Gloria Maccow, Ph.D.Gloria Maccow, Ph.D. Deborah Kukal, Ph.D.Deborah Kukal, Ph.D.

Welcome to the MBMD Welcome to the MBMD Pain Patient Reports WebinarPain Patient Reports Webinar

Topics for this WebinarTopics for this Webinar

• Psychological assessment with the MBMD.

• Introduction of new norm group for pain population.

• Description of customized Pain Patient Interpretive Reports.

Rationale for the MBMDRationale for the MBMD

Treating the Whole Patient versus Treating the Disease.

Sir William Osler and Jacob Bigelow, eminent nineteenth century physicians.

2121stst Century MedicineCentury Medicine

• Medical diseases affect millions of lives and consume billions of dollars.

• Healthcare costs for management of chronic diseases are astronomical.

• A substantial proportion of healthcare costs is for treatment of conditions with psychosocial sources.

• Clinical behavioral medicine interventions may reduce the frequency of medical use. (Regier, 1994)

Health MaintenanceHealth Maintenance

• Which psychosocial factors preserve health and reduce the likelihood of developing a disease? (primary prevention)

• Which psychosocial factors predict one’s adjustment to the diagnosis of disease? (secondary and tertiary prevention)

Psychosocial FactorsPsychosocial Factors

– Affective and psychiatric disorders (depression and anxiety conditions).

– Cognitive appraisals (self-efficacy, optimism/pessimism, perceived control).

– Coping strategies (active behavior, avoidance and denial).

– Resources (social, economic, familial, spiritual).

– Life context (stressful events, perceived stress level, and functional capacity).

Interactive Nature of the Interactive Nature of the DSMDSM--IV IV MultiaxialMultiaxial SystemSystem

AXIS III & IVAXIS III & IVMedical & PsychosocialMedical & Psychosocial

AXIS IIAXIS IIPersonality DynamicsPersonality Dynamics

AXIS IAXIS IClinical PresentationClinical Presentation

(Anxiety, Dysthymia(Anxiety, Dysthymia= Fever, Cough)= Fever, Cough)

(Coping Style=(Coping Style=Psychic Immune Psychic Immune

System)System)

(Marital, Economic, Health(Marital, Economic, Health= Infectious Agents)= Infectious Agents)

Questions . . . and AnswerQuestions . . . and Answer

• Which psychological factors can work for or against the success of medical interventions like surgery? Or medications?

• How can we quickly assess these characteristics in a reliable and valid manner?

• Use a multi-modal instrument that integrates information from multiple domains to inform clinical judgment.

What is the MBMD?What is the MBMD?

• The MBMD™ (Millon™ Behavioral Medicine Diagnostic) inventory is designed to provide the critical psychological information doctors need to treat the whole patient.

• The MBMD is a 165-item, self-report inventory with 29 clinical scales, three Response Patterns scales, one Validity indicator, and six Negative Health Habits indicators.

• It is designed to assess psychological factors that can influence the course of treatment of medically ill patients.

MBMD Theoretical ModelMBMD Theoretical Model

Psychiatric Indications(depression, anxiety)

Coping Styles

Stress Moderators(optimism, social support)

Negative Health Behaviors

Health Maintenance Health Care Delivery

Health Care Outcomes

MBMDMBMD

• MBHI foundation (1970s)

• MBMD Published 2001– Normative updates and specialized reports

in 2006 (Bariatric) and 2010 (Pain)

• Administer to patients 18-80 years old

• Completion time 20-25 minutes, 165 T/F items

• Profile and Interpretive Reports

MBMD 7 DomainsMBMD 7 Domains

• Response Patterns

• Negative Health Habits

assess response patterns and problematic behavior that will alert the clinician to issues that deserve attention.

• Psychiatric Indications

• Coping Styles

• Stress Moderators

• Treatment Prognostics

• Management Guides

assess psychiatric or psychosocial variables that may shape the way patients deal with health problems and identify attitudes that may exacerbate their ailments and interfere with their overall prognosis.

MBMD Domains and ScalesMBMD Domains and Scales

MBMD Domains and ScalesMBMD Domains and Scales

Psychiatric DisordersPsychiatric Disorders

Depressed Patients Have

– Greater medical utilization

– More complications after surgery

– Longer hospital stays

– More custodial care

– Less improvements during rehab

– Less likely to return to premorbid quality of life

– Associated with other unhealthy lifestyle behaviors (Smoking, sexual dysfunction, less exercise, alcohol use)

(e.g., Barsky et al., 1986)

Psychiatric DisordersPsychiatric Disorders

Medical Patients with Anxiety Have

– Poorer treatment outcome

– Increased medication use, less adherence

– Increased medical utilization

– Decreased comprehension of information

• Associated with other unhealthy lifestyle behaviors - use of alcohol; abuse of sleep meds

MBMD Domains and ScalesMBMD Domains and Scales

Cognitive AppraisalCognitive Appraisal

CABG Surgery: Pessimistic individuals receiving coronary artery bypass graft (CABG) surgery more likely to be re-hospitalized for post-surgical complications:

– Wound infections– Angina– Myocardial Infarction– Another bypass or angioplasty over the following 6

months

(e.g., Scheier et al., 1999)

MBMD Client PopulationsMBMD Client Populations

• Medical patients involved in treatment• Men and women 18-80 with at least a

6th grade reading level• Patients being seen for treatment of

cancer, diabetes, HIV/AIDS, heart problems, injuries, organ transplants, etc.

