APA Bio-Psycho-Social and CBT Presentation by Skillings and Arnold

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This session sponsored by APA Division 38: Health Psychology For information about D38’s benefits and services for SCIENTISTS and

PRACTIONERS across the professional life span, Please visit our web site: www.health-psych.org

Combining the Biopsychosocial and CBT Models in Practice Jared L. Skillings, PhD, ABPP Kevin D. Arnold, PhD, ABPP

Case Study: Biopsychosocial Model

•  Patient hospitalized with AHF; Hx of SA, family conflict, & non-adherence §  Cardiologist writes “prescription” for SA sobriety.

•  Patient is re-hospitalized after 5 weeks. §  Says to the physician: “Doc, I followed your

directions. Are you going to let me die now?”

•  Question - Should this patient be selected for an LVAD (i.e. mechanical heart pump)?

Case Study: CBT

•  Generalized Anxiety and Irritable Bowel Syndrome §  Presentation with Anxiety

in Social, Travel, Intimacy §  History of Exposure to

Toxic Stress and Unpredictable Hostility and Disregard from Parents

§  IBS had Intermittently Become Acutely Severe

§  How Does the IBS Play into the GAD?

BPS Model of IBS Additional Factors from a CBT Model Cognitive •  Risk Appraisals •  Catastrophic Thinking •  Anxiety-based Problem

Solving •  Mind Reading Emotional •  Lack of Skills to Tolerate

Distress from Anxiety •  Embarrassment Behavioral •  EDBs—Avoidance of Risk

Environments, Safety Planning, Social Isolation

Mayer EA. Emerging disease model for functional gastrointestinal disorders. Am J Med 1999;107(5A):13S.

Introductions




Objectives

§  Identify 4 aspects of biopsychosocial functioning that should be reviewed in every patient/client encounter.

§  Identify 3 places in the biopsychosocial continuum of care to utilize CBT methods.

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Caveats

•  This presentation will not make you a Clinical Health Psychologist or a Cognitive Behavioral Psychologist.

CRSPPP

•  Clinical Health Psychology: §  http://www.apa.org/ed/graduate/specialize/health.aspx

•  Cognitive Behavioral Psychology: §  http://www.apa.org/ed/graduate/specialize/behav.aspx

Biomedical, Psychogenic, and Sociocultural Models

Jared L. Skillings, PhD, ABPP Spectrum Health System; Grand Rapids, MI

Biomedical Model

Leading causes of death: USA, 1958-2010

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Real-life Examples?

Total health care investment

Part of the Problem?

Recent Biomedical Example

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Psychogenic models

http://www.nature.com/nm/journal/v16/n7/fig_tab/nm0710-756_F1.html

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REBT Model

Biobehavioral Treatment Markers

C. McGrath, et al., (2013). JAMA Psychiatry,70(8), 821-‐829

Average effect size = 1.43

Low Insula: Rem to CBT, NR to Drug High Insula: Rem to Drug, NR to CBT Remit when matched to brain type

No demographic, clinical correlate of PET

Biobehavioral Treatment Markers

C. McGrath, et al., (2013). JAMA Psychiatry,70(8), 821-‐829

Social Determinants Of Health


Healthy People 2020

Biopsychosocial Model


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Biopsychosocial Model

•  Focus = holistic well-being •  Conceptually integrative

§ Mind and body are necessarily linked.

•  Interventions may be biomedical, psychological, familial, environmental, or cultural.

•  Prevention is an important focus.

http://www.cdc.gov/pcd/issues/2012/11_0324.htm

Integrating Biopsychosocial Conceptualization into CBT

Kevin D. Arnold, PhD, ABPP The Center for Cognitive and Behavioral Therapy

Columbus, Ohio www.ccbtcolumbus.com

Why CBT without BPS is Problematic

•  Health-related behaviors are learned within contexts.

