Using the Millon Behavioral Medicine Diagnostic (MBMD) in Bariatric Surgery

Using the in Bariatric Surgery Using the Millon Behavioral Medicine Diagnostic () in Bariatric Surgery Michael Antoni, Ph.D. Anne-Marie Kimbell, Ph.D. Topics 1. Psychosocial testing in bariatric surgery. 2. The and its use with patients for bariatric surgery. 3. Using data from the to identify patient assets and liabilities. Copyright 2017. Pearson Inc., and/or its affiliates. All rights reserved, 1

Using the in Bariatric Surgery Trends in Prevalence of Obesity and Severe Obesity (Youth and Adult) 45.0 40.0 35.0 30.0 25.0 20.0 15.0 10.0 5.0 0.0 Overall Percent 39.6 37.7 35.7 33.7 34.9 18.5 16.8 16.9 16.9 17.2 7.7 7.7 4.9 5.7 5.6 6.3 5.6 6.4 6 5.6 2007-2008 2009-2010 2011-2012 2013-2014 2015-2016 Obesity Youth Severe Obesity Youth Obesity Adult Severe Obesity Adult https://jamanetwork.com/journals/jama/fullarticle/2676543 Trends in Bariatric Surgery 250,000 Estimate of Bariatric Surgery Numbers 216,000 200,000 150,000 158,000 173,000 179,000 193,000 196,000 100,000 50,000 0 2011 2012 2013 2014 2015 2016 https://asmbs.org/resources/estimate-of-bariatric-surgery-numbers Copyright 2017. Pearson Inc., and/or its affiliates. All rights reserved, 2

Using the in Bariatric Surgery Psychosocial Factors That Predict Bariatric Surgery Outcomes Factor Optimal Outcomes Negative Outcomes Outlook Positive (Optimism) Negative (Pessimism) Coping Positive (Active, Planning, Independence) Negative (Denial, Dependency) Support Social Support Social Isolation Health Behaviors Health Promoting Behaviors (Exercise) Health-Defeating Behaviors (Non- Adherence, Substance Abuse) Psychiatric Issues and Stress-Related Conditions Some Factors Associated with Bariatric Surgery Sequelae Medical Co-Morbidities Advanced Age Surgical Volume at Institution Copyright 2017. Pearson Inc., and/or its affiliates. All rights reserved, 3

Using the in Bariatric Surgery Psychosocial Factors Associated with Bariatric Surgery Post-Surgical Behaviors Prior history of binge eating Prior history of compliance problems Disturbances of body image Psychiatric Conditions (e.g., depression) Personality Factors (Stress Intolerance; Acting-Out) NIH has promoted development of guidelines for predicting postsurgical behaviors (LeMount, Moorhead, Parish, Reto & Ritz, 2004) Paucity of Theoretically-Driven Pre- Surgical Psychosocial Evaluations Most use homemade combinations of psychological interviews and tests. No guidelines for decision making based on theory-driven algorithms. Most tests not normed on medical patients and NONE normed on Bariatric patients. Copyright 2017. Pearson Inc., and/or its affiliates. All rights reserved, 4

Using the in Bariatric Surgery GUIDELINES: Psychological Assessment in Bariatric Surgery Candidates (ASBS, 2004) Content Areas Behavioral Eating behavior and physical activity Alcohol and substance use Cognitive and Emotional Cognitive functioning Coping skills and emotional modulation Psychiatric issues and psychopathology Current Life Situation Stressors Social Support Motivation and Expectations Adherence Testing Issues Clinical Rationale (enhance interview, objective data reduce liability) Test Selection Criteria (relevance, validity, reliability, specific norms) Test Options (multi-scale, single-scale, specific to BS) Actual Practices in 2004 (Survey of 188 surgery programs in ASBS registry) 40% did not use PSY test 86% of programs required PSY screen 50% measured PSY symptoms only (depression) 33% measured personality Copyright 2017. Pearson Inc., and/or its affiliates. All rights reserved, 5

Using the in Bariatric Surgery Actual Practices in 2004 (Survey of 188 surgery programs in ASBS registry) Major psychopathology (schizoid, bipolar) Decisions made using: History of suicide attempts Active binge-eating disorder History of medical noncompliance No algorithm exists for use of Psy Tests (Bauchowitz et al., 2005 Psychosomatic Medicine) : A Psychosocial Assessment Copyright 2017. Pearson Inc., and/or its affiliates. All rights reserved, 6

