The Prevalence of Gambling Addiction and Sexual Addiction among Male Inpatients under Treatment for Alcohol Addiction in Norway.

By Tone Roald, University of Glasgow

With special acknowledgements to Iain Brown

Abstract

In this report the prevalence of gambling addiction and sexual addiction among 67 male inpatients receiving treatment for alcohol addiction in Norway was investigated. For this purpose, the South Oaks Gambling Screen (SOGS)and the Sexual Addiction Screening Test (SAST) were employed. 1,5% of the sample could be classified as probable sex addicts, a proportion lower than the one found in the general population in the US. Possible causes for this finding are discussed. 7.5% of the sample could be identified as addicted to gambling, a prevalence rate higher than normally found in general populations. Consequently, a shared underlying process for alcohol addiction and gambling addiction can be suggested and screening for problem gambling when treating problem drinkers might prove to be an important step in preventing relapse.     

Introduction

Scientific concepts often reflect prevailing social, cultural, political and economic considerations and undergo regular alterations.  The concept of addiction is no exception and consequently there are many definitions of the term "addiction".  A number of criticisms have been raised regarding the use of the term.  To give a few examples, it has often been employed without being defined, when a definition has been given it has often been vague (Goodman, 1990) and it has been an inaccurate concept used by lay people as well as scientists (Shaffer, 1999).  However, there is a general agreement regarding the central identifying features of an addiction. These features involve particularly salience, conflict and relief.  Salience refers to the centrality of the addiction in the person's life.  The addiction is the most important component in the addict's life and the person's behaviours, thinking and feelings evolve around the addiction.  Conflict refers to quarrels the addicted person encounters with people around them regarding their immoderate engagement in behaviours surrounding the addiction, as well as to disputes the addicted individuals has with themselves as they know they are too preoccupied with their addiction.  Relief points to the immediate increased level of hedonic tone as the addiction is pursued.  In addition, tolerance, withdrawal, relapses and reinstatements are further common components of an addiction.  Tolerance develops as the addict needs increased engagement in the behaviour to experience the same effect compared to earlier in the course of the addiction.  Withdrawal effects are unpleasant reactions to the cessation of the addictive activity while relapse and reinstatement are returns into a former state of the addiction, even after periods of abstinence (Brown, 1993a).  These central features are given in Brown's (1993a) Checklist of the Common Components of Addiction (p. 206):

 

Salience	The addictive activity becomes the most important thing in the person's life and dominates thinking (preoccupation and cognitive distortions) feeling (cravings) and behaviour (deterioration of socialised behaviour).
Conflict	Disputes about the extent of excessive behaviour arise both between the addicted person and others around and with the addicted person themselves. Continual choosing of short term pleasure and relief leads to disregard of adverse consequences and long term damage which in turn increases the apparent need for the activity as a coping strategy.
Tolerance	Increased amounts of the addictive activity are required to achieve the former effects
Withdrawals	Unpleasant feeling states and/or physical effects when the addictive activity is discontinued or suddenly reduced
Relief	The effects of the addictive activity are so powerful that there is a rebound effect when it ceases (withdrawals) and when it is over the only way to avoid feeling more miserable than before (to find relief) is to do it again at the earliest opportunity
Relapse and reinstatement	Tendency for repeated reversions to earlier patterns of addictive behaviour to recur and for even the most extreme patterns typical of the height of the addiction to be quickly restored even after many years of abstinence and control

 

However, the term "addition" is hardly used in diagnostic manuals such as The Diagnostic and Statistical Manual of Mental Disorders IV (DSM-IV) by the American Psychiatric Association and The International Classification of Diseases-10 (ICD-10) by the World Health Organisation (WHO).  The sections on psychoactive substance use are in both manuals based on the underlying assumptions and conceptual framework developed by a WHO Working Group, and are therefore similar in their intellectual foundation (Jaffe, 1992).  As the term "addiction" became a concept surrounded by a lively and sometimes heated debate, the WHO attempted in the 1970's to employ the notion of dependence (Brown, 1993a).  In both the DSM-IV and the ICD-10 the term " addiction" is hardly used and the notion of dependence is adhered to. The notion of dependence is narrower than the term "addiction" and generally refers to substance dependence, such as alcohol, tobacco and other drugs (Brown, 1993a).  In DSM-IV (p. 181) the criteria for substance dependence are as follows:

 

A maladaptive pattern of substance use, leading to clinically significant impairment or distress, as manifested by three (or more) of the following, occurring at any time in the same 12-month period:

 

1) tolerance, as defined by either of the following:

·         a need for markedly increased amounts of the substance to achieve intoxication or

        desired effect.

