Assessment and Treatment of Addictive Behaviors Carl W. Lejuez, PhD

1. Assessment and Treatment of Addictive BehaviorsCarl W. Lejuez, PhD Class #3 Assessment of Gambling and eating disorders

2. Eating Disorders: Overview • Eating controlled by factors including appetite, food, family, peer, and cultural practices, and attempts at voluntary control • Dieting to a body weight leaner than needed for health is highly promoted by current fashion trends, sales campaigns for special foods, and in some activities and professions • Eating disorders involve serious disturbances in eating behavior, such as extreme and unhealthy reduction of food intake or severe overeating, as well as feelings of distress or extreme concern about body shape or weight. • Eating disorders are not due to a failure of will or behavior; rather, they are real, treatable medical illnesses in which maladaptive patterns of eating take on a life of their own. • Main types are anorexia nervosa and bulimia nervosa

3. Eating Disorders: Overview 2 • Several family and twin studies are suggestive of a high heritability of anorexia and bulimia and researchers are searching for genes that confer susceptibility to these disorders • Scientists suspect that multiple genes may interact with environmental and other factors to increase the risk of developing these illnesses. Identification of susceptibility genes will permit the development of improved treatments for eating disorders

4. Eating Disorders: Prevalence • Frequently develop during adolescence or early adulthood, but can occur during childhood or later in adulthood • Approximately 1% of adolescent girls develop anorexia nervosa. • Approximately 2-3% of young women develop bulimia nervosa. • Two percent of adults suffer from binge eating disorder. • 90% of those with eating disorders are adolescent & young women. • Bulimia is as high as 15% in college aged women. • Although the common perception is that eating disorders are most prevalent among white, upper middle class young women, recent research indicates that of those who suffer from eating disorders: • 1 in 5 are poor • 1 in 4 are non-white • teenagers with asthma, attention deficit disorder, diabetes, and other chronic illnesses are reported to experience eating disorders 2 to 4 times more often

5. Eating Disorders and Males • 5-10% of eating disorders occur among males • Men more frequently use excessive and obsessive exercise and body-building prior to and during their eating disorder • Issues relating to sexuality and gender identity are sometimes associated with male eating disorders and there appears to be a higher rate of eating disorders among gay males • Men may be less likely to seek treatment for an eating disorder because of the social stigma of have a problem that has generally been perceived as a "woman's problem." • The signs, symptoms and treatment needs of eating disorders in males are similar to those of women

6. Anorexia: Prevalence • Onset is usually in adolescence and affects females 10:1 over males. Prevalence in young women is up to 1% • Some will have episodes of binge eating or purging. Anorexia is a life-threatening disorder, with mortality over 10% • An estimated 0.5 to 3.7 percent of females suffer from anorexia nervosa in their lifetime

7. Bulimia: Prevalence • An estimated 1.1 percent to 4.2 percent of females have bulimia nervosa in their lifetime

8. Risk factors • Biological • Genetic predisposition • Hypothalmic dysregulation/dysfuntion • Seratonin deficits

9. Other Risk Factors • Family/environment • Abuse • overcontrolling • Personality • Perfectionism • Compliance • Inhibition • Neuroticism/anxiety • Low self-esteem • Depression • Poor introceptive awareness

10. Anorexia Complications • Dehydration • Changes in metabolism & reduced energy • Dry skin/sallow complexion • Growth of fine hair over body and face • Purple nail beds and cold extremities • Dizziness, low blood pressure, fainting • Anemia • Tooth decay • Osteoporosis • Gastrointestinal Complications • Hypoglycemia/hypothermia • Kidney/pancreas failure • Endocrine dysregulation • Cardiac problems/ heart failure

11. Bulimia Complications • Electrolyte abnormalities • Dehydration/kidney disease • Reduction of blood calcium • Tooth decay/enamel erosion • Digestive and intestinal problems • Muscle spasms and headaches • Colon abnormalities • Abnormal thyroid hormone and growth • Bleeding and infection of the throat • Enlargement of lymph or salivary glands • Pancreatic disease

12. Anorexia: General Features • Intense fear of gaining weight • Belief that they are fat, but actually very thin • Restriction of calories • Avoids social situations where s/he may have to eat in front of others • Unusual eating habits or rituals • Obsessive or compulsive exercise • Hyperactivity or fatigue • Isolation from friends and family

13. Bulimia: General Features • Fear of being fat • Eats in secret • Uses bathroom immediately after meals • Purges foods in many different ways • Hoards food • Mood swings • Abuse of alcohol or other substances • Over-exercising • Isolation from friends and family

14. Anorexia: DiagnosisSymptom 1 • Refusal to maintain body weight at or above a minimally normal weight for age and height (85%)

15. Anorexia: DiagnosisSymptom 2 • Intense fear of gaining weight, even though underweight

16. Anorexia: DiagnosisSymptom 3 • Disturbance in the way in which one's body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, denial of seriousness of current low body weight.

