Background
Gambling engagement is often thought of to be on a continuum, ranging from non-gambling and recreational gambling on one end, to a psychiatric condition—gambling disorder, on the other (Volberg et al.,
2015). The broader term problem gambling, applied in this study, is often used to include those that suffer significant consequences from their gambling without filling the criteria for a diagnosis (Blaszczynski & Nower,
2002; Neal, Delfabbro, & O’Neil,
2005). Prevalence rates of problem gambling vary pending on study and cultural settings, with an average across all countries of 2.3% (Williams, Volberg, & Stevens,
2012). In Sweden, 1.3% of the adult population are categorized problem gamblers, and of those 0.6% are considered disordered gamblers (Public Health Agency of Sweden, 2019).
The co-occurrence of psychiatric comorbidity in general is high among problem gamblers, and anxiety disorders has repeatedly been linked to problem gambling (Raylu & Oei,
2002; Shaffer & Martin,
2011). A meta-analysis conclude that anxiety disorders is one of the most prevalent (37.4%) psychiatric condition in population-representative samples of problem gamblers (Lorains, Cowlishaw, & Thomas,
2011). Lifetime prevalence among problem gamblers have been found to be as high as 60% (Kessler, Hwang, Labrie, et al.,
2008). If studying treatment seeking problem gamblers, the numbers are even higher.
Less clear, however, is the pattern of specific anxiety disorders among problem gamblers. Studies on community samples have found the lifetime prevalence for panic disorder among problem gamblers to be between 5.1 and 21.9% (Kessler, Hwang, Labrie, et al.,
2008; Petry, Stinson, & Grant,
2005), for social phobia 10.1% (Petry et al.,
2005), for Generalized Anxiety Disorder (GAD) between 11.2 and 16.6% (Kessler, Hwang, Labrie, et al.,
2008; Petry et al.,
2005) and for Post-Traumatic Stress Disorder (PTSD) 14.8–24% (Kessler, Hwang, Labrie, et al.,
2008; Moore & Grubbs,
2021; Toneatto & Pillai,
2016).
In a systematic review and meta-analysis of the prevalence of
concurrent co-morbid psychiatric disorders among treatment-seeking problem gamblers, Dowling et al. (
2015) found that the anxiety disorders with the highest weighted mean effects were social phobia (14.9%; range 5–50), GAD (14.4%; range 3.8–50), panic disorder (13.7%; range 3.8–38.9) and post-traumatic stress disorder (12.3%; range 5.0-34.2). However, the variation across studies were high, indicating a diversity in study population and methodology.
Studies examining the association between problem gambling and specific anxiety disorders have yielded diverse results. Cunningham-Williams et al. (
1998) found that problem gamblers, compared to non-gamblers, were significantly more likely to have phobias (14.6% vs. 9.5%), but none of the other anxiety disorders studied. Opposite this, Petry (
2005) found panic disorder (with and without agoraphobia) to be strongly related to pathological gambling, whereas the relationships between phobias and generalized anxiety disorder were weaker but still significant.
Anxiety can cause problem gambling and problem gambling can cause anxiety (Hartmann & Blaszczynski,
2018; Holdsworth, Haw, & Hing,
2012). The nature of this reciprocal effect between problem gambling and specific anxiety disorders is unclear but can, in line with the Pathway Model (Blaszczynski & Nower,
2002), be understood according to different paths. When anxiety (or other mental health issues) is present before the gambling problems, gambling can be seen as result of poor coping strategies; that is, gambling is used as way to escape emotional distress. This subtype is labeled ‘the emotionally vulnerable’ group according to Blaszczynski & Nower (
2002). For this subtype, gambling behaviours may be viewed as a manifestation of maladaptive coping, with a more general underlying vulnerability involving for example an anxiety disorder. Studies have found it to more common among younger respondents to report gambling for coping reasons (Sundqvist, Jonsson, & Wennberg,
2016; Wardle, Dobbie, Kerr, & Reith,
2009). Gambling for coping reason has also been linked to more severe gambling problems (McGrath, Stewart, Klein, & Barrett,
2010) and female gender (Francis, Dowling, Jackson, Christensen, & Wardle,
2014). Alternatively, problem gambling can precede the onset of anxiety and hence can be seen as a response to gambling-related stressors, such as feelings of guilt or financial difficulties. This path is labeled the behaviorally conditioned in the Pathway model, and is characterized by the absence of premorbid sensitivity. In line with the emotionally vulnerable path, an Australian longitudinal study (Billi, Stone, Marden, & Yeung,
2014) found anxiety to be the only health condition that independently predicted the progression to high-risk gambling. Two studies have found problem gambling to predict the subsequent onset of generalized anxiety disorder and posttraumatic stress disorder (Chou & Afifi,
2011; Kessler, Hwang, LaBrie, et al.,
2008), suggesting a behaviorally conditioned path. Another study found that, compared to non-gamblers, those reporting any gambling behavior at baseline were at increased risk to have any anxiety disorder (panic disorder, social and specific phobia, GAD) at follow-up (Parhami, Mojtabai, Rosenthal, Afifi, & Fong,
2014). And Blanco et al., (
2015) found that childhood-onset anxiety had significant main effects in predicting lifetime gambling (but not disorder).