·         markedly diminished effect with continued use of the same amount of the substance

 

2) withdrawal, as manifested by either of the following:

·         the characteristic withdrawal syndrome for the substance

·         the same (or closely related) substance is taken to relieve or avoid withdrawal symptoms

 

3) the substance is often taken in larger amounts or over a longer period than was intended

 

4) there is a persistent desire or unsuccessful efforts to cut down or control substance use

 

5) a great deal of time is spent in activities necessary to obtain the substance (e.g., visiting multiple 

    doctors or driving long distances), use the substances (e.g. chain smoking), or recover from its  

    effects

 

6)    important social, occupational, or recreational activities are given up or reduced because of

     substance use.

 

7) the substance use is continued despite knowledge of having a persistent or recurring physical or

    psychological problem that is  likely to have been caused or exacerbated by the

    substance (e.g., current cocaine use despite recognition of cocaine-induced depression , or continued

    drinking despite recognition that an ulcer was made worse by alcohol consumption)

 

There are many similarities between the DSM-IV criteria for substance dependency and the common features that constitute an addiction.  Especially salience, tolerance and withdrawal are central aspects for both concepts.  However, symptoms of tolerance and withdrawal are neither sufficient nor necessary for the diagnosis of substance dependence and some individuals display compulsive use of the substance without physiological dependence (Frances and Miller, 1998).  Substance abuse is distinguished from substance dependence in DSM-IV.  There are four substance abuse criteria, which require one of them to have been present during the last 12 months to establish a diagnosis.

 

In this report, the term "addiction" is preferred to the terms "dependence" and "abuse" and includes individuals who could be classified as for instance alcohol dependent or alcohol abusers according to the DSM-IV.  It is beyond the scope of this report to evaluate the different models of addiction and the terms "dependence" and "abuse" do refer to the employment of the disease model of addiction. The terms "problem gambling" and "problem drinking" are not used in this report as the equivalent term cannot be used in relation to sex ("sexual problems") as it would refer to a much wider range of problems than the term "sexual addiction" does. The term "addiction" is value-laden and often used in conjunction with the disease model, but does not necessarily refer to the employment of it.  Due to the lack of a neutral concept, the term "addiction" is used in this report, without the intention of subscribing to any of the models.

 

 The concept of addiction has been applied to a wide variety of human activities (Orford, 1985) and a number of researchers argue that some behaviours can become addictive.  Marks (1990a) terms behavioural excesses that are dysfunctional and purposeful and that have no external substances as a goal for "behavioural (non-chemical) addictions". Certain forms of gambling and sexual behaviour have been viewed as sharing many features with chemical addictions and even some forms of treatment of problematic gambling and sexual behaviour have been based on treatment approaches developed for chemical addictions (Jaffe, 1992).  Moreover, both gambling and sexual behaviour have the potential to become behavioural excesses that are dysfunctional and purposeful and having no external substances as a goal.  Gambling and sexual excesses can therefore sometimes be classified as "behavioural addictions".

 

Little research has been conducted into the effects of concurrent behavioural and chemical addiction. However, it is shown that concurrent alcohol use and other drug use in the same individual is common (Miller, 1998) and that multiple drug addictions are seen in the majority of individuals that seek help (McKay et al. , 1998; cited in McKay and McLellan, 1998).  Multiple addiction to alcohol and other drugs have significant diagnostic and treatment implications (e.g. Grant, 1996; cited in Miller, 1998; Miller, Guttmann and Chawla, 1997). As multiple drug addiction is common and have signinficant diagnostic and.treatment implications, it is lileky that concurrent behavioural and chemical addictions have extensive consequences as well . Thus, we were investigating how common concurrent behavioural and drug addictions are by using gambling and sexual addiction as well as alcohol addiction as examples of behavioural and chemical addictions respectively.

 

 

Diagnostic criteria for gambling addiction:

In DSM-IV pathological gambling is classified as a disorder of impulse control. The criteria for a diagnosis of pathological gambling in DSM-IV (pp. 615-618) requires absence of mania or hypomania and the presence of minimum 5 of 10 features within the last 6 months. These defining features of pathological gambling are:

 

·         Preoccupation with gambling (e.g. preoccupied with relieving past gambling experiences, handicapping or planning the next venture, or thinking of ways of which to get money to gamble).

·         Tolerance: Needs to gamble with increasing amounts of money in order to achieve the desired excitement

·         Withdrawal: restlessness or irritability when attempting to cut down or stop gambling

·         Escape: Gambling as a way of escaping from problems or relieving dysphoric mood (e.g. feelings of helplessness, guilt, anxiety or depression).

