Behavioral Flashcards
Patient engagement techniques (3)
5 A’s
TTM (transtheoretical model)
MI (motivational interviewing)
5 A;’s
Ask
Assess
Advise
Agree
Arrange/Assist
What is TTM (transtheoretical model)
= framework for understanding process of behavior initiation, change, cessation
-integrative bio-psycho-soc
-conceptualize process of behavior change
-RECOGNIZE current stage and tailor guidance
** occurs in increments
** stages of change = key component
TTM stages of change (6)
“PCP AM(R)”
-Pre-contemplation (unaware or no intentions to change, 60% of ppl)
-Contemplation (within 6 mos)
-Preparation (plan to change now)
-Action
-Maintainence
-(Relapse)
Motivational Interviewing
-collaborative, pt-centered
-evocation of pts own motivation
-encourage autonomy to own soln
** be a “detective” of motivation
MI skills: OARS
Open-ended questions
Affirmations
Reflections (repeat back)
Summaries (plan)
MI key processes (4)
EFEP
Engage
-build connection, ID goals
Focus
-pt ideas, single topic, small changes
Evoke
-their “why”
-goal is **change talk > sustain talk
-listen for DARN (desire, ability, reasons, needs)
-how ready 1-10? Why not less?
Plan
-what changes ready to make today?
-SMART goals, “Rx”
-explore barriers
-facilitate & assess confidence
** OARS for all
SMART goals
Specific
Measurable
Achievable (realistic!)
Relevant (important to pt)
Timed
FITTE
Freq
Intensity
Time
Type
Enjoyment
MI: 4 guiding principles
RULE
-Resist the Righting Reflex
-Understand their motivation & use that
-Listen reflectively & summarize
-Empower- w their own ideas & decisions!
Additonal MI principles: EDRS
-Empathy
-Develop discrepency btw actions & goals
-Roll w resistance- “sound like you’ve struggled”
-Support self-efficacy, affirmations
Psychotx
CBT & others
CBT
thoughts - behaviors - actions
** central component of obesity tx
** also 1o for BED, bulimia
-also component for anorexia, pre-pub ob
CT addresses…
-maladaptive thinking –> maladaptive behav
-automatic thoughts (link to neg feelings)
-distortions
-catastrophizing
- teach setback as temporary lapse
- positive thinking to replace undermining thoughts
BT concepts
-change behavior and feelings will follow
-reinforce or extinguish behaviors (ribbons, stars / orlistat aversive), RESTRUCTURE ENV
-relaxation training
10 components of BT
- Self-monitor (diet, ex, wts)
- Stimulus control
- Problem solving
- Goal setting (SMART)
- Contingency management
- Social supports
- Relapse prevention
- Stress mgmt, alts to food
- Reward for goals
- Ongoing contact
Other types of tx
-DBT (form of CBT, tx BED & others)
-Interpersonal (component of MI, tx LOC-ED girls)
-FRAMES (?)
Eating disorders (most to least common, 6)
-BED (LOC-ED in kids <12yo)
-NES
-Grazing (not DSM-V)
-BN
-AN
-Sleep-related ED (parasomnia, not ED)
*50% genetic component in twin studies
1 most common eating disorder (2-3.5% of pop)
BED criteria
-esp in p/w obesity
(50% of pts w severe obesity!)
(compulsive d/o)
-1x/wk for 3 mos
-large amounts, lack of control
-marked distress
-NO compensatory behav
Assoc w 3+:
rapid eating
uncomfortably full
eating when not hungry
hiding
feeling disgusted
BED tx
** Tx 1st before obesity
-CBT first line (w topiramate may be best)
-Lisdexa can also be first line
Also off label:
Topiramate
Phentermine
Phen/Top
Phen/Fluox
Fluoxetine
Zonisamide
Buproprion
Sertraline
Citalopram
-IPT & DBT options as well
LOC-ED
<12 yo
don’t meet criteria for BED
tx w IPT for girls
NES criteria (3)
-AM anorexia
-PM hyperphagia*
-insomnia
** 25-50% of daily cals after PM meal, ++carbs
Often w PM worsening mood, nocturnal awakenings to eat (AWARE)
NES tx
** highly responsive to sertraline
-encourage regular meals earlier in daytime
-↑ protein
BN criteria
-binge eating
+compensatory behaviors
-self-eval unduly influenced by body image
*** 1x/wk x 3 mos
Some epi:
10% of women over lifetime!