In the majority of studies on gambling and mental health, anxiety is treated as a homogeneous entity and is often one in a large set of risk factors analyzed. Hence, even though the link between problem gambling and anxiety appears to be well established, the evidence has been less conclusive for the relationship between problem gambling and specific anxiety disorders. This calls for more studies that disentangles the different anxiety conditions in relation to problem gambling. In addition, problem gambling, as well as anxiety, differ across subgroups. Examining strata, rather than the gambling population as a whole, might reveal subgroup specific patterns.
Aim
The aim of this study is to examine the association between problem gambling and specific anxiety disorders in a non-clinical population. In addition, we also aimed at examining this association in different strata of the population.
Results
In the unstratified sample, all anxiety disorders were significantly associated with problem gambling (see Table
2), with social phobia and GAD remaining significant after simultaneously controlling for the other anxiety disorders. This pattern clearly differed when instead analyzing different subgroups of the study population. Overall, having had any anxiety disorder was associated with problem gambling in most groups except among age 25- and high SES. The weakest association between any anxiety and problem gambling was among men, and the strongest among younger (age − 25) and middle SES.
Among females, all anxiety disorders, except GAD, was significantly associated with problem gambling. The strongest association was for PTSD and problem gambling (OR = 2.5, CI = 1.3–4.8). When simultaneously controlling for the other anxiety disorders, social phobia was the only one remaining significantly related to problem gambling. Among males, social phobia was the only anxiety disorder significantly related to problem gambling (OR = 2.1, CI = 1.1–3.8), and this association remained significant when controlling for the other anxiety disorders.
In the group with participants age 24 and younger, all anxiety disorders but PTSD was significantly associated with problem gambling. GAD was most strongly associated (OR = 3.6, CI = 1.7–7.8). After simultaneously controlling for the other anxiety disorder, social phobia and GAD, but not panic disorder, remained significantly associated with problem gambling. For the group age 25 and above, social phobia and PTSD was significantly associated with problem gambling, with social phobia remaining significantly associated after adjusting for the other anxiety disorders.
The pattern of anxiety disorders differed across groups of socio-economic status. In the group with low SES the only anxiety disorder significantly associated with problem gambling was PTSD, and this was still true after controlling for the other anxiety disorder. For participants with middle SES, all anxiety disorders, but GAD, was significantly associated with problem gambling, with social phobia remaining significantly associated with problem gambling after adjusting for the influence of the other anxiety disorder. Within the group of individuals with high SES, anxiety was not at all significantly associated with problem gambling.
