Concepts and controversies regarding tolerance and withdrawal in gambling disorder

Gambling disorder is classified in the DSM-5 as a behavioral addiction. However, the inclusion of tolerance and withdrawal symptoms as diagnostic criteria for the disorder remains poorly understood and characterized by a lack of empirical support. While the need for increasing excitement is considered central to the concept of tolerance in gambling, alternative explanations for the phenomenon exist. Concomitantly, withdrawal may not be limited to neurobiological processes generating adverse subjective and physiological arousal that contribute to persistent gambling. Clarifying the concepts and functional role of tolerance and withdrawal in the addiction process has significant implications for accurate clinical assessment and targeted symptoms in the treatment of gambling disorders.