Transcript Dennis, M.L., Scott, C.K., Funk, R., & Foss, M.A. (2005

Multifinality: Same underlying
cause, different disorders.
Jeremiah Weinstock, PhD
OPG Summit 2014
Berkeley, CA
Workshop Outline
1. Defining multifinality and its
application to psychiatric
disorders.
2. Common risk factors for gambling
disorder and other psychiatric
disorders.
3. Treatment implications of
multifinality
A Related Concept: Equifinality
Several pathways to the same outcome.
Behaviorally
Conditioned
Emotionally
Vulnerable
Classical and
Operant
Conditioning
Gambling
Disorder
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.
Social Anxiety
Disorder
EXAMPLE:
Perfectionism
Anorexia
Nervosa
Major
Depression
However, context and expression of the underlying
factor varies across disorders.
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.
Gambling Disorder
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:
1. Early maladaptive schemas
2. 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:
3. Gambling at a slot machine is one method to
cope with one’s emotions. It is a way to
dissociate.
4. 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
Prevalence Rate (%)
Within gambling disorder, the lifetime prevalence rates
of other disorders are:
100
80
60
40
20
0
Alcohol Use
Disorder
Mood Disorder Anxiety Disorder
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
[email protected]
314.977.2134