Table 2
Prevalence of anxiety disorders among different subgroups of cases and controls. Crude and adjusted odds ratio. N = 1876
All
| | | | | | |
Panic Disorder | 11.4 | 7.9 |
1.5
|
(1.0-2.2)
| 1.3 | (0.9–1.8) |
Social Phobia | 8.8 | 4.0 |
2.4
|
(1.5–3.6)
|
2.0
|
(1.3–3.1)
|
GAD | 4.5 | 2.2 |
2.1
|
(1.2–3.7)
|
1.9
|
(1.1–3.5)
|
PTSD | 5.3 | 2.4 |
2.3
|
(1.3-4.0)
| 1.7 | (1.0-3.1) |
Any | 22.4 | 13.9 |
1.8
|
(1.4–2.4)
| | |
Female
| | | | | | |
Panic Disorder | 19.5 | 11.9 |
1.8
|
(1.1-3.0)
| 1.5 | (0.9–2.5) |
Social Phobia | 13.5 | 5.4 |
2.8
|
(1.5–5.2)
|
2.1
|
(1.1–4.2)
|
GAD | 6.7 | 3.6 | 2.0 | (0.90 − 4.5) | 1.8 | (0.8–4.3) |
PTSD | 11.9 | 5.1 |
2.5
|
(1.3–4.8)
| 1.7 | (0.9–3.6) |
Any | 35.6 | 21.1 |
2.1
|
(1.3–3.1)
| | |
Male
| | | | | | |
Panic Disorder | 7.3 | 5.8 | 1.3 | (0.74 − 2.2) | 1.1 | (0.6-2.0) |
Social Phobia | 6.5 | 3.2 |
2.1
|
(1.1–3.8)
|
1.9
| (1.0-3.6)
|
GAD | 3.4 | 1.6 | 2.2 | (0.97 − 5.2) | 2.1 | (0.9-5.0) |
PTSD | 1.9 | 0.9 | 2.1 | (0.68 − 6.2) | 1.7 | (0.6–5.4) |
Any | 15.8 | 10.1 |
1.7
|
(1.1–2.5)
| | |
Age − 24
| | | | | | |
Panic Disorder | 10.6 | 6.0 |
1.8
|
(1.1–3.1)
| 1.4 | (0.8–2.5 |
Social Phobia | 7.4 | 2.7 |
2.9
|
(1.5–5.6)
|
2.2
| (1.1–4.4)
|
GAD | 6.0 | 1.7 |
3.6
|
(1.7–7.8)
|
3.2
| (1.4-7.0)
|
PTSD | 4.1 | 1.8 | 2.3 | (0.99 − 5.3) | 1.7 | (0.7–4.1) |
Any | 20.9 | 10.3 |
2.2
|
(1.5–3.4)
| | |
Age 25-
| | | | | | |
Panic Disorder | 12.4 | 10.2 | 1.3 | (0.75 − 2.0) | 1.1 | (0.6–1.9) |
Social Phobia | 10.6 | 5.5 |
2.0
|
1.1–3.6)
|
1.8
| (1.9–3.4)
|
GAD | 2.8 | 2.9 | 0.96 | (0.36 − 2.6) | 0.9 | (0.4–2.5) |
PTSD | 6.7 | 3.0 |
2.3
|
(1.1–4.8)
| 1.7 | (0.8–3.3) |
Any | 24.3 | 18.3 | 1.4 | (0.97 − 2.1) | | |
Low SES
| | | | | | |
Panic Disorder | 11.9 | 9.5 | 1.3 | (0.63 − 2.7) | 1.0 | (0.44 − 2.1) |
Social Phobia | 11.8 | 6.1 | 2.1 | (0.96 − 4.4) | 1.3 | (0.56 − 3.2) |
GAD | 4.9 | 1.4 | 3.8 | (0.99-14.3) | 3.2 | (0.8-13.3) |
PTSD | 11.8 | 4.4 |
2.9
|
(1.3–6.6)
|
2.7
| (1.1–6.5)
|
Any | 26.7 | 16.3 |
1.9
|
(1.1–3.2)
| | |
Middle SES
| | | | | | |
Panic Disorder | 12.9 | 7.2 |
1.9
|
(1.1–3.3)
| 1.5 | (0.89 − 2.7) |
Social Phobia | 9.2 | 3.2 |
3.1
|
(1.6-6.0)
|
2.6
|
(1.3–5.3)
|
GAD | 3,5 | 1.5 | 2.3 | (0.83 − 6.5) | 2.0 | (0.71 − 5.9) |
PTSD | 4.0 | 1.4 |
3.0
|
(1.1–8.3)
| 1.7 | (0.57 − 5.2) |
Any | 22.9 | 10.2 |
2.5
|
(1.6–3.8)
| | |
High SES
| | | | | | |
Panic Disorder | 7.1 | 8.1 | 0.86 | (0.39 − 1.9) | 0.72 | (0.3-1.7) |
Social Phobia | 6.3 | 3.8 | 1.7 | (0.70 − 4.2) | 1.9 | (0.8-4.8) |
GAD | 6.2 | 3.6 | 1.7 | (0.69 − 4.1) | 1.7 | (0.7-4.1) |
PTSD | 1.8 | 2.6 | 0.68 | (0.15 − 3.1) | 0.68 | (0.1-2.8) |
Any | 17.1 | 16.7 | 1.0 | (0.60 − 1.8) | | |
Discussion
In this study, the associations between problem gambling and specific anxiety disorders were examined in different subgroups, using a case control design with a sample from the general Swedish population. Overall, having had any anxiety disorder was significantly more common among the cases compared to their controls in most subgroups, except for the group aged 25 and over, and in the group with high SES. The magnitude of the associations varied with the lowest among males (70% greater risk compared to their controls) and the highest for middle SES (150% greater risk then their controls).