·         Chasing: After losing money when gambling, often return another day in order to get even ("chasing one's losses").

·         Lying: Lies to family members, therapists or others to conceal the extent of involvement with gambling

·         Loss of control: made repeated unsuccessful efforts to control, cut back or stop gambling

·         Illegal acts: Committed illegal acts, such as forgery, fraud, theft or embezzlement, in order to finance gambling

·         Risked significant relationship: jeopardised or lost significant relationship, job, education or career opportunity because of gambling

·         Bailout: Reliance on others to provide money to relieve a desperate financial situation caused by gambling.      

As it is beyond the scope of this report to evaluate whether gambling is pathological or not, the term "pathological gambler" is substituted with the term "gambling addict" when possible. 

 

Gambling addiction and other addictions

In order to emphasise the similarities between substance dependencies and pathological gambling, the diagnostic criteria for pathological gambling are in the DSM modelled after the diagnostic criteria for substance dependency (Lesieur and Heinemann, 1988).  Preoccupation, tolerance, withdrawal and loss of control are central in diagnosing both substance dependency as well as pathological gambling.  Further commonalities are reported by Lesieur and Heineman (1988) and include changes in level of arousal, overlapping social worlds and similar relapse patterns.  They often occur simultaneously or sequentially and treatment is often based on the same approaches (Lesieur and Heineman, 1988).  In addition, research has shown that pathological gambling can prompt neuroadaption, and therefore resembles the effects of chemicals on the brain (Wray and Dickerson, 1981; cited in Shaffer, 1999).  Bergh, Sodersten and Nordin (1997) found changes in the dopamine system in pathological gamblers, for instance. 

 

Many individuals identified as addicted to gambling are addicted to chemicals as well.  Prevalence rates of alcohol addiction and other substance related disorders have been reported from 47% to 52% in individuals addicted to gambling (Schneider and Irons, 1997).  It has also been suggested that in individuals addicted to both drugs and gambling, the gambling addiction can increase in severity once the gambler stops using the drug.  This increased severity of gambling addiction may also increase the chances of relapse in respect to the drug use (Lesieur and Heineman, 1988). Treatment should focus on both the chemical addiction and the gambling in order to prevent relapse. (Schneider and Irons, 1997).

 

Prevalence rates

Prevalence rates have increased significantly over time. In a meta-analysis of 120 surveys carried out in the US, Ronneberg et al. (1999) found that the lifetime prevalence rate of gambling addiction in studies conducted after 1993 was 75% higher than the prevalence rates obtained in earlier studies.  This extreme increase is likely to be caused by different methods for measuring gambling addiction as well as a general increase in the prevalence rate.

 

Based on the results of the South Oaks Gambling Screen (SOGS) or other screens developed to measure gambling addiction, individuals are generally categorised as having no gambling problem, being potential pathological gamblers or probable pathological gamblers (Ronneberg et al., 1999).   In this report, "probable pathological gamblers" refer to individuals who score 5 or more points at the SOGS and who are likely to be classified as pathological gamblers according to the DSM-III criteria. Te "Potential pathological gamblers" refer to individuals who score 3 to 4 points on the SOGS.  They do behave similarly to gambling addicts (probable pathological gamblers), but the manifestation of an addiction is milder and they might fall short of the DSM-III criteria for pathological gambling.  Another distinction is made between "lifetime" and "current" potential and probable pathological gamblers.  "Lifetime" potential and probable pathological gamblers are individuals who at some point in their life filled the SOGS criteria for potential or probable pathological gamblers.  "Current" potential and probable pathological gamblers refer to individuals who have filled the criteria for potential or pathological gamblers in the last 12 months.  National prevalence surveys have been conducted in New Zealand and in Sweden.  These surveys have employed the SOGS or versions of it. In the national prevalence study in Sweden (Ronneberg et al., 1999) between 2.3%-3.1% could be classified as lifetime potential pathological gamblers while 0.95%-1.45% could be classified as lifetime probable pathological gamblers.  This prevalence rate is probably a best estimate of the actual prevalence rate in Norway.  In the New Zealand study, about 1.2% could be classified as lifetime pathological gamblers and 4.1% as lifetime potential pathological gamblers (Abbott and Volberg, 1992; cited in Ronneberg, 1999).  In the US, the prevalence rates of lifetime pathological gambling varied from 1%-3%, depending on jurisdiction. The lifetime prevalence rate for potential pathological gambling varied from 2.2% to 8.2% (Ronneberg et al., 1999). 

