Beyond the assessment score : examining the essential meaning of tolerance and withdrawal symptoms in individuals affected by gambling disorder through constructivist grounded theory

Abstract

Objective: Given its roots in dependence syndrome, gambling disorder was officially classified as the first behavioral addiction by the American Psychological Association (2013). This new classification led to a wave of researchers’ enthusiasm to pathologize excessive behaviors as addictive. Despite the new classification, gambling tolerance and withdrawal (the hallmark symptoms in behavioral addiction) are heavily understudied. A knowledge gap was identified in the current study. This study aimed to investigate the nature of the symptoms. With better understanding, there may either be alternative conceptualizations of behavioral addiction or more solid addiction perspective-aligned counseling practices. Method: The conceptual framework was created using exploratory constructivist grounded theory with the aid of co-joint interviews and a mood-tracking device. Due to stigmatization, individuals with gambling disorder from the wider community were generally reluctant to participate in the study. Through purposive sampling, 23 help-seeking individuals with gambling disorder (19 males and 4 females) were recruited from local government-funded counseling units, followed by a rigorous process to establish trust and integrity of the findings. For instance, the primary findings were validated through a 6-member focus group, triangulation of data and the researcher’s reflexive memo. Findings: Four main themes emerged: a) The destructions and seeking help; b) The inexplicable sense of impulse and repeated failure; c) Caught in the middle, the motivational dilemma and typical conditions of gambling disorder; and d) Meaning-making by promoting deep understanding of tolerance and withdrawal symptoms. From these themes, a conceptual framework was developed that embedded four components (Charms, Challenges, Costs and Carrots). This framework was derived from the ambivalence experienced in gambling disorder, which refers to the motivational struggle linked with a cluster of DSM-5 symptoms and the reciprocal effect of life satisfaction without gambling. Specifically, tolerance and withdrawal were adaptation responses in which individuals with gambling disorder “coped with” the reduced sensitivity to the pleasurable effect(s) of gambling and rebound effect(s) associated with cessation attempts. The reduced sensitivity may be linked with winning expectancy, inflated confidence to win, perceived personal competency and misinformation about gambling. Pleasure may be buffered by increasing the size of the wager and by the risk of a bet. Distressful rebound may originate from the unreconciled conflict and anticipated regret (the notion of fear of missing out) of the monetary aspect of gambling, leading to persistent motivation to gamble. Lastly, representing a small but significant step in promoting knowledge transfer, an unplanned preliminary study (i.e., was not part of the original doctoral proposal) was conducted to develop an assessment scale on gambling-related tolerance and withdrawal symptoms. Conclusions and Implications for Practice: This work offers a novel conceptual framework of gambling tolerance and withdrawal that highlights the essentiality of the addiction model adopted to better understand gambling disorder. Beyond the assessment score, it also lays a solid foundation to guide clinical work on the effects of the symptoms.