17. Anorexia: DiagnosisSymptom 4 • In postmenarcheal females, amenorrhea, i.e., the absence of at least three consecutive menstrual cycles

18. Anorexia: DiagnosisSubtypes • Restricting type: • During the current episode of anorexia nervosa, the person has not regularly engaged in binge-eating or purging behavior (i.e., self-induced vomiting or the misuse of laxatives, diuretics or enemas) • Binge-eating/purging type: • During the current episode of anorexia nervosa, the person has regularly engaged in binge-eating or purging behavior (i.e., self-induced vomiting or the misuse of laxatives, diuretics or enemas).

19. Bulimia: DiagnosisSymptom 1 • Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following:  • eating, in a discrete period of time (e.g., within any 2-hour period), an amount of food that is definitely larger than most people would eat during a similar period of time and under similar circumstances • a sense of lack of control over eating during the episode (e.g., a feeling that one cannot stop eating or control what or how much one is eating) 

20. Bulimia: DiagnosisSymptom 2 • Recurrent inappropriate compensatory behavior in order to prevent weight gain, such as self-induced vomiting; misuse of laxatives, diuretics, enemas, or other medications; fasting; or excessive exercise. 

21. Bulimia: DiagnosisSymptom 3 • The binge eating and inappropriate compensatory behaviors both occur, on average, at least twice a week for 3 months. 

22. Bulimia: DiagnosisSymptom 4 • Self-evaluation is unduly influenced by body shape and weight. 

23. Bulimia: DiagnosisSymptom 5 • The disturbance does not occur exclusively during episodes of Anorexia Nervosa. 

24. Bulimia: DiagnosisSpecific Type • Purging Type: during the current episode of Bulimia Nervosa, the person has regularly engaged in self-induced vomiting or the misuse of laxatives, diuretics, or enemas • Nonpurging Type: during the current episode of Bulimia Nervosa, the person has used other inappropriate compensatory behaviors, such as fasting or excessive exercise, but has not regularly engaged in self-induced vomiting or the misuse of laxatives, diuretics, or enemas

25. Binge Eating Disorder: Overview • A newly recognized eating disorder characterized by frequent episodes of uncontrolled overeating. • The prevalence of binge eating disorder in the general population is still being determined. Researchers estimate that approximately 25% of obese individuals suffer from frequent episodes of binge eating (Fairburn, 1998). • Binge eating disorder affects women slightly more often than men--estimates indicate that about 60% of people struggling with binge eating disorder are female, 40% are male (NIH, 1993). • People who struggle with binge eating disorder can be of normal or heavier than average weight. • Many people who suffer from binge eating disorder have a history of depression (NIH, 1993). • People struggling with binge eating disorder often express distress, shame, and guilt over their eating behaviors.

26. Binge Eating Disorder: Diagnosis • Frequent episodes of eating large quantities of food in short periods of time often secretly, without regard to feelings of “hunger” or “fullness.” • Frequently feeling of “out of control” during binges • Eating large quantities of food rapidly, w/o tasting • Eating alone • Feelings of shame, disgust, or guilt after a binge • Binge eating disorder often results in some of the health risks associated with clinical obesity

27. Assessment Measures • EDE: Eating Disorder Evaluation • Structured Clinical Interview • EAT: Eating Attitudes Test (Garner) • EDI: Eating Disorders Inventory (Garner) • Comprehensive eating disorders scale • BULIT- Bulimia Test (Thalen) • Assesses all aspects of bulimia and some anorexia • BES- Binge Eating Scale (Gormally) • Primarily for binge eating in obese individuals • COEDS- College Oriented Eating Disorders Scale (Nowak)

28. Gambling Assessment

29. Gambling: Overview • Problem gambling is: • gambling behavior which causes disruptions in any major area of life: psychological, physical, social or vocational • The term "Problem Gambling" includes, but is not limited to, the condition known as "Pathological", or "Compulsive" Gambling, a progressive addiction characterized by increasing preoccupation with gambling, a need to bet more money more frequently, restlessness or irritability when attempting to stop, "chasing" losses, and loss of control manifested by continuation of the gambling behavior in spite of mounting, serious, negative consequences.

30. Gambling: Stats 1 • Some form of gambling legal in every state but Utah & Hawaii • In 1992, 54% of Americans purchased a lottery ticket, and 25% of them were in a weekly habit. • 24 states have casinos, and 37 have state lotteries • In 1996, $2.5 billion dollars was bet legally in the U.S. an estimated $90 billion illegally. • Of all college athletes, 25% of them bet, 4% on own games • The odds of winning the average lottery: 1 in 5 million • The odds of getting struck by lightning: 1 in 600,000 • Vegas expects 30,300,000 visitors this year.