Using the in Bariatric Surgery What is the? A multidimensional assessment designed to help clinical and health psychologists and medical professionals identify psychosocial factors that may support or interfere with a patient's course of medical treatment. Model Psychosocial characteristics and their relationship to multiple aspects of health maintenance and healthcare delivery as predictors of healthcare outcomes. Psychiatric Indications Coping Styles Stress Moderators Negative Health Habits Health Maintenance Health Care Delivery Health Outcomes Copyright 2017. Pearson Inc., and/or its affiliates. All rights reserved, 7

Using the in Bariatric Surgery Seven Domains Response Patterns (3 scales) Negative Health Habits (6 scales) Psychiatric Indications (5 scales) Coping Styles (11 scales) Stress Moderators (6 scales) Treatment Prognostics (5 scales) Management Guides (2 scales) Validity Indicator and Response Patterns Scale V Validity Description Provides information about the validity of the profile. X Y Z Disclosure Desirability Debasement Measures patient s tendency to be overly frank and self-revealing, or hesitant to share personal information. Measures patient s tendency to present self in favorable manner. Measures patient s tendency to present self in unfavorable manner. Copyright 2017. Pearson Inc., and/or its affiliates. All rights reserved, 8

Using the in Bariatric Surgery Negative Health Habits Scale Description N Alcohol Presence of alcohol-consumption problem. O Drug Greater use of non-prescription drugs and possible dependency. P Eating Problem with chronic overconsumption. Q R S Caffeine Inactivity Smoking Assesses if patient s consumption of caffeine is excessive. Notes if patient engages in physical exercise on a regular basis. Smokes tobacco-containing products on a regular basis. Psychiatric Indications Scale AA BB CC DD EE Anxiety/ Tension Depression Cognitive Dysfunction Emotional Lability Guardedness Description Assesses patient s level of anxiety and tension. Focuses on patient s vegetative or mood state. Assesses patient s capacity to recall past experiences, to think abstractly, and to represent events and interrelate and process them symbolically. Looks at dysregulation of affect and irritability in moods. Assesses patient s level of mistrust and defensiveness Copyright 2017. Pearson Inc., and/or its affiliates. All rights reserved, 9

Using the in Bariatric Surgery Coping Styles Scale Coping Style Non-Psychiatric Aspects of DSM Disorder 1 Introversive Schizoid 2A Inhibited Avoidant 2B Dejected Depressive 3 Cooperative Dependent 4 Sociable Histrionic 5 Confident Narcissistic 6A Nonconforming Antisocial 6B Forceful Sadistic 7 Respectful Compulsive 8A Oppositional Negativistic 8B Denigrated Masochistic Coping Styles and Millon s Personality Theory Self-Other Self (low) Other (high) Dependent Personalities Self (high) Other (low) Independent Personalities C o p i n g S t y l e s Passive Cooperative Confident Active Sociable Oppositional Copyright 2017. Pearson Inc., and/or its affiliates. All rights reserved, 10

Using the in Bariatric Surgery Stress Moderators Scale A B C D E F Illness Apprehension vs. Illness Acceptance Functional Deficits vs. Functional Competence Pain Sensitivity vs. Pain Tolerance Social Isolation vs. Social Support Future Pessimism vs. Future Optimism Spiritual Absence vs. Spiritual Faith Description Patients focus on and awareness of changes in their bodies. Patients perception that they are unable to perform activities of daily living. Patients tendency to be overly sensitized and reactive to mild to moderate pain. Patients perception of social supports in their lives. Patients outlook toward their future health status. Degree to which patients lack religious or spiritual resources for dealing with the stressors and fears of the medical condition. Treatment Prognostics Scale G Interventional Fragility vs. Interventional Resilience Description Predicts whether patients will be able to adjust emotionally to the demands of physically and psychologically stressful protocols. H I Medication Abuse vs. Medication Conscientiousness Information Discomfort vs. Information Receptivity Predicts likelihood that patients will have problems with or will misuse prescribed medication. Assesses a patient s lack of receptivity to specific details about diagnostic, prognostic, and treatment procedures and outcomes. Copyright 2017. Pearson Inc., and/or its affiliates. All rights reserved, 11