us 16-22 yox
25% w h/o sexual abuse
BN tx
** contraind
-CBT
-SSRI (fluox FDA, sert off label)
-combo of above
Also: topiramate, trazodone, ondansetron
**NO BUPROPRION
AN criteria (3)
Must have all 3:
1. restricted ENERGY intake leading to low weight (generally BMI < 18.5)
- intense FEAR of wt gain OR behaviors preventing gain
- DISTORTED body image, denial of medical seriousness
(amenorrhea no longer nessessary)
*osteoporosis 38-50%
*10% mortality suicide, among deadliest psych dz’s
Body image disorders (3)
Tx’s
-AN
-BDD (OCD)
-Body image dissatisfaction
BDD Tx: SSRI, CBT, top, lamo
Sleep disorders (5)
-OSA
-OHS
-Shift-work sleep disorder (SWSD)
-Sleep-related eating disorder (SRED)
-Insomnia
SWSD criteria
-chronic/recurrent disrupted sleep/wake pattern (altered circ rhythm)
-insomnia OR xs sleepiness
-causes distress/impairment
> 3 mos
*Distress/impairment
↑ incidence of obesity
20% of workers have nonstandard shifts
SWSD tx
-planned sleep 7-9 hrs
-sleep hygiene
-lighting exposure
-melatonin 0.5-3 mg
-sedatives before sleep
-stimulants during work (caffeine, modafinil)
SRED defs, epi %, assoc meds
= parasomnia NOT ED
“Sleep-eating” is not NES
Epi:
*1-5% of gen pop
*9-17% of pts w ED
*16% ppt by stress
*80% also have RLS, PLMS?D, somnabulisum
Assoc w sed & anti-psych:
-zolpidem
-triazolam
-amitriptyline
-olanzapine
-risperdone
-others psychotropics…
SRED tx
-stop offending agent (ZOLPIDEM)
-tx related disorder: RLS, OSA, PLMD…
-pramipexole
-other DA ag (carb/levo)
-CPAP for OSA
-Other tx:
Top
SSRI
Traz
Insomnia 2o causes & tx
medical disorder (eg BPH)
psych (MDD)
substance (EtOH)
another sleep disorder (RLS)
Tx: CBT #1, meds (weak rec)
Behavior disorders/ED & exclusion from bariatric surgery(5)
*no absolute contraind’s
(but most experts agree there are some contraind’s)
-still, pts are screened pre-op psych eval
-5-20% of pts excluded
1- recent or active SUICIDALITY
2- problematic SUBSTANCE abuse or EtOH use disorder
3- Unstable BIPOLAR w behav’s that could impact outcome of surg/adherence
4- SCHIZO us excluded, though no shown effect on outcome
5- COMP/PURGING behaviors also no effect on 1yr loss, but usually excluded
-need psych care after surg
BN tx
** contraind
-CBT
-SSRI (fluox FDA, sert off label)
-combo of above
Also: topiramate, trazodone, ondansetron
**NO BUPROPRION
NWCR %’s
(National Wt Control Registry)
-est 1994, 10K ppl over 10 yrs
-30+ lb wt loss >1yr
-avg age 40’s, 80% are women
-4% w meds
-50% without a program
Long-term success assoc w:
-most w low cal low fat diet
-90% exercise 1+ hr per day (400 cal)
-75% take weekly weight
-62% <10hrs tv/wk
