APA Bio-Psycho-Social and CBT Presentation by Skillings and Arnold
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Transcript of APA Bio-Psycho-Social and CBT Presentation by Skillings and Arnold
Welcome!
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
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
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
Jared L. Skillings, PhD, ABPP Spectrum Health System; Grand Rapids, MI
Healthy People 2020
Biopsychosocial Model
Jared L. Skillings, PhD, ABPP Spectrum Health System; Grand Rapids, MI
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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
Why CBT without BPS is Problematic
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.)
Why CBT without BPS is Problematic
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
Why CBT without BPS is Problematic
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
CBT and BPS Integration
• 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.)
CBT and BPS Integration
• 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
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
• How CBT can Apply to Prevention?
Future Course of Action: CBT and Public Health
• 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
Jared L. Skillings, PhD, ABPP Spectrum Health System; Grand Rapids, MI
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”
Jared L. Skillings, PhD, ABPP Spectrum Health System; Grand Rapids, MI
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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Welcome!
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