Using the in Bariatric Surgery Treatment Prognostics Scale J Utilization Excess vs. Appropriate Utilization Description Assesses the likelihood that a patient will use medical services more than the average patient with a similar medical condition. K Problematic Compliance vs. Optimal Compliance Identifies patients who resist following medical recommendations. Management Guide Scale L M Adjustment Difficulties Psych Referral Description Assesses the risk of treatment complications. Indicates whether the patient might benefit from psychosocial intervention. Copyright 2017. Pearson Inc., and/or its affiliates. All rights reserved, 12

Using the in Bariatric Surgery Bariatric Norms Bariatric Surgery Patient Norms From 2005 2006, data collected on bariatric surgery patients from surgery sites across U.S. Used to develop bariatric-specific norms. New bariatric norms along with new scoring and interpretation software released in 2006. Reports designed to emphasize physical and emotional differences between bariatric and general medical population patients. Copyright 2017. Pearson Inc., and/or its affiliates. All rights reserved, 13

Using the in Bariatric Surgery Bariatric Surgery Patient Norms Sample Demographics 711 pre-screened bariatric surgery candidates from six geographically diverse regions in US 585 females (82.2%) 126 males (17.8%) Age 19 68 (Mean = 39 years) Bariatric Surgery Patient Norms Sample Demographics Height: 54 75 (mean = 65 ) Weight: 181 572 lbs (mean = 296 lbs) BMI: 31 84 (mean = 48) Race: White (65%), Hispanic (19%), AA (8%) Marital Status: Married (54%), Single (23%), Divorced (10%) Copyright 2017. Pearson Inc., and/or its affiliates. All rights reserved, 14

Using the in Bariatric Surgery Characteristics of the Bariatric Sample Major Disease Groups Disease Group n % Accident/Injury 7 1 Arthritis 33 5 Depression 20 3 Diabetes 57 8 Female (OB/GYN) 6 1 Headaches 3 <1 Heart Disease 12 2 Pain 35 5 Stress/Nerves 2 <1 Other 211 30 Not Reported 325 46 Total 711 Bariatric Surgery Patient Norms: General Findings Bariatric patients physically and emotionally different from others. More masochistic (Self-punitive, degrading) More concerned about illness More prohibited from doing desired activity More pain sensitive More pessimistic Exhibit more risky behaviors than general med patients These tendencies get reflected in score transformations. Copyright 2017. Pearson Inc., and/or its affiliates. All rights reserved, 15

Using the in Bariatric Surgery Theoretical Model to Guide Psychosocial Evaluation in Bariatric Surgery (Millon, 2006) Pre-Operative Factors Psychiatric Indicators Personality Coping Style Stress Moderators Negative Health Behaviors Treatment Prognostics Post-Operative Behaviors Binge Eating Following Nutritional Advice Starting Exercise Regimen Post-Operative Outcomes Surgical Recovery/ Complications Physical Target (Weight Loss and Maintenance) Longer-term Health Outcomes (CHD, DM) Processes That Influence Bariatric Surgery Outcomes Copyright 2017. Pearson Inc., and/or its affiliates. All rights reserved, 16

Using the in Bariatric Surgery Bariatric Summary PRESURGICAL INTERVENTION PATIENT BEHAVIOR POSTSURGICAL OUTLOOK POSTSURGICAL CARE PRESURGICAL INTERVENTION A. Before the decision to perform surgery is made: Is considered: 1. An additional psychosocial evaluation 2. A psychiatric consultation 3. Supportive psychosocial counseling 4. A pain management program Unnecessary Unnecessary Unnecessary Unnecessary Copyright 2017. Pearson Inc., and/or its affiliates. All rights reserved, 17

Using the in Bariatric Surgery PATIENT BEHAVIOR B. The likelihood that this patient will: Is classified as: 1. Be released from the hospital ahead of schedule 2. Change her unhealthy habits 3. Refrain from engaging in unhealthy eating behavior 4. Follow nutritional advice 5. Comply with a medical regimen 6. Maintain an exercise program 7. Maintain her postsurgical weight loss 8. Avoid long-term health complications 9. Refrain from taking legal action regarding her surgery Average High High Average Average Average High High High POSTSURGICAL OUTLOOK C. The likelihood that surgery will improve this patient s: 1. Overall quality of life 2. Psychosocial functioning 3. Body image 4. Physical health 5. Mental outlook 6. Sexual activity 7. Employment/vocational opportunities Is classified as: Good Good Good Good Good Good Good Copyright 2017. Pearson Inc., and/or its affiliates. All rights reserved, 18

