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Assessment and Treatment of Addictive Behaviors Carl W. Lejuez, PhD. Lecture 8 Gambling and Eating Disorders Treatment. Gambling. Behavior Therapy. Gambling is a learned behavior Operant: Triggered by gambling related discriminative stimuli Reinforced over time through:

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Assessment and treatment of addictive behaviors carl w lejuez phd l.jpg

Assessment and Treatment of Addictive BehaviorsCarl W. Lejuez, PhD

Lecture 8

Gambling and Eating Disorders Treatment

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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 urges…So, 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 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

    • Petry video

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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

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    Additional Treatment

    • Current Therapy Critique


    • Overeating Treatment