefficient of 0.78. Finally, the alpha coefficient for the Egotism factor was 0.80. Each of these inter-item alpha coefficients represents adequate to good internal reliability (Cronbach, 1951), consistent with other gambling-related measures (Stinchfield, 2003). Examination of frequencies revealed a significant negative skew in the Escape factor. Square root data transformation was performed to establish univariate normality for subsequent analyses (Tabachnick and Fidell, 1989). 3.4. Convergent and discriminant validity Three standard multiple regression analyses were performed to test our hypotheses. Because three univariate analyses were conducted, a more stringent overall alpha level of 0.017 was adopted for each overall regression model to reduce the chance of Type I

error. Some cases (N = 6 or 4% of the original sample) were deleted from analyses because of missing or uncategorizable data. Most of these six cases were discarded because the participant’s primary gambling choice was bcasino,Q which may encompass either strategic or non-strategic gambling. The remaining analyses included 140 participants. In one regression analysis, Escape was the DV, and gender, gambling choice, DES, GSI and impulsivity were the IVs. The overall regression equation was statistically significant, F(5, 136) = 5.09, P V 0.001. The coefficients are presented in Table 2. The regression equation accounted for 15.8% (12.7% adjusted) of the variance in responses to the Escape items. Three variables accounted for significant unique portions of the variance. Women were more likely than men to engage in escape-related gambling (b = 0.27, P V 0.01). Greater DES scores (b = 0.39, P V 0.001) were also significantly associated with greater gambling-related escape. As predicted, impulsiveness and strategic gambling choice did not significantly account for additional unique variance. Dissociation was the DV in another regression analysis, with the same IVs as before. The overall regression equation was statistically significant, F(5, 136) = 6.95, P V 0.001, accounting for 20.3% (17.4% adjusted) of the overall variance in Dissociation, with coefficients presented in Table 3. General dissociation (DES) was the only measure that was significantly associated with the gambling-related Dissociation factor, with greater Dissociation related to greater DES score (b = 0.43, P V 0.001). None of the remaining variables significantly predicted Dissociation. When the Egotism factor was the DV, the overall regression equation was again statistically significant, F(5, 136) = 7.56, P V 0.001, accounting for 21.8%

Table 2 Linear regression analyses to assess predictors of escape gambling Independent variable Gender Strategic vs. non-strategic GSI DES Impulsivity

B

Std. err. 0.50 0.23 0.21 0.15 0.00

0.16 0.16 0.13 0.04 0.02

b

Pb 0.27 0.12 0.16 0.39 0.01

0.01 n.s. n.s. 0.001 n.s.

R 2 = 0.158; adj. R 2 = 0.127; GSI = General Severity Index; DES = Dissociative Experiences Scale.

D.M. Ledgerwood, N.M. Petry / Psychiatry Research 144 (2006) 17–27 Table 3 Linear regression analyses to assess predictors of dissociation gambling Independent variable

B

Gender Strategic vs. non-strategic GSI DES Impulsivity

Std. err. 1.52 0.52 0.74 0.90 0.18

0.82 0.83 0.69 0.20 0.10

b

Table 5 Spearman rho coefficients for non-transformed variables Variable

Pb 0.15 0.05 0.10 0.43 0.16

n.s. n.s. n.s. 0.001 n.s.

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GEM factor Escape

Gendera Strategic vs. non-strategicb GSI DES Impulsivity

0.22** 0.03 0.13 0.28** 0.02

Dissociation Egotism factor 0.07 0.02 0.22* 0.41** 0.23**

0.31** 0.17* 0.19* 0.27** 0.28**

R 2 = 0.203; adj. R 2 = 0.174; GSI = General Severity Index; DES = Dissociative Experiences Scale.

Gender: female = 1, male = 2; b Strategic = 1, non-strategic = 2; * P V 0.05, ** P V 0.01; GSI = General Severity Index; DES = Dissociative Experiences Scale.

(18.9% adjusted) of the variance as shown in Table 4. After controlling for other variables, gender accounted for a significant portion of the variance, with men obtaining significantly higher scores on the Egotism factor than women (b = 0.24, P V 0.01). Impulsivity and DES score also accounted for a significant portion of the variance in scores on the Egotism factor. Greater impulsivity (b = 0.25, P V 0.01) and dissociation (b = 0.22, P V 0.05) were also associated with greater Egotism factor scores. No other variables accounted for a significant portion of the variance in Egotism factor score. To illustrate the direction of the relationships between the DVs and IVs, Spearman correlation coefficients are presented in Table 5. Correlation coefficients corresponding to the results of the regression analyses are all in the predicted direction. As predicted, Escape was significantly associated with female gender. Escape was also positively correlated with DES score. Dissociation was positively associated with DES score, but also showed some modest positive correlation with impulsivity and GSI score. The Egotism factor was associated with male gender, strategic gambling preference and impulsivity. How-

ever, the Egotism factor also evidenced some correlation with DES score.