 

Schneider and Irons (1997) report that 9-14% of individuals under treatment for chemical addiction can be diagnosed as potential pathological gamblers and the same rate applies to probable pathological gamblers when surveys have been employed. Lesieur and Heineman (1988) found that 14% of patients in a therapeutic community in the US, addicted to a variety of drugs, could be classifies as lifetime probable pathological gamblers and another 14% as lifetime potential pathological gamblers according to the SOGS.  In a Greek study by Mantala (1997), 14.3% of a sample of drug and alcohol addicts receiving treatment for their addiction could be classified as lifetime probable pathological gamblers.  Another 10.7% could be classified as lifetime potential pathological gamblers.   

 

Sexual Addiction

The relatively new area of sexual addiction is a highly controversial topic that has been subjected to a heated debate.  According to Adams (1998) a growing consensus among professionals has led to a move from the question regarding the existence of sexual addiction to the question of treatment strategies.  Opposingly, Gold and Heffner (1998) argue that most literature in the field concerns the nature of the phenomenon and its designation, and that little empirical research to validate the construct has been conducted. In short, they claim, it is an area with many conceptions and minimal data.

 

Definition of sexual addiction

There seem to be an agreement among professionals that sexual behaviour can occur in excess and be highly distressing for the individual experiencing it (Goodmann, 1992). This phenomenon has been given different names, most frequently sexual addiction, sexual compulsivity and sexual dependence (for a discussion on why the phenomenon should not be regarded as sexual compulsivity and sexual dependence, see Goodmann, 1992).   Professionals who do not want to regard sexual addiction as a existing phenomenon frequently do not recognise behavioural addictions on the basis that the behavioural addictions do not lead to tolerance and withdrawal effects (Gold and Heffner, 1998).  However, in the DSM-IV criteria for substance abuse, tolerance and withdrawal is neither sufficient nor necessary for a diagnosis.  Furthermore, Robertson (1990; cited in Gold and Heffner, 1998) argues that sexual behaviour generates changes on the neuronal level in the brain, like gambling addiction, and therefore resembles the effect of chemicals on the brain.  Sexual addiction is not included in DSM-IV.  Nevertheless, the DSM-IV criteria for substance dependence can easily be applied to the construct of sexual addiction (Gold and Heffner, 1998).

 

Schneider and Irons (1997) give a list of behaviours commonly displayed in individuals with additive sexual disorder.  These commonly displayed behaviours are (p. 226):

1.     Signs and symptoms of a substance related disorder.  In the course of evaluation or treatment of chemical dependence or alcoholism, the patient reveals a sexual history consistent with an additional diagnosis of an addictive sexual disorder.

2.     A pattern of multiple substance addiction relapses. In the process of intensive review, addictive sexual behaviour is found to be a significant factor associated with or preceding substance relapse.

3.     Acute relationship crisis precipitated by disclosure or discovery of secret sexual behaviour outside the relationship, particularly when this is a recurring theme.

4.     Unexpected diagnosis of an STD in the patient or sexual partner

5.     Legal consequences resulting from impropriety in personal life (e.g. arrest for solicitation, public indecency, sexual assault, or domestic violence associated with "marital rape").

6.     Professional or work-related consequences (e.g. a sexual harassment complaint; professional sexual misconduct; loss of position, status or employment associated with physical absences; or loss of productivity related to sexual activity or desire).

7.     Financial crisis associated with diversion of resources for telephone sex lines, pornography, prostitution, "keeping" or "entertaining" sexual partners, or payment made (bribery or extortion) to keep the sexual indiscretions from becoming known.       

 

Carnes (1983, 1989) gives anecdotal accounts of all these features in sexually addicted individuals.  Moreover, Gold and Heffner (1998) state that sexual addicts report preoccupation, increased severity of the addiction over time, withdrawal symptoms such as depression and anxiety, continuation despite adverse consequences and loss of control.  Little empirical research that supports these claims exist, and no research neither supporting nor rejecting these claims was found when this report was written.  As research in the area of sexual addiction is relatively new, it is likely that future studies will give scientific support for these anecdotal accounts, as occurred with gambling addiction.       

 

 

Schneider and Irons (1998) propose the following diagnostic criteria for Addictive Sexual Disorder where each of the following should be present:

1.     DSM-IV criteria met for one of the following: paraphilia, sexual disorder not otherwise specified (NOS), or impulse-control-disorder NOS.

2.     Addictive features present as indicated by a) loss of control over a sexual behaviour, b) continued sexual behaviour despite significant adverse consequences, and c) obsession or preoccupation with the fantasies, urges or behaviour.