• Bariatric Surgery Candidates• Pain patients

Standardization SampleStandardization Sample

MBMD Sample N = 720 Bariatric sample N = 700

September 1994-May 2000 August 2004-May 2005

Applications of the MBMDApplications of the MBMD

• Presurgical psychological evaluations

• Identification of assets and liabilities that may affect the outcome of surgery or medical treatment

• Treatment planning and recommendations

MBMD Prevalence Scores (PS)MBMD Prevalence Scores (PS)

• Estimates of prevalence data in population anchors scoring system

• Normal vs. Prevalence Continuum• Three adjusted percentages set the target

Prevalence Scores from which PS transformations were developed

• Cutoff Scores

– PS = below 35 Asset– PS = 75 to 84 Moderate Liability– PS = 85 to 115 Marked Liability

MBMD Interpretive ReportMBMD Interpretive Report

• Graphical Profile Summary• Interpretive Report• Healthcare Provider Summary

ComponentsComponents

MBMD Interpretive ReportMBMD Interpretive Report

• Interpretive Considerations• Psychiatric Indications• Coping Styles• Stress Moderators• Treatment Prognostics• Management Guide• Noteworthy Responses

Response Patterns and Response Patterns and Negative Health HabitsNegative Health Habits

MBMD Profile and ScalesMBMD Profile and Scales

Healthcare Provider SummaryHealthcare Provider Summary

• Psychiatric Indications• Coping Styles• Case Management Issues

– Stress Moderators– Treatment Prognostics– Management Guide

Healthcare Provider SummaryHealthcare Provider Summary

MBMD and the Pain PopulationMBMD and the Pain Population

Pain in America

– Over 100 million adults in America suffer from chronic pain, costing the U.S. $635 billion in annual healthcare costs*

– More than 75% of pain sufferers report feeling depressed**

*Institute of Medicine Report from the Committee on Advancing Pain Research, Care, and Education: Relieving Pain in America, A Blueprint for Transforming Prevention, Care, Education and Research. The National Academies Press, 2011.

**2006 Voices of Chronic Pain Survey. http://painfoundation.org/media/resources/voices-survey- report.pdf

Biopsychosocial Factors and PainBiopsychosocial Factors and Pain

Approaches to treating pain cover a vast spectrum:

– Simple bed rest– Mild medications– Acupuncture– Physical Therapy– Injections– Powerful opioid drugs – Individual and Group Psychotherapy, and – A variety of surgical procedures

Biopsychosocial Factors and PainBiopsychosocial Factors and Pain

• Despite this panoply of interventions, some patients fail to achieve pain relief.

• For these—the chronic pain patients—a downward spiral (Bruns & Disorbio, 2009) of pain, disability, despair, high healthcare utilization, and overall poor quality of life results in immense costs for both the individual and society.

The Pain ExperienceThe Pain Experience

• Biological: stimulation of nerves sends information to the brain about possible tissue damage.

• Genetics and prior experiences: form cognitive and affective lens that affects how pain is experienced. This, in turn produces a behavioral response.

Psychosocial Evaluation and PainPsychosocial Evaluation and Pain

• In recognition of this complex interplay, a biopsychosocial model has come to be widely accepted as the most heuristic approach to chronic pain (Gatchel, Peng, Peters, Fuchs, & Turk, 2007).

• With psychosocial factors now firmly a part of this integrated conception of chronic pain, mental health professionals have assumed an important role in pain assessment and treatment.

Psychosocial Assessment for Psychosocial Assessment for Pain PatientsPain Patients

• Customized MBMD for Pain Patients in a series of studies conducted over a 2-year period.

• Established new norms from nationally representative pain sample.

• Demonstrated reliability and validity of MBMD scales.

• Developed Narrative Reports for two major pain populations (pre-surgical and non- surgical).

