From Last Class

1. Eating Disorders & Substance Use DisordersApril 2, 2014PSYC 2340: Abnormal PsychologyBrett Deacon, Ph.D.

2. From Last Class • Suicide • Body shape exercise results • Causes of eating disorders

3. Biomedical Model: F.E.A.S.T. http://www.feast-ed.org/ • “F.E.A.S.T. believes eating disorders are treatable biologically based brain illness.” • “Eating disorders are inherited illness: 50-80% of the risk is genetic.” • “The head of the US NIMH refers to anorexia nervosa as a brain disorder.” • “Brain chemistry, function, and structure are altered in eating disorder patients.”

4. Biological Influences • Politics of eating disorders • My experience at the 2012 Academy for Eating Disorders conference • Why might some people wish to emphasize the biological causes of EDs and minimize the psychosocial causes?

5. Politics and Biology of EDs • From a colleague: “…what you are seeing is a sort of biological backlash against what was an overly culturally based paradigm that stayed in force for too long and a societal perception that people with EDs are deliberately caught up in being overly vain and intense in their pursuit of the thin-ideal standard of female beauty and could just stop their disorder anytime they wanted by eating. So there is this sort of hope that biology can break this perception. I think it is just as foolhardy to go too far down the biological road as the cultural road - but pro-bio model people argue that this is necessary to counter such a long run of a cultural model (not a biopsychosocial model - but a pure cultural model). It's frustrating - because I think we are missing out on the lessons of other disorders.”

6. Treatment of Bulimia Nervosa • Cognitive-behavior therapy (CBT) • Education (medical consequences, ineffectiveness of purging for weight control) • No dieting – frequent, small meals • Modifying thoughts about body shape, weight, eating • Coping strategies for resisting binging and purging

7. Treatment of Disordered Eating • Using the exposure therapy for anxiety model with eating disorders • Basic principles: • Problem is cased by negative beliefs • Problem is maintained by maladaptive (safety) behaviors • Exposure to feared stimuli and elimination of avoidance behavior changes beliefs and improves the problem • These principles apply across anxiety disorders

8. Cognitive-Behavioral Conceptualization of Eating Disorders • “Core” Pathology • Overvaluation of weight & shape • Attempts to control weight and shape • Associated Features • Cognitive biases toward threat • Negative thoughts about eating, weight, & shape • Behaviors intended to prevent feared outcomes

9. Eating Disorder-Related Behaviors Body-Related Checking Comparing Reassurance-seeking Eating-Related Small bites, slow pace Excessive chewing Bizarre mixing Other oddities • Dietary Restraint • Avoiding high calorie foods • Skipping meals • “Calorie counting” • Compensatory • Purging • Laxatives/Diuretics • Over-exercising

10. The Take-Home Message: • Overvaluation of weight/shape takes many forms • “Unless I’m thin, no one will ever love me.” • “If I weigh more than 110 pounds, I won’t be successful.” • “If I ever ‘indulge’ in food, it means I lack self-discipline.” • “I can’t tolerate knowing my stomach isn’t perfectly flat.” • “I’ll lose control of my weight if I don’t closely monitor it.” • Eating Disorder-Related Behaviors MAINTAIN the core pathology of Eating Disorders

11. Change Behavior = Change Beliefs • “The most powerful way of achieving [belief] change is by helping patients make changes to the way that they behave and then analyzing the effects of these changes.” (Fairburn, 2008, p.27) • Behavioral Exercises (i.e. Exposure) • Patient is encouraged to: • Behave in a manner that is incongruent with overvaluing weight and shape • Comparing the results of these behaviors to predictions

12. Framework of the CBT Approach • 1.Identify behavioral changes that will facilitate belief change (hierarchy) • 2. Systematically guide patient in behavioral change • 3. Assess results of behavioral change in the short and long term

13. Treatment of Disordered Eating • What would exposure and the elimination of safety behaviors look like for a client with an eating disorder?

14. Treatment of Bulimia Nervosa • Medical treatment • Antidepressants – moderate reductions in binging and purging • Not effective when used alone in long-term • Confers no advantage to CBT alone

15. Treatment of Bulimia Nervosa • Psychological treatment • CBT is treatment of choice • Interpersonal psychotherapy – gains similar to CBT at longer-term follow-up

16. Treatment of Anorexia Nervosa • No effective medical treatment • Psychological treatment • Weight restoration – first and easiest goal to meet • Psychoeducation – food, weight, nutrition, health • Behavioral and cognitive interventions • Treatment often involves the family • Long-term prognosis – worse than bulimia

17. Substance Use Disorders I(Chapter 11)

18. A Few Questions… • Instead of discussing Substance Use Disorders, why aren’t we discussing Addictions? • What are the effects of chronic alcohol use? • What do doctors do with this information? • Is alcoholism a chronic, progressive disease that requires lifelong abstinence to overcome? Can alcoholics ever recover and become social drinkers without treatment?