3.     Has reached the establishment phase of an addictive behaviour for a period of at least six months.

4.     The focus of attachment is usually on relationships wherein the partner is viewed as narcissistic projection-objects to be used for self-aggrandisement and self-gratification and then discarded when they are no longer needed. The goal of entering a relationship is to have sex or romance, rather than sex and romance being a part of a relationship.  The patient may identify with the term "love" or "relationship" addict. Type of nonparaphilic compulsive sexual behaviour include compulsive cruising and multiple partners, compulsive fixation on an unattainable person, compulsive masturbation, compulsive multiple love relationships, and compulsive sexuality within a relationship.

 

 

Sexual addiction and other addictions

Depression, obsessive-compulsiveness and paranoia are phenomena repeatedly observed in sexual addicts.  The individuals often receive treatment for these phenomena without the sexual addiction being addressed.  Furthermore, shoplifting, gambling, extensive spending, alcohol addiction as well as other drug addiction is commonly observed in sexual addicts (Carnes, 1983).  In a study by Carnes (1991; cited in Schneider, 1994) it was found that 42% of 1000 inpatients receiving treatment for their sexual addiction disclosed concurrent chemical dependency.  38% had an eating disorder, 28% were compulsive workers, 26% compulsive spenders and 5% compulsive gamblers. 17% reported sexual addiction to be their only compulsive behaviour.  Irons and Schneider (1994) found that among health care professionals diagnosed as sexual addicts, 38% were addicted to alcohol as well.  These results suggest that a significant number of individuals who receive treatment for chemical addictions are addicted to some form of behaviours too.  The treatment of one addiction does not necessarily cure the other addiction (Carnes, 1983).

 

Prevalence studies regarding sexual addiction are hardly found.  However, Carnes (1991; cited in Schneider, 1991) reports that from 3% to 6% of the American population suffer from sexual addiction. 

 

The purpose of this study

As shown, behavioural addictions may occur simultaneously with chemical addictions.  They can also alternate with chemical addictions (Schneider and Irons, 1997). This has theoretical and practical consequences.  Since multiple drug addiction has extensive treatment implications, simultaneous or alternate behavioural addictions would have serious implications for the treatment of the chemical addicted individual.  Goodman (1990) argues that if behavioural and chemical addictions occur more frequently together than would be expected if they were not related, a shared underlying process for all addictions should be suggested. The underlying process could then be expressed in one or more behavioural manifestations chosen by the requirements and limitations of the situation the individual is in.  Treatment should then focus on the present addiction(s) as well as the general underlying addictive process.

 

This study is carried out to assess the prevalence of gambling and sexual addiction in inpatients under treatment for alcohol addiction and to compare the obtained estimates to the prevalence of gambling and sexual addiction in the general population.  Thus, the obtained prevalence rate of gambling addiction will be compared to a best estimate of the prevalence of gambling addiction in the general population. This is conducted by comparing the obtained prevalence rate to the prevalence rate of gambling addiction in the general population of Sweden.  In regard to sexual addiction, the obtained prevalence rate will be compared to the prevalence rate in the general population of the US reported by Carnes (1991).  Assessments of the relationship between two behavioural addictions (sex and gambling) and a chemical addiction (alcohol) can then be made.    

 

Method

 

Sample

Initially 86 of 114 asked adult men participated in this study. However, 3 questionnaires did not give sufficient information for any evaluation, and could not be employed in the study.  Furthermore, only the data from heterosexual males was used for statistical analysis as one part of the questionnaire is not reliable for other groups.  Thus the data from one bisexual and one transsexual were excluded and in addition, individuals who were addicted to more than one substance were excluded as it would be difficult to determine how the drugs would influence their sexual behaviour. The remaining data consisted of data from 67 individuals addicted to alcohol and 6 individuals addicted to heroin.  As data from 6 individuals is insufficient for any statistical analysis, the data from the 6 heroin addicts had to be excluded from the study as well.  Consequently, this report is based on the answers from 67 inpatient alcohol addicts. Their level of alcohol addiction was not established, neither at what stage in treatment they were. Their age ranged from 28 to 63, with the mean at 46.3. The individuals were classified in terms of occupation according to Goldthorpe and Hope's (1974) occupational classification scale. 31,3% could be classified as unskilled workers, 23.9% could be classified as skilled workers (such as plumbing and decorating), 10.4% could be classified as professionals (such as managers, teachers and writers) 4.5% could be classified as manual labourers and 29.9% did not answer this question.  In terms of marital status 47.8% of the sample were single, 41.8% were divorced, 7.5% were married and 3% were widowed.

