mbmd: bariatric surgery - downloads.pearsonclinical.com · using the millon behavioral medicine...

Using the MBMD in Bariatric Surgery

Michael Antoni, Ph.D. and Anne-Marie Kimbell, Ph.D.

Copyright © 2017. Pearson Inc., and/or its affiliates. All rights reserved, 1

Michael Antoni, Ph.D.

Anne-Marie Kimbell, Ph.D.

Using the Millon

Behavioral Medicine

Diagnostic

(MBMD) in Bariatric

Surgery

MBMD

Topics

Psychosocial testing in bariatric surgery.

The MBMD and its use with patients for

bariatric surgery.

Using data from the MBMD to identify patient

assets and liabilities.

1.

2.

3.




MBMD

Trends in Prevalence of Obesity and

Severe Obesity (Youth and Adult)

https://jamanetwork.com/journals/jama/fullarticle/2676543

16.8 16.9 16.9 17.218.5

4.9 5.6 5.6 6 5.6

33.735.7 34.9

37.739.6

5.7 6.3 6.47.7 7.7

0.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

40.0

45.0

2007-2008 2009-2010 2011-2012 2013-2014 2015-2016

Overall Percent

Obesity Youth Severe Obesity Youth Obesity Adult Severe Obesity Adult

MBMD

Trends in Bariatric Surgery

158,000

173,000179,000

193,000 196,000

216,000

0

50,000

100,000

150,000

200,000

250,000

2011 2012 2013 2014 2015 2016

Estimate of Bariatric Surgery Numbers

https://asmbs.org/resources/estimate-of-bariatric-surgery-numbers




MBMD

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

MBMD

Some Factors Associated with Bariatric

Surgery Sequelae

Advanced AgeMedical

Co-Morbidities

Surgical Volume

at Institution




MBMD

NIH has promoted development of guidelines for predicting post-surgical behaviors (LeMount, Moorhead, Parish, Reto & Ritz, 2004)

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)

MBMD

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.




MBMD

GUIDELINES: Psychological Assessment in

Bariatric Surgery Candidates (ASBS, 2004)

Content Areas Testing Issues

Behavioral

• Eating behavior and physical activity

• Alcohol and substance use

Clinical Rationale (enhance

interview, objective data

reduce liability)

Cognitive and Emotional

• Cognitive functioning

• Coping skills and emotional modulation

• Psychiatric issues and psychopathology

Test Selection Criteria

(relevance, validity, reliability,

specific norms)

Current Life Situation

• Stressors

• Social Support

Test Options (multi-scale,

single-scale, specific to BS)

Motivation and Expectations

• Adherence

MBMD

Actual Practices in 2004 (Survey of 188

surgery programs in ASBS registry)

33% measured

personality

86% of programs required PSY

screen

40% did not use PSY test

50% measured PSY symptoms only (depression)




MBMD

No algorithm exists for use of Psy Tests (Bauchowitz et

al., 2005 Psychosomatic Medicine)

Actual Practices in 2004 (Survey of 188

surgery programs in ASBS registry)

Active binge-eating

disorder

Decisions made using:

Major psychopathology (schizoid, bipolar)

History of suicide attempts

History of medical non-

compliance

MBMD:

A Psychosocial

Assessment




MBMD

What is the MBMD?

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.

MBMD

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

MBMD Model




MBMD

Seven MBMD Domains


(6 scales)Response Patterns

(3 scales)


(5 scales)

Stress Moderators

(6 scales)

Coping Styles

(11 scales)

Management Guides

(2 scales)

Treatment Prognostics

(5 scales)

MBMD

Validity Indicator and Response

Patterns

Scale Description

V ValidityProvides information about the validity of

the profile.

X Disclosure

Measures patient’s tendency to be overly

frank and self-revealing, or hesitant to

share personal information.

Y DesirabilityMeasures patient’s tendency to present self

in favorable manner.

Z DebasementMeasures patient’s tendency to present self

in unfavorable manner.




MBMD


Scale Description

N Alcohol Presence of alcohol-consumption problem.

O DrugGreater use of non-prescription drugs and

possible dependency.

P Eating Problem with chronic overconsumption.

Q CaffeineAssesses if patient’s consumption of caffeine

is excessive.

R InactivityNotes if patient engages in physical exercise

on a regular basis.

S SmokingSmokes tobacco-containing products on a

regular basis.

MBMD


Scale Description

AAAnxiety/ Tension

Assesses patient’s level of anxiety and

tension.

BB DepressionFocuses on patient’s vegetative or mood

state.

CCCognitive Dysfunction

Assesses patient’s capacity to recall past

experiences, to think abstractly, and to

represent events and interrelate and

process them symbolically.

DDEmotional Lability

Looks at dysregulation of affect and

irritability in moods.

EE GuardednessAssesses patient’s level of mistrust and

defensiveness




MBMD

Coping Styles

ScaleMBMD

Coping StyleNon-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

MBMD

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




MBMD

Stress Moderators

Scale Description

AIllness Apprehension vs.

Illness Acceptance

Patients’ focus on and awareness of

changes in their bodies.

BFunctional Deficits vs.

Functional Competence

Patients’ perception that they are unable

to perform activities of daily living.

CPain Sensitivity vs.

Pain Tolerance

Patients’ tendency to be overly sensitized

and reactive to mild to moderate pain.

DSocial Isolation vs.

Social Support

Patients’ perception of social supports in

their lives.

EFuture Pessimism vs.

Future Optimism

Patients’ outlook toward their future health

status.

FSpiritual Absence vs.