MBMD Pain Norm Sample

• 1,200 chronic pain patients drawn from diverse sites across the U.S. (648 female, 552 male)

• User sites represent patients from all geographical areas of the U.S. being seen in the following settings:– Private Practice– Multidisciplinary pain clinics– Hospital-based pain clinics– Headache, spinal cord treatment

• Patients represent a variety of race/ethnicities, ages, and education levels

Reliability and ValidityReliability and Validity

Reliability– Test-Retest:

.66 - .93 for 32 Response Patterns & Scales

– Internal Consistency:median alpha = .75

Validity– Concurrent: see Study 1 – 3 Results– Predictive: see Study 4 Results

MBMD Validation StudiesMBMD Validation Studies

Study 1: MBMD Correlations with MMPI-2 in Chronic Pain patients at hospital-based pain clinic over 3 yr period (N = 596)

– Most coefficients = .50 - .70), strongest correlations with MMPI content scales

– Also related MBMD to MMPI-RF clinical Scales (most coefficients = .50 - .70)

MBMD Validation StudiesMBMD Validation Studies

Study 2: MBMD Correlations with SCL-90, and Distress and Risk Assessment Method (DRAM) in private practice setting as part of pre-treatment eval (N = 170)

– SCL-90 correlations: r = .70 - .80

– DRAM corrs: r = . .56 - .80 with MBMD Psychiatric Scales

MBMD Validation StudiesMBMD Validation Studies

Study 3: MBMD Correlations with Pain Measures (Dallas Pain Quest [DPQ], BBHI- 2,and Pain Outcomes Profile [POP] in functional restoration clinic treating workers’ compensation cases (N = 161)

– DPQ corrs: r = .50 - .60 w/MBMD Psychiatric Scales; .30 - .40 w/MBMD stress moderators

– BBHI-2 corrs: r = .50 - .60 w/MBMD Psychiatric Scales; .35 - .65 w/MBMD stress moderators

MBMD Validation StudiesMBMD Validation Studies

Study 4: MBMD Prediction of Treatment Outcomes in subset of Study 3 patients (N = 110) who completed > 15 days of treatment.

MBMD scales with strongest predictive validity for poor treatment outcomes:

– Psychiatric Indicators: Depression, Cog Dysfunction and Guardedness

– Coping Styles: Nonconforming, Forceful, Oppositional

– Stress Moderators: Future Pessimism, Pain Sensitivity

– Management Guides/Treatment Prognostics: Adjustment Difficulties, Psych Referral, Utilization Excess

Use MBMD Pain Patient Reports for . . .Use MBMD Pain Patient Reports for . . .

• Pre-treatment psychosocial evaluations to help professionals select suitable treatments.

• General and expanded behavioral health evaluations to help determine the most appropriate intervention, such as individual psychotherapy, pain management groups, biofeedback, functional restoration/work hardening programs, or multidisciplinary pain programs.

• Monitoring of treatment interventions and outcomes.

Customized Pain Patient ReportsCustomized Pain Patient Reports

• Presurgical Pain Patient Report• Nonsurgical Pain Patient Report

Reports based on – comprehensive review of literature,– input from experienced practitioners, – extensive reliability and validity data.

Report ComponentsReport Components

Presurgical Report• Graphical profiles

• Presurgical Pain Patient Summary– Presurgical Considerations

– Postsurgical Considerations

• Interpretive Report

• Healthcare Provider Summary

MBMD Percentile Scores Based MBMD Percentile Scores Based on Chronic Pain Normson Chronic Pain Norms

PostPost--Surgical ConsiderationsSurgical Considerations

Report ComponentsReport Components

Nonsurgical Report• Graphical profiles

• Nonsurgical Pain Patient Summary– Pretreatment Considerations

– Longer-Term Management

• Interpretive Report

• Healthcare Provider Summary

LongerLonger--Term ManagementTerm Management

MBMD InformationMBMD Information

Sample Reports for the MBMD Pain Patient Reports and other Millon Inventories www.PsychCorp.com/MillonInventories

Complimentary Pain Patient Reports Trial Package– Includes an overview of the instrument and materials to

score and report one complimentary assessment– Call 800.627.7271 x 263200 and request item PO78TP

To order or for more information on the MBMD and other Millon Inventories

– 800.627.7271– PsychCorp.com/MBMD– PsychCorp.com/MillonInventories

Questions & AnswersQuestions & Answers

ReferencesReferences

Barsky, A., Wyshak, G., & Klerman, G. (1986). Medical and psychiatric determinants of outpatient medical utilization. Medical Care, 24, 548–560.

Bruns, D., & Disorbio, J. M. (2009). Assessment of biopsychosocial risk factors for medical treatment: A collaborative approach. Journal of Clinical Psychology in Medical Settings, 16, 127–147.

Gatchel, R. J., Peng, Y. B., Peters, M. L., Fuchs, P. N., & Turk, D. C. (2007). The biopsychosocial approach to chronic pain: Scientific advances and future directions. Psychological Bulletin, 133(4), 581–624.

ReferencesReferences

Regier, D. (1994). Healthcare reform: Opportunities and challenge. In S. Blumenthal, K. Matthews, & S. Weiss (Eds.), New research frontiers in behavioral medicine: Proceedings of the national conference (pp. 19–24). Washington, DC: Government Printing Office.

Scheier, M. F., Matthews, K., Owens, J., Schultz, R., Bridges, M., Magovern, G., & Carver, C. S. (1999). Optimism and rehospitalization after coronary artery bypass graft surgery. Archives of Internal Medicine, 159, 829–835.

Webinar Specific QuestionsWebinar Specific Questions gloria.maccow@pearson.comgloria.maccow@pearson.com