 

Instruments

The subjects completed a questionnaire pack (Appendix 1) that consisted of four parts; a consent form, a form for demographic information, the SOGS and the SAST.  

 

The SOGS was developed by the Gambling Treatment Team at South Oaks hospital in the US, based on the DSM-III criteria for pathological gambling.  It is a paper and pencil test that can be used to discriminate between non-gamblers, potential pathological gamblers, and probable pathological gamblers over a lifetime.  It has demonstrated high internal consistency in a wide variety of settings and it has proved to be a reliable and valid instrument for screening individuals with a problem with pathological gambling.  In the development of the test, both separate items as well as the entire screen was tested for reliability and validity in hospital workers, university students, prison inmates and inpatients under treatment for chemical addiction (Lesieur and Blume, 1987).  However, its usefulness as a diagnostic tool in community surveys is yet to be determined, and it is not known whether prevalence estimates obtained by the use of SOGS correspond to the prevalence of pathological gamblers if interviews employing the DSM and ICD criteria were conducted.  Furthermore, it has not been updated as the criteria for pathological gambling have slightly changed with the introduction of DSM-IV(Ronneberg et al., 1999).

 

Sexual addiction was measured by using the SAST (Dr. Carnes, The Meadow, US) The SAST is a paper and pencil test which consists of 25 questions related to the individual's current sexual behaviour and their attitude and feelings towards their sexual behaviour.  It is an assessment tool to be used in conjunction with clinical evaluation and within that context it can provide indication of sexual addiction (Carnes, 1989).  It has shown a high discriminating ability between sexual addicts and non-addicts when the scores are above 13 and is the most reliable and most commonly used screening instrument for sexual addiction.  The SAST is not a reliable instrument for measuring sexual addiction in homosexuals, females and adolescents (Carnes, 1991).  It has been adjusted to females but no research has investigated its reliability and validity.   The SAST was adjusted to measure lifetime sexual addiction. This because sexual disorders have been frequently reported in chronic male alcoholics (Schiavi, 1990).  Current measures would therefore underestimate the proportion of individuals in which sexual addiction might occur after the individual has reached sobriety.

 

The questionnaire pack was given to the participants in Norwegian (Appendix 2). The SOGS had already been translated by Renavangen Clinic for Gambling Addiction.  The rest of the questionnaire pack was first translated by the researcher, who is a native speaker of Norwegian and has spent 3 years  in Britain. Subsequent, Mr. Krogstad, a professional interpreter, scrutinised the translation and finally approved of the translation.

 

Procedure

The clients at the different institutions were first informed about the present investigation by the staff in a group meeting. A few days later the researcher would visit the institution and in a group meeting further inform the clients about the project. The clients were told that the research was conducted in order to investigate gambling and sexual addiction in alcohol and heroin addicts to increase the scientific understanding of the relationship between different forms of addiction. They were told that it took from 10 to 20 minutes to fill in the questionnaire and that it was important that everyone did it individually.  Furthermore, they were told to part the consent form from the following questionnaire and hand them in separately, with the questionnaire in the enclosed envelope.  It was explained that by collecting both separately, anonymity would be ensured.

 

 

 

Results

This investigation was carried out to assess the prevalence of gambling and sexual addiction in inpatients under treatment for alcohol addiction and to compare the obtained estimates to the prevalence of gambling and sexual addiction in the general population.

 

Table 1:  SOGS scores by Problem Drinkers

SOGS Scores by Problem Drinkers	" No  Problem" (0-2)	Potential Pathological Gamblers (3-4)	Probable Pathological Gamblers (5+)
Problem Drinker N=67	91% n=61	1.5% n=1	7.5% n=5

 

91% of the participants were classified as having "no problem" in regard to gambling addiction. 1.5% could be classified as potential pathological gamblers and 7.5% could be classified as probable pathological gamblers.

 

Table 2: SAST scores by Problem Drinkers.

 

SAST scores by Alcohol Addicts	"No Problem" (0-10)	Possible Sex Addicts (11-12)	Probable Sex Addicts (13+)
Alcohol Addicts N=67	98.5% n=66	0% n=0	I.5% n=1

 

Individuals classified as having "no problem" score from 0-10 on the SAST and are unlikely to be classified as sex addicts.  The term "possible sex addict" refers to individuals who score 11-12 on the SAST.  They do behave similarly to sex addicts, but the manifestation of an addiction is milder and they are therefore likely to fall short of a diagnosis as a sex addict.  The term "probable sex addict" refers to individuals who score above 13 on the SAST and who are highly likely to be diagnosed as a sex addict.  From the table we can see that 98.5% of the participants in the study seemed to have "no problem" in regard to sexual addiction.  There were no possible sex addicts in this sample.  One of the participants (1,5%) could be classified as a probable sex addict. 

