Multifinality: Same underlying cause, different disorders. Jeremiah Weinstock, PhD OPG Summit 2014...
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Transcript of Multifinality: Same underlying cause, different disorders. Jeremiah Weinstock, PhD OPG Summit 2014...
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Multifinality: Same underlying cause, different disorders.
Jeremiah Weinstock, PhD OPG Summit 2014
Berkeley, CA
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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
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A Related Concept: Equifinality Several pathways to the same outcome.
Behaviorally Conditioned
Emotionally Vulnerable
Antisocial & Impulsivity
Gambling Disorder
Pathways ModelBlaszczynski & Nower
(2002)
Classical and Operant
Conditioning
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What is MultifinalitySame underlying factor can lead to several different psychological outcomes.
DisorderA
Disorder B
DisorderC
Underlying Factor
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What is MultifinalitySame underlying factor can lead to several different psychological outcomes.
EXAMPLE:
However, context and expression of the underlying factor varies across disorders.
Social Anxiety Disorder
Anorexia Nervosa
Major Depression
Perfectionism
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MultifinalityExplains 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.
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MultifinalityLeads 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.
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Gambling DisorderNot 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.
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Multifinality: Underlying ProcessesHow can we think about these processes?
Distal Risk Factors
Nolen-Hoeksema & Watkins, 2011
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Multifinality: Underlying ProcessesHow can we think about these processes?
Proximal Risk Factors
Distal Risk Factors
Nolen-Hoeksema & Watkins, 2011
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Multifinality: Underlying ProcessesHow can we think about these processes?
Proximal Risk Factors
Distal Risk Factors
Addiction Disorders
Antisocial Personality
Disorder
Generalized Anxiety Disorder
Nolen-Hoeksema & Watkins, 2011
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Multifinality: Underlying ProcessesHow can sexual abuse lead to antisocial personality disorder?
Poor Attachment
Sexual Abuse as a child
Antisocial Personality
Disorder
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Multifinality: Underlying ProcessesHow can sexual abuse lead to addiction?
Copes by dissociation
Sexual Abuse as a child
Addiction Disorders
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Multifinality: Underlying ProcessesHow can sexual abuse lead to generalized anxiety disorder?
Hypervigilence for threats
Sexual Abuse as a child
Generalized Anxiety Disorder
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Gambling & AbuseChildhood 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
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Gambling & AbuseChildhood 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
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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
Alcohol U
se Diso
rder
Mood Diso
rder
Anxiety
Disord
er0
30
60
90
Prev
alen
ce R
ate
(%)
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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.
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Gambling Disorder & MoodHow 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
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Gambling Disorder & AnxietyA 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
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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
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Limitations of DSM-5The 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.
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Integrated TreatmentsIn 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
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Integrated Treatments
Korman et al., 2008;
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Integrated TreatmentsIn 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;
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Next Steps for Clinical PracticeDo 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
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SummaryMultifinality 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.