Table 4 Linear regression analyses to assess predictors of the egotism gambling Independent variable Gender Strategic vs. non-strategic GSI DES Impulsivity

B

Std. err. 2.24 0.53 0.40 0.42 0.25

0.74 0.75 0.62 0.18 0.09

b

Pb 0.25 0.06 0.06 0.22 0.24

0.01 n.s. n.s. 0.05 0.01

R 2 = 0.218; adj. R 2 = 0.189; GSI = General Severity Index; DES = Dissociative Experiences Scale.

a

4. Discussion The results of this study offer initial evidence of the convergent and discriminant validity, and the internal consistency, of the GEM scales. The principal components analysis three-factor solution presented here is consistent with prior research that has investigated gambling-related escape (Brown and Coventry, 1997; Getty et al., 2000; Lesieur, 2001), dissociation (Jacobs, 1988; Kofoed et al., 1997; Diskin and Hodgins, 1999, 2001), and attentionseeking, sensation-seeking and impulsivity (Blaszczynski et al., 1997; Lesieur, 2001). The consistency of this research with these studies illustrates that gamblers experience gambling in diverse ways. 4.1. GEM validity The Escape factor was significantly related to female gender in the current study, a result that is generally consistent with findings reported by others (Brown and Coventry, 1997; Getty et al., 2000). The Escape factor was also moderately correlated with general dissociation. However, it was not significantly related to psychiatric symptoms as rated by the GSI. Previous studies have identified a relationship between a suppressive or escape-oriented coping style and experience of depression among members of Gambler’s Anonymous (Getty et al., 2000). Escape from loneliness, isolation and boredom has also been cited as a motivation for gambling among women (Brown and Coventry, 1997). However, others have

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disputed this finding, noting a lack of correlation between loneliness, social isolation and gambling (Trevorrow and Moore, 1998). Our findings were consistent with some of these findings, in that participants with greater general dissociation appear to be more likely to use gambling as a means of escape from painful emotional experiences. Both dissociation and escape may be strategies for coping with painful emotional experiences that involve avoidance of the painful situation (Gupta and Derevensky, 1998; Jacobs, 1988). However, general psychiatric severity was not related to escape gambling in our sample. General dissociation, as measured by the DES, was significantly associated with the Dissociation factor on the GEM. Gambling-related dissociation tends to increase with greater severity of gambling problems (Gupta and Derevensky, 1998). Further, problem gamblers generally scored higher on generalized dissociation than non-problem gamblers (Diskin and Hodgins, 1999). With regard to the Egotism factor, the results of this study are consistent with past research on narcissism in gambling, and there are also some similarities with studies of sensation-seeking and impulsiveness (Blaszczynski et al., 1997; Vitaro et al., 1997; Coventry and Constable, 1999). While egotism is not synonymous with impulsivity, there was a significant relationship between the two variables. The current study suggests egotism may be an important feature of an impulsive/sensationseeking style among some gamblers, especially male gamblers. Further research may explore the extent to which egotism is a more prominent characteristic among gamblers whom Blaszczynski and colleagues have called bantisocial–impulsivistsQ (Blaszczynski et al., 1997; Blaszczynski and Nower, 2002). These individuals are theorized to be characterized by greater impulsivity, behavioral problems, aggression, substance use, legal problems and interpersonal problems. Egotism may also be a factor that characterizes this group. Evidence supporting this notion comes from studies that suggest that narcissism is an important characteristic of aggression and antisocial personality (Baumeister et al., 2000). In summary, these results further establish the concepts of gambling-related escape and narcissism or egotism that were originally assessed in the Gambling

