1. Multifinality: Same underlying cause, different disorders. Jeremiah Weinstock, PhD OPG Summit 2014 Berkeley, CA

2. 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

3. A Related Concept: Equifinality Several pathways to the same outcome. Behaviorally Conditioned Emotionally Vulnerable Antisocial & Impulsivity Gambling Disorder Pathways Model Blaszczynski & Nower (2002) Classical and Operant Conditioning

4. What is Multifinality Same underlying factor can lead to several different psychological outcomes. Disorder A Disorder B Disorder C Underlying Factor

5. What is Multifinality Same 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

6. 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.

7. 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.

8. 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.

9. Multifinality: Underlying Processes How can we think about these processes? Distal Risk Factors Nolen-Hoeksema & Watkins, 2011

10. Multifinality: Underlying Processes How can we think about these processes? Proximal Risk Factors Distal Risk Factors Nolen-Hoeksema & Watkins, 2011

11. Multifinality: Underlying Processes How can we think about these processes? Proximal Risk Factors Distal Risk Factors Addiction Disorders Antisocial Personality Disorder Generalized Anxiety Disorder Nolen-Hoeksema & Watkins, 2011

12. Multifinality: Underlying Processes How can sexual abuse lead to antisocial personality disorder? Poor Attachment Sexual Abuse as a child Antisocial Personality Disorder

13. Multifinality: Underlying Processes How can sexual abuse lead to addiction? Copes by dissociation Sexual Abuse as a child Addiction Disorders

14. Multifinality: Underlying Processes How can sexual abuse lead to generalized anxiety disorder? Hypervigilence for threats Sexual Abuse as a child Generalized Anxiety Disorder

15. 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

16. 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

17. 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

18. 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.

19. 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

20. 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

21. 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

22. 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.

23. 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

24. Integrated Treatments Korman et al., 2008;

25. 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;

26. 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

27. 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.

28. FOR MORE INFORMATION Jeremiah Weinstock, Ph.D. Department of Psychology Saint Louis University jweinsto@slu.edu 314.977.2134