290 likes | 607 Views
Multifinality: Same underlying cause, different disorders. Jeremiah Weinstock, PhD OPG Summit 2014 Berkeley, CA. Workshop Outline. Defining m ultifinality and its application to psychiatric disorders. Common risk factors for gambling disorder and other psychiatric disorders.
E N D
Multifinality: Same underlying cause, different disorders. Jeremiah Weinstock, PhD OPG Summit 2014 Berkeley, CA
Workshop Outline • Defining multifinality and its application to psychiatric disorders. • Common risk factors for gambling disorder and other psychiatric disorders. • Treatment implications of multifinality
A Related Concept: Equifinality Several pathways to the same outcome. Behaviorally Conditioned Gambling Disorder Classical and Operant Conditioning Emotionally Vulnerable Antisocial & Impulsivity Pathways Model Blaszczynski & Nower (2002)
What is Multifinality Same underlying factor can lead to several different psychological outcomes. Disorder A Underlying Factor Disorder B Disorder C
What is Multifinality Same underlying factor can lead to several different psychological outcomes. EXAMPLE: However, context and expression of the underlying factor varies across disorders. Social Anxiety Disorder Perfectionism Anorexia Nervosa Major Depression
Multifinality Explains why not everyone who is exposed to trauma develops post-traumatic stress disorder (PTSD). Requires examination of a client’s entire developmental history, instead of current symptom profiles. DSM-5 is based upon observable symptoms that typically present together. It is not based upon etiology.
Multifinality Leads to several conclusions about psychopathology: • Genes and/or events are not always deterministic. • The same underlying processes contribute to the development of many disorders. • Helps explain comorbidity and why disorders reliably cluster together. • The DSM classification scheme has limitations.
GamblingDisorder Not everyone who gambles develops the disorder: • About 85% of Americans have gambled in their lifetime. • About 2-3% of Americans experience sub-clinical problems related to gambling • About 1% of Americans meet diagnostic criteria for gambling disorder.
Multifinality: Underlying Processes How can we think about these processes? Distal Risk Factors Nolen-Hoeksema & Watkins, 2011
Multifinality: Underlying Processes How can we think about these processes? Distal Risk Factors Proximal Risk Factors Nolen-Hoeksema & Watkins, 2011
Multifinality: Underlying Processes How can we think about these processes? Distal Risk Factors Proximal Risk Factors Antisocial Personality Disorder Addiction Disorders Generalized Anxiety Disorder Nolen-Hoeksema & Watkins, 2011
Multifinality: Underlying Processes How can sexual abuse lead to antisocial personality disorder? Sexual Abuse as a child Poor Attachment Antisocial Personality Disorder
Multifinality: Underlying Processes How can sexual abuse lead to addiction? Sexual Abuse as a child Copes by dissociation Addiction Disorders
Multifinality: Underlying Processes How can sexual abuse lead to generalized anxiety disorder? Sexual Abuse as a child Hypervigilence for threats Generalized Anxiety Disorder
Gambling & Abuse Childhood abuse is a significant risk factor for gambling disorder (and many other disorders). The link between the two is posited via proximal risk factors of: • Early maladaptive schemas • Use of emotion focused coping Hodgins et al., 2010; McCormick et al., 2012; Petry & Steinberg, 2005; Shorey et al., 2012
Gambling & Abuse Childhood abuse is a significant risk factor for gambling disorder (and many other disorders). The link between the two is posited via proximal risk factors of: • Gambling at a slot machine is one method to cope with one’s emotions. It is a way to dissociate. • Within gamblers, dissociation is linked to $pending more than one intend$. Hodgins et al., 2010; McCormick et al., 2012; Petry & Steinberg, 2005; Shorey et al., 2012
Gambling Disorder Comorbidity Within gambling disorder, the lifetime prevalence rates of other disorders are: More often than not, the other disorder develops first. Kessler et al., 2008; Petry, Stinson & Grant, 2005
Gambling Disorder & Alcohol How are the two related? • Sensation seeking • Desire to experience strong feelings and arousal • Impulsivity • Rash decision making without considering consequences • Interaction between the two • Bad decisions are made when intoxicated.
Gambling Disorder & Mood How are the two related? • Gambling in response to depression: • Gambling is an easy way to induce positive affect (i.e., negative reinforcement). • “Relieves” social isolation • Gambling causes depression: • Losing money gambling temporarily induces depressive affect. • Social isolation frequently occurs due to hiding the problem from others. O’Brien, 2011
Gambling Disorder & Anxiety A client stated, “I get very frightened and am socially awkward. Gambling is a way to be social without having to be social.” The severity of gambling disorder is positively associated with comorbid anxiety disorders. El-Guebaly et al., 2006
Comorbidity: Treatment Implications Comorbid disorders complicate gambling treatment: • History of substance use disorder negatively impacts ability to achieve abstinence from gambling. • History of a mood disorder increase length of time it takes to begin a period of abstinence. • Current alcohol use disorder increase risk of relapse. Hodgins & el-Guebaly, 2010
Limitations of DSM-5 The development a psychopathology is massively multi-factorial. Need to go beyond a diagnosis of common observable symptoms and examine what factors influence and/or maintain the behavior.
Integrated Treatments In a sample of individuals diagnosed with both PTSD & gambling disorder: • PTSD treatments were perceived as more helpful A pilot study of Seeking Safety, a treatment for comorbid PTSD & substance use disorders, was tested with gambling disorder. • Efficacious in reducing both gambling and PTSD symptoms. Najavits, 2011; Najavits et al., 2013
Integrated Treatments Korman et al., 2008;
Integrated Treatments In a sample of individuals with gambling disorder and anger issues: • Compared to TAU, an integrated treatment led to greater treatment engagement, reduction in gambling behavior, substance use, and anger Korman et al., 2008;
Next Steps for Clinical Practice Do I need to become a jack of all trades? • No, but improved assessment and screening is beneficial for all clients. At my clinic, the primarily modality of treatment is group therapy. How do I tailor group treatment to diverse clients? • Groups focused on treating underlying processes? • Dissociation, emotional regulation (e.g., anger), impulsivity
Summary Multifinality suggests that common underlying factors can lead to diverse outcomes. • Helps explain comorbidity Response to early events, and more immediate life events influence the path/outcome. Ignoring these underlying factors during treatment may be detrimental to our clients and their long-term well-being.
FOR MORE INFORMATION Jeremiah Weinstock, Ph.D. Department of Psychology Saint Louis University jweinsto@slu.edu 314.977.2134