•  Contexts: §  Situations in which Learning

occurs §  Situations that trigger learned

reactions •  Contexts incorporate all

three BPS spheres: 1. Biological

§  Internal biological system operations

§  Internal sensations and capacity of biological systems to adapt

1. Biological §  Internal biological system

operations §  Internal sensations and

capacity of biological systems to adapt


2. Psychological § Previous Learning Reactions

to Triggers §  Different Reactions have

Different Likelihoods §  Automatic Meaning Making

and Inferences, and §  Automatic Thoughts

(Catastrophizing, Discounting, Mind Reading, All-or-None, etc.)


3. Social §  Relationships provide Praise,

Attention and/ or Punishment,

§  Relationship Systems create Coping Resources, and

§  Learning of Relationships as sources of Reward or No-Reward for Certain Behaviors


How CBT Relies on the BPS Model

•  Ideas and Automatic Inferences about Risk are Learned within BPS §  Ideas which Occur or Don’t Occur based

on Triggers and Learning History Set-up Automatically Thinking Certain Ideas AND Not Other Ideas

§  Biological: Observing and Interpreting Risks about learned physiologic responses (increase in HR, localized pain)

§  Psychological: Awareness of Emotions Validates Ideas and Automatic Inferences (rather than all the evidence from reality)

§  Social: Ideas and Inferences about Risk are Learned through Modeling of Others Ideas and Social Rewards for Certain Ideas vs. More Realistic Thoughts (including “negative attention)

CBT and BPS Integration

•  Case Conceptualization: Assess Current Factors §  Individual Behavioral and Cognitive

Contributions •  Existing Behavior Patterns/Habits, EDBs

•  Current Automatic Thoughts and Beliefs/Meanings

§  Biomedical and Physical Health Contributions

•  Current Physical Disorders/Diseases, Learned Physiologic Reactions to Certain Triggers, Neuro-cognitive Abilities and Decrements

§  Past and Current Social Contributions •  Family System, Social Network, Socio-

vocational Relationships, Community Culture


•  Case Conceptualization: Integrate Learning with Current Factors §  Individual Behavioral and

Cognitive Contributions •  Existing Learned Triggers/

Associations and Various Learned Expectations for Rewards Depending on Reactions

§  Bio-medical and Physical Health Contributions

•  Experience of Physical Health (vs. Knowledge) Can Be Rewards and Punishment

§  Past and Current Social Contributions

•  How have Others in the Past and Currently Reacted to Both Bio-medical and Psychological Health Status (Attention, Praise, Criticism, Withdrawal, etc.)


•  Case Conceptualization: Motivation and Interest to Change

•  SOC and MI •  Capacity to Take Control of 1)

Rewards Received from Self and Others, 2) Exposure to Triggers for Ideas, 3) Exposure to Behavioral Reaction Triggers

•  Capacity to Accept Chronic States vs. EDBs

•  Capacity to Self-Manage Physical Experiences (Relaxation, Meditation, Mindfulness)

•  Willingness of Social Systems to Change vs. Perpetuate Homeostatic Drive

Targets of Change within CBT

•  Bio-Medical and Behavioral Activation Techniques §  Compliance with medical treatments §  Access to Appropriate Care and

Procedures •  Psychological

§  Change High-Risk Behaviors §  Modification of Automatic Thoughts §  Development or Strengthening of

Healthy Behaviors §  Overcome Avoidance Behaviors §  Improve Reality-based Conceptual

Understanding •  Social

§  Modification of Family and Social Structures and Roles to Support Change

§  Modification of Patient’s Understanding of Two and Three Person Interactions/Relationships

Back to the Case of IBS and GAD

•  How Context Predicts §  Interpretation of Medical

Interactions and Treatment Compliance

§  Risk Appraisal re: Bio-Medical Symptoms and Social/ Personal Risk

§  How Treatment Balances Validation with Exposure Therapy

•  Anxiety and IBS Sx Management

Future Course of Action: CBT and Public Health

•  A Key Goal of Public Health: Prevention •  What are the Three Levels of Prevention?

§  Primary, Secondary, Tertiary

Levels of Prevention


•  A Key Goal of Public Health: Prevention •  What are the Three Levels of Prevention

§  Primary, Secondary, Tertiary

•  How CBT can Apply to Prevention?