Spiritual Faith

Degree to which patients lack religious or

spiritual resources for dealing with the

stressors and fears of the medical

condition.

MBMD


Scale Description

G

Interventional Fragility

vs. Interventional

Resilience

Predicts whether patients will be able to

adjust emotionally to the demands of

physically and psychologically stressful

protocols.

H

Medication Abuse vs.

Medication

Conscientiousness

Predicts likelihood that patients will have

problems with or will misuse prescribed

medication.

I

Information Discomfort

vs. Information

Receptivity

Assesses a patient’s lack of receptivity to

specific details about diagnostic,

prognostic, and treatment procedures and

outcomes.




MBMD


Scale Description

JUtilization Excess vs.

Appropriate Utilization

Assesses the likelihood that a patient

will use medical services more than the

average patient with a similar medical

condition.

KProblematic Compliance

vs. Optimal Compliance

Identifies patients who resist following

medical recommendations.

MBMD

Management Guide

Scale Description

L Adjustment DifficultiesAssesses the risk of treatment

complications.

M Psych ReferralIndicates whether the patient might benefit

from psychosocial intervention.




MBMD

Bariatric Norms

MBMD

Bariatric Surgery Patient Norms

• From 2005–2006, data collected on bariatric

surgery patients from surgery sites across U.S.

• Used MBMD 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.




MBMD


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)

MBMD


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%)




MBMD

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

MBMD

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.




MBMD

Theoretical Model to Guide Psychosocial Evaluation in Bariatric Surgery (Millon, 2006)

Pre-OperativeFactors

Post-Operative Behaviors

Post-Operative Outcomes

• Psychiatric

Indicators

• Personality Coping

Style

• Stress Moderators

• Negative Health

Behaviors

• Treatment

Prognostics

• Binge Eating

• Following

Nutritional Advice

• Starting Exercise

Regimen

• Surgical

Recovery/

Complications

• Physical Target

(Weight Loss and

Maintenance)

• Longer-term

Health Outcomes

(CHD, DM)

MBMD

Processes That Influence Bariatric

Surgery Outcomes




MBMD

Bariatric Summary

PRESURGICAL

INTERVENTIONPATIENT BEHAVIOR

POSTSURGICAL

OUTLOOK

POSTSURGICAL

CARE

MBMD

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




MBMD

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

MBMD

POSTSURGICAL OUTLOOK

C. The likelihood that surgery will improve this

patient’s: Is classified as:

1. Overall quality of life

2. Psychosocial functioning

3. Body image

4. Physical health

5. Mental outlook

6. Sexual activity

7. Employment/vocational opportunities

Good

Good

Good

Good

Good

Good

Good




MBMD

POSTSURGICAL CARE

D The likelihood that this patient will benefit from a: Is classified as:

1. Physical rehabilitation program

2. Stress and/or sleep management course

3. Bariatric support group

4. Nutritional instruction plan

Doubtful

Doubtful

Doubtful

Doubtful

MBMD

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)




MBMD

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)

MBMD

POST-SURGICAL CARE

Post-Surgical Treatment Suggestions:

Algorithms

Post-surgical physical

rehabilitation program

Post-surgical stress

management

- Anxiety

- Functional Deficit

- Pain Sensitivity

- Intervention Fragility

+ Anxiety

- Emotional Lability

+ Illness Apprehension


+ Psy Ref




MBMD

Post-Surgical Treatment Suggestions:

Algorithms

Post-surgical bariatric

support group

Post-surgical weight loss

nutritional instruction

+ Anxiety

+ Depression

- Inhibition

+ Dejection

+ Denigrated

+ Functional Deficit

+ Social Isolation

- Future Pessimism

+ Adjustment Difficulties

- Introversion

- Nonconforming

- Oppositional


- Info discomfort

- Problematic Compliance

Interpretation




MBMD

Prevalence Score (PS)

PS

Interpretation/

Interpretive Benchmarks

< 35 Asset

75-84 Moderate or Present Liability

85+ Marked or Prominent Liability.

MBMD

MBMD Interpretive Model

1. Medical condition

2. Clinical Observations and Interviews

3. Other test results

4. Background and demographics gender, age, etc.

A.

Review Patient

Information

1. Validity

2. Disclosure

3. Desirability

4. Debasement

B.Analyze Modifying

Indices

1. Psychiatric Indications

2. Coping Styles

3. Stress Moderators

4. Treatment Prognostics

C.Analyze Sections

of Profile

D.Integrate

Profile

1. Analyze Patterns

2. Assess importance of minor score variations

3. Noteworthy Responses

4. Healthcare Provider Summary




Case Study

MBMD

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




MBMD

Sample Report

Name Female A

Age 34

Gender F

Race White

Marital Status Married

Education Bachelor’s Degree

MBMD

Response Patterns and





MBMD

Psychiatric Indications and

Coping Styles

MBMD

Stress Moderators




MBMD

Treatment Prognostics and

Management Guides

MBMD

Bariatric Summary




MBMD

MBMD




MBMD

Summary

The MBMD’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.

MBMD

Clinical Presentation




MBMD

Training Opportunities

Online Training Available (earn up to 3 APA CE credits)

www.PearsonClinical.com/MBMD

PearsonClinical.com/MBMD

Customer Support

800-627-7271 (USA)

866-335-8418 (Canada)

http://www.pearsonclinical.com/MBMD

http://www.pearsonclinical.com/psychology/products/100000231/millon-behavioral-medicine-diagnostic-mbmd.html#tab-details

mbmd: bariatric surgery - downloads.pearsonclinical.com · using the millon behavioral medicine...

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