After also controlling for the other anxiety disorders, social phobia was the most common anxiety disorder to be associated with problem gambling across groups. This was true for both men and women, in both age groups, but only for the middle SES group. GAD was also associated with problem gambling in the whole study population, but this association was only statistically significant in one of the subgroups - younger (age − 24). Younger had three times higher risk of having had GAD compared to their controls, after controlling for the other anxiety disorders. PTSD was only significantly associated with problem gambling in the group with low SES. Panic Disorder was the anxiety disorder with the weakest association with problem gambling.
Previous studies on community-based samples have generally found stronger associations between each anxiety disorder and problem gambling. This can likely be explained by the fact that our study includes gamblers with mild problems (PGSI 3+), whereas other studies have mainly focused on groups with more severe gambling problems. For example, both Petry et al. (
2005) and Kessler et al. (
2008) used five out of ten DSM-IV criteria as a cut of for problem gambling, yielding a sample of gamblers with more severe gambling problems compared to our study sample. This pattern is also found in studies of the association between substance use disorders and anxiety disorders, where alcohol- and drug dependence is significantly associated with several anxiety disorders whereas for the group with milder symptoms (abuse) the associations are weaker (Smith
2012; Smith & Book,
2008).
Further, in contrast to the results in our study, Petry et al. (
2005) found social phobia to be the anxiety disorder with the weakest association to problem gambling. In addition, in their study panic disorder, which in our study had the lowest (and non-significant OR), had the strongest association to problem gambling. There are several possible explanations for this discrepancy, such as different study populations, methods and measures used. Another reason for the difference found might be the increased use of online gambling during the years since the study of Petry et al. (
2005) was conducted. This in turn might attract individuals that avoid public locations such as land-based casinos. However, our results are in line with Brooker et al. (
2009), who also found problem gambling to be associated with social phobia, but not with panic disorder. Brooker et al. (
2009) used the same measure and cut of for problem gambling as in this study.
In addition, the results from our study differ slightly from previous research where low SES repeatedly has been associated with a greater risk of mental health issues in general (Hudson,
2005; Hudson & Roth,
1988; Kivimäki et al.,
2020). Specific to gambling, Maas et al. (
2016) found that the magnitude of the relationship between anxiety disorders and problem gambling severity varied significantly depending on whether a person were of high or low SES, with the strongest association among the low SES group. Even though the group with high SES had the weakest association also in our study, the association between any anxiety and problem gambling was stronger among the group with middle SES, then in the low SES group. In addition, the most common anxiety disorder among the problem gamblers across groups in this study, social phobia, was not at all significantly related to gambling in the low SES group. PTSD, however, was significantly associated with problem gambling only among the group with low SES. However, those results should be interpreted with caution since the low SES group is the smallest subgroup studied (n = 401).
A major strength in this study is the use of a representative sample from the general population, as well as the inclusion of problem gamblers ranging in severity from mild to severe, which mirrors the actual gambling situation in society and generates more generalizable results compared to results from studies using treatment seeking samples. Another strength is that the assessment of anxiety disorders was based on clinical interviews rather than self-assessment measures. In addition, the stratified analyses made it possible to reveal patterns specific to different subgroups. The participation rate was 84% which can be regarded as satisfactory in this context.
A limitation with this study is the fact that excessive gamblers tend to go in and out of gambling problems, which may affect the groups of cases and controls. Since group allocation is defined based on PGSI or SOGS scores about a year before the clinical interview, there is a risk that cases include problem gamblers in remission, and that the control group includes a few problem gamblers. This, however, is to some extent taken care of by only using life-time measures in the analyses. Another limitation is that the SWELOGS interviews only covers four anxiety disorders. Further, due to the nature of the study design, the results can only be interpreted as associations rather than causal relationships. Finally, there is a risk that the adjusted model might be over adjusted, due to the fact that the anxiety disorders studied are interrelated. For this reason, the crude odds ratios are of interest as well.
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