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

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Assessment and Treatment of Addictive
BehaviorsCarl W. Lejuez, PhD

• Lecture 10
• Gambling and Eating Disorders Treatment

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Gambling
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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

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Behavior Therapy Approach

• Techniques include
• Aversion therapy
• Behavioral monitoring
• Contingency management
• Relaxation training
• Exposure
• Desensitization or flooding
• Imaginal
• in vivo

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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

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Problem Solving Approach

• Gambling is due to urgesSo, goal is to
• Redirect with alternative coping strategies
• Sounds like what???

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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

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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?

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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

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Pharmacological Treatment

• Neurotransmitter studies suggest that deficits in
  seratonin, dopamine, and norepinepherine all
  contribute to gambling vulnerability
• Preliminary evidence for the efficacy of SSRIs
  (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

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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

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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

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Eating Disorders
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Pharmacological Treatment

• Primarily anti-depressant medication
• Tricyclics
• Imipramine
• desipramine
• MAO inhibitors
• SSRIs

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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

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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

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Co-Morbid Conditions

• Depression
• Anxiety
• Substance Use
• Personality Disorders
• Consensus that Eating Disorders are primary
  disorders and not simply the result of other
  conditions

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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

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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

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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

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3 stages of Treatment

• Stage 3
• Relapse prevention
• Identifying triggers
• Dealing with lapses
• Continuing to work on new lifestyle

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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