Self-Report Inventory (Lesieur, 2001) and Jacobs’s (1988) conception and measurement of gamblingrelated dissociation experiences. These findings are important because the validity and reliability of these constructs has not been widely assessed empirically. 4.2. Heterogeneity of pathological gambling Consistent with the second main hypothesis, the current study also offers evidence in favor of the heterogeneity of PG. The factors presented in this article suggest a conceptual framework for understanding differing groups of pathological gamblers. Results obtained in this study are consistent with two types of gamblers from the model of PG proposed by Blaszczynski and Nower (2002). Specifically, they suggest that the two most severe types of pathological gamblers are the bemotionally vulnerableQ gamblers and the bantisocial impulsivists.Q The first group is characterized by underlying anxiety or depression, poor coping and adverse family experiences; gambling provides them a means of dissociation and escape from negative affective states. The second group is characterized by impulsivity, antisocial behavior, disinhibition, thrill seeking and propensity toward boredom. An additional pathway to PG proposed by Blaszczynski and Nower (2002), bbehaviorally conditionedQ problem gamblers, does not appear to be represented in the current experiential questionnaire. Gamblers of this type may be a specific subgroup (e.g., less severe, non-treatment seeking) that requires additional study. Several studies have found that many individuals with less severe PG either stop gambling on their own (Hodgins and el-Guebaly, 2000) or stop gambling through self-help programs (Hodgins et al., 2001). Regardless, the results of this study are consistent with the notion of differing subgroups of pathological gamblers with differing underlying pathology and motivations for gambling. 4.3. Limitations and future directions While the initial evidence for the convergent validity of the gambling experience factors is persuasive, there are several limitations to the present study. Perhaps most importantly is the generalization of these results to other groups. This study was conducted with individuals who are seeking treatment

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for gambling disorders, and may thus reflect the gambling experience of individuals who feel subjective distress over their gambling. Others with gambling problems may experience less distress or may be less likely to seek treatment for gambling. Thus, this study should be repeated with problem and pathological gamblers drawn from community samples. However, every effort was made to sample treatment-seeking pathological gamblers from a variety of locations and treatment modalities. Thus, the results of this study should generalize to treatment-seeking gamblers. Another issue is the retrospective self-report of reasons for gambling. Self-reported motivations for engaging in any behavior may be affected by recall bias. Further study may explore reasons for gambling while individuals are actively gambling. An additional limitation is the range of gamblingrelated experiences selected for the study. Although research suggests that narcissism, dissociation and escape are important for understanding the motivations of pathological gamblers, individuals with gambling problems may have other psychological motivations for engaging in behaviors that are ultimately damaging to themselves and their families. One must also consider the numerous other biological, genetic, sociological and social/environmental influences on gambling. More study is needed to broaden our understanding of the biopsychosocial elements of PG and to operationalize these concepts. Finally, because some sites recruited small numbers of research participants, we were unable to conduct meaningful site comparisons. Specifically, it would be important to assess gender differences between sites. Future studies should assess differences between sites in the number of years of gambling, access to various gambling types and differential socioeconomic status between sites. Despite these limitations, the current study provides initial evidence for the reliability and validity of the GEM. These results also have implications for the treatment of PG. For example, if we can determine that an individual patient is driven to gamble more by escape from problems, or by a desire to boost selfimage, than by other factors, we may also be able to tailor psychotherapeutic interventions toward those predispositions. Consistent with the gambling literature, we found that pathological gamblers are not a

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homogeneous group that will easily fit into a single conceptualization of pathology and treatment (Blaszczynski and Nower, 2002). Further study is needed to understand and treat PG and to determine which treatments will be most appropriate for different subtypes of individuals with gambling disorders.

Acknowledgments This work was supported by NIH grants R01MH60417, R01-MH60417-suppl, R01-DA13444, R29-DA12056, P50-AA03510, P50-DA09241, the Patrick and Catherine Weldon Donaghue Medical Research Foundation, the State of Connecticut Department of Mental Health and Addiction Services Compulsive Gambling Treatment Program, and the Connecticut Council on Problem Gambling. We thank members of the Women’s Problem Gambling Research Group, including Paula Burns, Nancy Lantz, Susan McLaughlin, Carol O’Hare, Rosemary Poole, Loreen Ruggle, Nick Rupcich, Kathy Scanlan, Karen Steinberg and Karen Tourian, for their assistance on this project. We also thank staff and clients at the Arizona Council on Compulsive Gambling, Problem Gambling Services and United Community (CT) and Family Services Bettor Choice Program, The Custer Center/Trimeridian (IN and NV), Massachusetts Counsel on Problem Gambling, Nevada Council on Problem Gambling, Belmont Center for Comprehensive Treatment (PA), and Windsor Regional Problem Gambling Services (Ontario, Canada) for participation in this study. We thank Chris Armentano and Dr. Marvin Steinberg for their support of this project.

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