31. Gambling: Stats 2 • Nevada Casinos won $7.52 billion dollars in fiscal 1996 That's 5.2% higher than 1995 • Two out of three casino visitors in Mississippi are out of staters • In 1993, 92 million people visited casinos. • Legal Gambling revenues $30 billion dollars a year, more than movies, books, music, and arcades combined • 95% of all people live within 4 hrs of a casino • In 1988, this is the amount spent on lottery tickets per person. New York- $91.17 Pennsylvania- $121.48 New Jersey- $152.07 Conneticut- $158.53 Massachusets- $234.92 • On average, gamblers are 47 years old, and their hoseholds visit casinos 3.9 times a year, and wager $25-100 per visit

32. Gambling: Prevalence • Gambling exposure/access greatly increased • Estimates suggest between 1 and 1.5 percent of the population could be classified as pathological gamblers (DSM-IV) • Another 3% have some gambling problems • Pathological gambling may be as high as 5% in adolescents and college students • Higher rates and earlier onset in males

33. Pathological Gambling: Diagnosis – DSM-IV • Placed within the impulse controls disorders section of the DSM • Persistent and maladaptive gambling behavior indicated by 5 or more of the characteristics mentioned on the following slides

34. Pathological Gambling: Diagnosis – DSM-IV (1-5) • is preoccupied with gambling • needs to gamble with increasing amounts of money in order to achieve the desired excitement • has repeated unsuccessful efforts to control, cut back, or stop gambling • is restless or irritable when attempting to cut down or stop gambling • gambles as a way of escaping from problems or of relieving a dysphoric mood: (ex. helplessness, guilt, anxiety, depression)

35. Pathological Gambling: Diagnosis – DSM-IV (6-10) • after losing money gambling, often returns another day to get even ("chasing" one's losses) • lies to family members, therapist, or others to conceal the extent of involvement with gambling • has committed illegal acts such as forgery, fraud, theft, or embezzlement to finance gambling • has jeopardized or lost a significant relationship, job, or educational or career opportunity because of gambling] • relies on others to provide money to relieve a desperate financial situation caused by gambling

36. Gambling Assessments 2 • Gamblers Anonymous 20 Questions (GA-20): A list of 20 questions devised by Gamblers Anonymous to help individuals decide if they have a gambling problem. According to GA, most people with gambling problems will answer "yes" to at least seven of the 20 questions. The questions have not been scientifically validated.

37. Gambling Assessments 3 • South Oaks Gambling Screen (SOGS): A series of questions used to determine the presence of a gambling problem. Developed by Henry Lesieur and Sheila Blume of the South Oaks Psychiatric Hospital, the instrument consists of 20 items, with a score of five or higher considered evidence of pathological gambling. The South Oaks Gambling Screen has been the most widely used instrument in assessing the prevalence of pathological gambling among the general public, though it has not been specifically validated for that use. • SOGS-RA: A modified version of the South Oaks Gambling Screen used in assessing adolescents.

38. Gambling Assessments • NORC DSM Screen for Gambling Problems (NODS): A structured interview used to determine the prevalence of problem gambling in a population • The NODS consists of 17 questions designed to reflect the DSM-IV criteria and was devised by the National Opinion Research Center (NORC) for the 1999 National Survey of Gambling Behavior • The NODS classifies respondents as non-gamblers, low-risk (gamblers with no adverse effects), at-risk (gamblers meeting one or two of the DSM criteria), problem (gamblers meeting three or four criteria), and pathological (gamblers meeting five or more criteria)

39. Gambling Terms • Bad beat: A run of bad luck. • Bailout: Money given to a gambler that allows them to pay debts without suffering adverse consequences. • Chasing: Attempt to make up previous losses through additional gambling, a common symptom of a pathological gambler. It involves larger bets and/or greater risks. • Controlled gambling: A theory of treatment for pathological gambling in which the patient is allowed to gamble on a limited basis. Controlled gambling currently has few adherents in North America but is somewhat more popular overseas • Gam-Anon: A fellowship for the families of pathological gamblers with chapters throughout North America.

40. Gambling Types 1 • Disordered gambling: A term coined by Howard Shaffer, Matthew Hall, and Joni Vander Bilt in 1997 to encompass the range of pathological, problem and excessive gambling. • level 1: no gambling problems • level 2: problems that do not meet the criteria for pathological gambling • level 3: pathological gamblers.

41. Gambling Types 2 • Social gambler • Gamblers who exhibit few or none of the difficulties associated with problem or pathological gambling • Social gamblers will gamble for entertainment, typically will not risk more than they can afford, often gamble with friends, chase losses briefly, gamble for limited periods of time • Not preoccupied with gambling

42. Gambling Types 3 • Professional gambler • One who gambles as way to make part/all of living • Often confused with pathological gamblers, professional gambling is characterized by limited risks, discipline, and restraint, items all lacking in the pathological gambler. • Professional gamblers wager on games with skill elements rather than games of chance, and wait to bet until the odds are more in their favor. • Can lose control and exhibit chasing behavior, at which time they become problem or pathological

43. Chapter 9 • Motivational Style • Ambivalence • Confrontational / Denial Trap • Locus of change • Process of Change • Locus of change • Possibility of change • Empathy • Support • Motivational Techniques • Practical matters • Discrepancy • Menu of options