Using the in Bariatric Surgery POSTSURGICAL CARE D The likelihood that this patient will benefit from a: 1. Physical rehabilitation program 2. Stress and/or sleep management course 3. Bariatric support group 4. Nutritional instruction plan Is classified as: Doubtful Doubtful Doubtful Doubtful PATIENT BEHAVIOR Post-Operative Behaviors: Early Hospital Release-Algorithm Early Hospital Release Predicted by: EE (- Guardedness) Coping Style (+Sociable, Confident, Respectful) Stress Moderators (- Func Deficit, Pain Sens) Tx Prognostics (- Int Fragility, Utilization Excess) Copyright 2017. Pearson Inc., and/or its affiliates. All rights reserved, 19

Using the in Bariatric Surgery POST-SURGICAL OUTLOOK Quality of Life: Algorithm Overall QOL: Psychiatric (- Depression, Emotional Lability) Coping Style (- Denigrated) Stress Moderators (- Func Deficit, Pain Sens, Social Isolation, Future Pessimism) Management Guide (- Psy Referral) POST-SURGICAL CARE Post-Surgical Treatment Suggestions: Algorithms Post-surgical physical rehabilitation program - Anxiety - Functional Deficit - Pain Sensitivity - Intervention Fragility Post-surgical stress management + Anxiety - Emotional Lability + Illness Apprehension - Intervention Fragility + Psy Ref Copyright 2017. Pearson Inc., and/or its affiliates. All rights reserved, 20

Using the in Bariatric Surgery Post-Surgical Treatment Suggestions: Algorithms Post-surgical bariatric support group + Anxiety + Depression - Inhibition + Dejection + Denigrated + Functional Deficit + Social Isolation - Future Pessimism + Adjustment Difficulties Post-surgical weight loss nutritional instruction - Introversion - Nonconforming - Oppositional - Intervention Fragility - Info discomfort - Problematic Compliance Interpretation Copyright 2017. Pearson Inc., and/or its affiliates. All rights reserved, 21

Using the in Bariatric Surgery Prevalence Score (PS) PS Interpretation/ Interpretive Benchmarks < 35 Asset 75-84 Moderate or Present Liability 85+ Marked or Prominent Liability. Interpretive Model A. Review Patient Information B. Analyze Modifying Indices C. Analyze Sections of Profile D. Integrate Profile 1. Medical condition 2. Clinical Observations and Interviews 3. Other test results 4. Background and demographics gender, age, etc. 1. Validity 2. Disclosure 3. Desirability 4. Debasement 1. Psychiatric Indications 2. Coping Styles 3. Stress Moderators 4. Treatment Prognostics 1. Analyze Patterns 2. Assess importance of minor score variations 3. Noteworthy Responses 4. Healthcare Provider Summary Copyright 2017. Pearson Inc., and/or its affiliates. All rights reserved, 22

Using the in Bariatric Surgery Case Study Female, Age 34 Somewhat anxious related to marital infidelity Obese Familial history of obesity: both parents and younger sister obese; 15-year-old daughter overweight Type 2 diabetes on oral medication Copyright 2017. Pearson Inc., and/or its affiliates. All rights reserved, 23

Using the in Bariatric Surgery Sample Report Name Female A Age 34 Gender F Race White Marital Status Married Education Bachelor s Degree Response Patterns and Negative Health Habits Copyright 2017. Pearson Inc., and/or its affiliates. All rights reserved, 24

Using the in Bariatric Surgery Summary The s bariatric norms can help determine a candidate s psychological suitability for surgery, assist patients in making significant lifestyle changes, and prepare medical staff to respond to patients likely reactions following surgery. Clinical Presentation Copyright 2017. Pearson Inc., and/or its affiliates. All rights reserved, 28

Using the in Bariatric Surgery Training Opportunities Online Training Available (earn up to 3 APA CE credits) www.pearsonclinical.com/ PearsonClinical.com/ Customer Support 800-627-7271 (USA) 866-335-8418 (Canada) Copyright 2017. Pearson Inc., and/or its affiliates. All rights reserved, 29