 

The association between age, marital status, occupational grading and SOGS score was investigated.  Age was significantly negatively correlated with SOGS score (Spearman Correlation, p<0.0001).  No association between marital status or occupational grading and SOGS score was found (Kruskal-Wallis Tests, p=414 and p=0.10, respectively).  Insufficient numbers of participants from some of the institutions ruled out the possibility of conducting a statistical analysis to compare the prevalence of gambling addiction between the different institutions.      

 

 

In order to compare the results of the present study to the prevalence of gambling addiction in the general population, a comparison of the SOGS scores obtained in the present study to the SOGS scores obtained from a sample of the Swedish population by Ronneberg et al. (1999) was conducted. A significant difference was found between the proportion of probable pathological gamblers in the two studies (p-value=0.05).  No other significant difference was found.

 

 

 

 

 

 

Table 3: Sogs score by present study and Ronneberg et al. (1999)

 

SOGS scores  by Study	"No Problem" (0-2)	Problem Gamblers (3-4)	Probable Pathological Gamblers (5+)
Ronneberg et al. (1999) N=7139	96.1% n=6861	2.7% n=193	1.2% n=86
Present study N=67	91% n=61	1.5% n=1	7.5% n=5

 

 

To compare the proportion of sexual addiction among the inpatients under treatment for alcohol addiction obtained in this study to the proportion of sexual addiction in the general population, we can look at the figures obtained by Carnes (1991).  He found between 3-6% of a sample of the general population in the US to be probable sex addicts.  The proportion of probable sex addicts in this sample is lower (1.5%).  However, as the sample size of Carnes' (1991) study is not reported, it is not possible to formally assess whether the difference between these figures is statistically significant.

 

 

Discussion

 

7.5% of the sample could be identified as addicted to gambling and 1.5% could be identified as sexually addicted. These results suggest a higher prevalence of gambling addiction and a lower prevalence of sexual addiction among inpatients under treatment for alcohol addiction than in the general population. 

 

There are some serious limitations to this study that need to be considered.  We have to bear in mind that it relies on uncorroborated, retrospective data, and thus the respondents' biases and inaccurate perceptions may have undermined the reliability and validity of the results.  The response rate was approximately 75% and it is difficult to determine how data from the remaining 25% would affect the results.  It might be that individuals with gambling and sexual addiction preferred not to take part in the study as they for instance found it embarrassing to disclose gambling and/or sexual addiction.  The direction of the effects of any such biases and distortions are impossible to ascertain.  Moreover, some institutions required the participants to be fully informed about the investigation before taking part.  Thus, all subjects were told that the study was investigating the interaction between gambling, sexual and alcohol addiction.  The effect this awareness may have had on the participants' responses is difficult to establish.  Furthermore, as the SAST is only reliable for heterosexual men, females and men of other sexual orientations were excluded from the study.  Therefore, these results are limited in their generalisability and should only be seen as suggestive.

 

A prevalence rate of 1.5% of sexual addiction was found among inpatients under treatment for alcohol addiction. The rate of sexual addiction among the general population in Norway is not known and the obtained prevalence rate was therefore compared to prevalence rates among the general population in the US found by Carnes (1991).  The obtained prevalence rate was lower than the rate estimated by Carnes and there might be many reasons for the low prevalence rate of sexual addiction in the present sample. First of all, sexual addiction is not a defined topic among either professional or lay people in Norway.  Thus, individuals with sexual addiction might be less willing to disclose details about their sexual behaviour as they may find their behaviour more abnormal than would people in the US. Clinical interviews together with the SAST might have been a better way of identifying sexual addicts.  Secondly, long-term use of alcohol is associated with impairment in sexual desire, arousal or orgasm, or presence of pain during intercourse.  However, when sobriety is achieved these sexual impairments diminish (Ordorica and Nace, 1998).  Even if the prevalence of sexual addiction is low among alcohol addicts, sexual addiction might be reinstated when alcohol is no longer used.  Thus, sexual addiction as a possible factor in relapse should be considered. Furthermore, the SAST always followed the SOGS as it was presumed that the SOGS asked for less personal information than the SAST.  It was believed that the response rate would be higher if the SOGS was placed before the SAST, compared to a counterbalancing where the SAST following the SOGS only 50% of the times it was handed out.  An order effect can easily have led to confounding of the SAST results.  Maybe the participants suffered from the effects of fatigue or boredom, for instance, when filling in the SAST.  Finally, it might be that the prevalence of sexual addiction among recovering alcohol addicts actually is lower than in general populations.   Before such a claim can be accepted, sexual addiction would have to be more thoroughly investigated, taking the afore mentioned accounts into consideration.  As research in the area of sexual addiction is in its infancy, a sound scientific basis needs to be established before any overall conclusion can be reached.