•  Examples of How CBT can Contribute to Public Health Goals §  Targets for Primary and Secondary Prevention

CBT Efforts •  CBT and PCPs for Primary Prevention (Pediatrics) •  CBT and PCPs for Secondary Prevention

(Pediatrics and Family Physicians/IMs) §  Tertiary Prevention: Disease Management and

Improved Daily Functioning and QOL

Model for Integrating Medicine and Psychology


MI-MAP

•  Purpose: To make “psychosocial factors easier yet more comprehensive for physicians, nurses, health psychologists, general psychologists, and social workers.”

Boyer, B. (2008). Chapter 1: Theoretical Models in Health Psychology and the Model for Integrating Medicine and Psychology. In B. Boyer & M. Paharia (2008). Comprehensive Handbook of Clinical Health Psychology. (pp. 3-30).

Disease Factors

•  Disease onset §  Symptomatic vs. latent §  Traumatic (cause or prognosis)

•  Disease progression §  Acute vs. Chronic §  Episodic vs. Constant

•  Types of symptoms §  Functional interference §  Visible to others §  Contagious to others

Treatment Regimen

•  Complexity •  Intrusiveness •  Accessibility •  Cost •  Side effects

Individual (patient) factors

•  Intelligence •  Information •  Literacy and Health literacy) •  Culture •  Trust •  Health Beliefs •  Coping •  Social Support

Co-occurring psychopathology

•  Depressive Disorders •  Anxiety Disorders •  Substance Use & addiction •  Cognitive impairment & dementia •  Severe mental illness •  Personality Disorders •  Somatoform Disorders •  ADHD, LD, Autism

Case Example “Gail”


Demographics & Social History

•  61 year-old, Caucasian, married female. •  Social Hx was noncontributory.

§  Supportive family. Stable job. •  No substance abuse or drug use.

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Psychiatric History

•  Clear mental status •  Previous diagnoses of mild depression & anxiety. •  Treatment:

§  2 psychotherapy bouts years ago (anxiety & behavioral pain management)

§  PSY meds: Effexor in past

Medical history

•  Current diagnoses: Hyperlipidemia, GERD, OSA, chronic lower back pain

•  Historical diagnoses: migraine headaches, chronic facial pain, cystic acne

•  Surgical history: bladder suspension, colonoscopy & pollup removal

•  Treatment: Routine PCP visits, CPAP use, statin med, occassional pain med

Wound History

•  Started as insect bite 2½ years ago.

•  Pt. picked and scratched until wound formed.

•  Initiated medical treatment after 1½ years.

•  CA, derm, ID, and metabolic causes ruled out.

TREATMENT

1.  Psychotropic medication 2.  Psychotherapy (which kind?) 3.  Deep brain stimulation surgery

Course of Treatment

•  Referred to psychiatry. OCD correctly diagnosed. Started Effexor 225mg daily.

•  Referred to psychology for CBT (July 2012).

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Previous psychotherapy

•  Psychological support

•  Stimulus control techniques alone

§ Limit and control times and amount of touching.

CBT case conceptualization

•  Precipitating factor(s)? § Insect bite § Hx of cystic acne

•  Perpetuating factor(s)? § Lack of education / denial § Punishment of medical Tx for dermatology

needs § Negative reinforcement

Habit Reversal Training (HRT)

1.  Inconvenience review

2.  Awareness training

3.  Competing response training

4.  Utilization of social support

5.  Generalization

Azrin, N. H., & Nunn, G. R. (1973). Habit reversal: A method of eliminating nervous tics and habits. Behaviour Research and Therapy, 11, 619–628. Teng, E.J., Woods, D.W., Twohig, M.P. (2005). Habit reversal as a treatment for chronic skin picking. Behavior Modification, 30 (4), 411-422.

Gail’s Treatment Process

•  8 CBT (primarily ERP) sessions over 6 months.

•  Effexor 225mg daily •  CBT Interventions:

•  Identification of triggers • Exposure w/ Response Prevention • Cognitive restructuring & education • Habit reversal training

Outcome = Wound Measurements

• Worst (May 2012) • 3½” x 2½” x ¾”

• Best (July 2014) • 1” x ¾” x ¾”

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APA Bio-Psycho-Social and CBT Presentation by Skillings and Arnold