19. Substance-Related Disorders • Levels of involvement with a substance • Use • Intoxication • Abuse (creates problems) • Dependence (addiction)

20. Substance-Related Disorders • Organization of DSM-IV substance-related disorders section: • Diagnostic criteria for substance abuse and substance dependence – same for use of all substances • Substance-specific diagnostic criteria for intoxication and withdrawal

21. DSM-IV Alcohol Abuse Criteria (> 1) • Have you ever missed a class or day of work, or done a bad job in class or at work, because you were drinking, or recovering from alcohol’s effects (e.g., a hangover)? • Have you ever driven a car or operated a machine while you were probably too drunk to drive? • Have you ever gotten into physical fights or bad arguments about your drinking? • Have you ever gotten into trouble with the law for your drinking?

22. DSM-IV Alcohol Dependence Criteria (> 3) • Have you found that when you started drinking, you ended up drinking much more than you were planning to? • Have you found that when you started drinking, you ended up drinking for a much longer period of time than you were planning to? • Have you ever tried unsuccessfully to cut down or stop drinking, or have you had a persistent desire to cut down or stop? • Have you spent a lot of time drinking or being hung over? • Have you had times when you would drink or use so often that you started to drink instead of spending time at hobbies or with your family or friends? • Has your drinking or using caused any psychological problems, like making you depressed or anxious, making it difficult to sleep, or causing blackouts?

23. DSM-IV Alcohol Dependence Criteria • Has your drinking ever caused a physical problem, or made a physical problem worse? • Have you found that you need to drink a lot more in order to get the feeling you wanted than you did when you first started drinking? • What about finding that when you drank or used the same amount, it had much less effect than before? • Have you ever had any withdrawal symptoms when you cut down or stopped drinking? • Have you ever started the day with a drink, or have you often drank to avoid experiencing withdrawal symptoms?

24. DSM-5: Substance Disorders • Diagnostic criteria: 2 or more of the following… • Larger or longer use than intended • Desire or unsuccessful efforts to control • Great deal of time spent regarding use • Craving/strong desire to use • Failure to fulfill major role obligations • Use despite social/interpersonal problems • Important activities given up or reduced • Use in physically hazardous situations • Continued use despite knowledge of problem • Tolerance • Withdrawal

25. DSM-5: Substance Disorders • Effects of consolidation of abuse and dependence on diagnostic prevalence? • Mewton et al. (2011): An evaluation of the proposed DSM-5 alcohol use disorder criteria using Australian national data • “Under DSM-5, the prevalence of alcohol use disorders would increase by 61.7% when compared with those diagnosed under DSM-IV. When investigating the most appropriate diagnostic threshold, the 3+ threshold maximized agreement between DSM-IV and DSM-5 diagnoses, and produced similar prevalence estimates to those yielded by DSM-IV.”

26. Alcohol: Facts and Statistics • In the United States • Most adults are light drinkers or abstainers • Over 50% of the U.S. (> 12 years age) report current use • 15 million Americans are alcohol dependent • 54 million (23%) binged in past month • Rates are highest among men, Caucasians, and Native Americans

27. Alcohol Use • Psychological and physiological effects • Sedative (depressant) effects • Euphoria (at lower doses) • Depresses inhibitory centers in brain • Lowers inhibitions • Affects cognitive and motor functions

28. Alcohol Use • What are the effects of chronic alcohol use?

29. Alcohol Use • Negative effects of chronic alcohol use • Tolerance and withdrawal • Liver disease, pancreatitis, cardiovascular disorders, brain damage • Fetal alcohol syndrome (more on this later) • Protection from heart disease (with mild-to-moderate use) • Positive effects of chronic, moderate alcohol use?

30. Alcohol in America • Differences in views of alcohol and its appropriate use • Is alcohol “good” or “bad?” • American ambivalence toward alcohol

31. Alcohol in America • “To alcohol – the cause of, and solution to, all of life’s problems.” – Homer Simpson

32. Letter to constituent from Congressman Billy Matthews detailing his stance on whiskey:“My dear friend, I had not intended to discuss this controversial subject at this particular time. However, I want you to know that I do not shun a controversy. On the contrary, I will take a stand on any issue at any time, regardless of how fraught with controversy it may be. You have asked me how I feel about whiskey. Here is how I stand on the issue:”

33. “If when you say whiskey, you mean the Devil's brew; the poison scourge; the bloody monster that defiles innocence, dethrones reason, destroys the home, creates misery, poverty, fear; literally takes the bread from the mouths of little children; if you mean the evil drink that topples the Christian man and woman from the pinnacles of righteous, gracious living into the bottomless pit of degradation and despair, shame and helplessness and hopelessness; then certainly, I am against it with all of my power.”

34. “But, if when you say whiskey, you mean the oil of conversation, the philosophic wine, the ale that is assumed when great fellows get together, that puts a song in their hearts and laughter on their lips, and the warm glow of contentment in their eyes; if you mean Christmas cheer; if you mean that stimulating drink that puts the spring in the old gentlemen's step on a frosty morning; if you mean the drink that enables the man to magnify his joy and his happiness and to forget, if only for a little while, life's great tragedies and heartbreaks and sorrows; if you mean that drink, the sale of which pours into our Treasury untold millions of dollars which are used to provide tender care for little crippled children, our blind, our deaf, our pitiful aged and infirm; to build highways, hospitals, and schools; then certainly, I am in favor of it. This is my stand, and I will not compromise.”