 

A prevalence rate of 7.5% of probable pathological gamblers and 1.5% of problem gamblers was found among inpatients under treatment for alcohol addiction in Norway.  Together this suggests that 9% of the sample had some form of gambling problem that is likely to interfere with the treatment of the alcohol addiction.  No association between either marital status or occupational grading and SOGS scores was found. Insufficient numbers of participants from some of the institutions ruled out the possibility of conducting a statistical analysis to compare the prevalence of gambling addiction between the different institutions.  A significant negative correlation between age and SOGS score was found.  Thus, generally speaking, the younger participants scored higher than older participants did on the SOGS.  However, the association between age and SOGS score is not clear. Lesieur and Heinemann (1988) found a positive correlation between age and SOGS score. Lesieur, Blume and Zoppa (1986) found a negative correlation, while Ladouceur and Mireault (1988; cited in Lesieur and Heinemann, 1988) found no correlation. As this study is limited in time and resources, the lifetime version of SOGS was employed.  For future studies, current as well as lifetime measurements should be employed as current gambling addiction might have more serious consequences for treatment and relapse rates than lifetime measures. However, lifetime measures are important as they can single out individuals who are in remission.  Individuals in remission in regard to their gambling addiction are also at risk for increased relapse rates and therefore important to identify (Lesieur and Blume, 1993).

 

The prevalence of gambling addiction in the present sample was compared to an estimate of gambling addiction in the general population in Sweden.  Differences and similarities between the two countries in terms of gambling availability need to be established as factors such as opportunity to gamble is linked to the prevalence of gambling addiction in the population (Brown and Fisher, 1996).  The level of gambling has increased rapidly worldwide and with the development of new information technology such as the Internet, this trend is not likely to come to an end.  Governments need to establish ways to anticipate the development of increasing gambling rates and associated gambling problems. A first step in this direction would be to conduct a nation-wide investigation into gambling, gambling habits and gambling addiction in the general population of Norway.       

 

Both Mantala (1997) and Lesieur and Blume (1988) found higher prevalence rates of gambling addiction among chemical addicted individuals than prevalence rates normally found in the general population.  The present study supports their findings.  Together these findings have theoretical implications for the understanding of addictions and practical implications for the treatment of addicted individuals.  First of all it implies an underlying addictive process which nature can best be investigated if commonalities between addictions are stressed and searched for.  Continued research into gambling and sexual addiction has thus immense value as important information can be deducted, as shown by Brown (1993) and Carnes (1989). This information can be employed and utilised in research and treatment of other addictions as well as increase the understanding of the etiological variables involved in treatment outcome for each individual who suffers.  By improving our theoretical understanding of addictions, more comprehensive and effective research can be conducted which can further lead to enhanced treatment quality and outcome. 

 

Prevalence studies are important in that they may emphasise problem areas that need attention, while the actual figures they produce should not be accorded disproportionate importance. By looking at prevalence rates of addiction, a dichotomy between addicts and non-addicts is emphasised.  However, it is more likely that addiction occurs on a continuum (Brown and Fisher, 1996). Individuals who fall short of a diagnosis as an addict may suffer serious adverse consequences from their "nearly" addicted state, which should by no means be ignored.    

 

The results from this preliminary study show a connection between gambling addiction and alcohol addiction. It shows that gambling addiction occurs among people receiving treatment for alcohol addiction and this aspect has treatment implications and needs attention.  Treatment of multiple addicted individuals should focus on the present addictions as well as the underlying addictive process.  Screening for gambling addiction when treating alcohol addicts might prove to be an important step in preventing relapse. 

 

Kirsch and Bohnenblust (1990) found assessment of behavioural addictions in treatment institutions for chemical addictions to be seldomly employed. When employed, there was a wide discrepancy in the type of screening tools employed and it appeared to be no agreement on standardised instruments for the assessment of multiple dependencies.  Thus, one area where future research would be useful is the development of reliable and valid screening instruments for multiple dependencies. The SOGS is a reliable and valid instrument for the assessment of problem gambling and pathological gambling but needs to be updated as new research is conducted.