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

1. Assessment and Treatment of Addictive BehaviorsCarl W. Lejuez, PhD Lecture 7 Gambling and Eating Disorders Treatment

2. Gambling

3. Behavior Therapy • Gambling is a learned behavior • Operant: • Triggered by gambling related discriminative stimuli • Reinforced over time through: • brief positive outcomes it provides (e.g., excitement from winning, escape from life stressors) • Lack of positive reinforcement for behaviors unrelated to gambling • Pavlovian/classical conditioning: • Arousal conditioned over time

4. Behavior Therapy Approach • Techniques include: • Aversion therapy • Behavioral monitoring • Contingency management • Relaxation training • Exposure • Desensitization or flooding • Imaginal • in vivo

5. Systematic Desensitization • In-vivo or Imaginal • Create list of specific triggers • Often starts from least arousing to most arousing • Standard muscle relaxation techniques • Experience/Imagine trigger and use relaxation • Some evidence of effectiveness • Has best evidence of success

6. Problem Solving Approach • Gambling is due to urges…So, goal is to: • Redirect with alternative coping strategies • Sounds like what???

7. Cognitive Therapy: Ladouceur • Gamblers continue because they maintain an unrealistic hope that they will recover losses if they continue to gamble • Maintained by erroneous beliefs about gambling: • predictability regarding the gamble • own skills maintain gambling • So, corrections of misperceptions should decrease belief that losses can be recouped • Based on researcher showing a range of cognitive errors by gamblers relating to their gambling • randomness

8. Correction of Randomness • Patient asked to describe how they first began gambling • How has you gambling changed • What extent do you have control over games • What does the patient say to themselves when gambling • Are they using information to “predict” results • Gamblers fallacy? • Why did you place one bet over another • How did you determine what to bet • In a game of chance, would you be willing to have your bet randomly determined?

9. Intervention Phase • Cognitive Correction • Identify erroneous perceptions • Evaluate and challenge adequacy of perceptions • Replace inadequate cognitions • Assess belief in new cognitions • Other components • Problem solving • Social Skills Training • Relapse Prevention (Marlatt) • Identify high risk situations • Develop ways to cope with high risk situations

10. Pharmacological Treatment • Neurotransmitter studies suggest that deficits in seratonin, dopamine, and norepinepherine all contribute to gambling vulnerability • Preliminary evidence for the efficacy of SSRI’s (fluvoxamine) and opioid antagonists (naltrexone) in the treatment of pathological gambling • 16 patients were placed in an 8-week placebo phase and then treated with fluvoxamine for the next 8 weeks, with the subjects blind to when they were taking the placebo or fluvoxamine. The authors reported that of the 10 subjects who completed the study, 7 showed improvement • Eighty three pathological gamblers entered a 1 week single-blind placebo followed by an 11 week double-blind placebo or naltrexone treatment. Greater improvement in drug condition • Patients who had stronger urge symptoms responded better to naltrexone treatment

11. Case Study • Peter 43 y/o married w/ 2 children • Video poker for 4 years • Initial win of $125, followed by losses • Played 3x/wk, losses of about $400/wk • Neglected wife and children • Kept truth from family • Confronted at work due to decreased productivity

12. Treatment for Peter • Identification and correction of faulty cognitions • Imagine last gambling session • Left work and went to gamble instead of going home • Did it without even thinking about it • Asked to think about what was going on • Had seen list of unpaid bills • Felt panic • Belief that the best way to get the $$$ was to gamble • Supplemented with problem solving, social skills training, and relapse prevention

13. Eating Disorders

14. Pharmacological Treatment • Primarily anti-depressant medication • Tricyclics • Imipramine • desipramine • MAO inhibitors • SSRIs

15. Treatment Context • Setting • Individual outpatient most common • Inpatient is not recommended unless: • Risk of suicide and/or severe depression • Compelling medical condition • Outpatient treatment has not worked

16. Treatment Context • Therapist variables • Gender of therapist unrelated to treatment success • Caring, nonthreatening, and informed therapist likely most effective • Should have knowledge of: • Biological factors • nutrition and weight regulation • Co-occurring symptoms/disorders

17. Co-Morbid Conditions • Depression • Anxiety • Substance Use • Personality Disorders • Consensus that Eating Disorders are primary disorders and not simply the result of other conditions

18. Process of Treatment • Most based in cognitive-behavioral theory • Fairburn (1985) • First detailed Eating Disorders CBT manual • About 20 weeks of treatment • 3 stages of treatment

19. 3 stages of Treatment • Stage 1 • Education • Introduction to importance of cognitions • Discussion of structure and goals • Nutrition information and planning • Core behavioral techniques introduced • Self-monitoring • Functional analysis • Stimulus control

20. 3 stages of Treatment • Stage 2 • Increasingly cognitive focus • Reduction of dietary restraints • Further development of coping skills • Dysfunctional cognitions are challenged with behavioral experiments

21. 3 stages of Treatment • Stage 3 • Relapse prevention • Identifying triggers • Dealing with lapses • Continuing to work on new lifestyle

22. CBT Treatment Outcome • Treatment leads to clinically significant: • Reductions in Binging • Reductions in Purging • Reductions in Dietary restraint • Improved body image • Fairburn et al., 1993 • 90% decline in ED behavior 1 year post tx • 36% in complete remission • Concurrent reduction in other conditions • Mood, self-esteem, substance use