Behavioral Medicine I and II

Question 1

list the 5 steps in smoking cessation treatment intervention

Answer 1

1. assessing patient’s readiness to quit
2. assessing physical dependence
3. addressing psychological and social determinants
4. designing a comprehensive treatment strategy
5. preventing relapse

Question 2

list the series of stages of a patient’s readiness to quit

Answer 2

• precontemplation: initial disinterest in quitting smoking
• contemplation: thinking about health risks and about quitting
• preparation: preparing to quit in near future
• action: currently taking action to stop smoking
• maintenance: maintaining nonsmoking

Question 3

describe the precontemplation stage in the stages of change model

Answer 3

• peron is not considering change at this point
  
  • perhaps patient does not see any problem
  • has tried and failed repeatedly and given up
• health provider’s task:
  
  • listen empathically to patient
  • educate: increase awareness of risks/benefits
  • raise doubt

Question 4

describe the contemplation stage in the stages of change model

Answer 4

• person is considering quitting but is ambivalent–weighing pros and cons
• health care provider should:
  
  • emphasize risks and benefits in relation to person’s medical, psychological and social status
  • help strengthen person’s sense of self-efficacy i.e. the belief that they can do it
  • focus on past “successes” even if short
  • patient vacillation is to be expected

Question 5

describe the preparation stage in the stages of change model

Answer 5

• person intends to take action in near future and has developed a plan of action
• health care provider should:
  
  • explore treatment options
  • help set “quit date”
    encourage realistic goals
  • provide support and encouragement
  • consider action-oriented programs

Question 6

describe the action stage in the stages of change model

Answer 6

• person has now made specific modification in lifestyle i.e. has quit smoking
• health care provider should:
  
  • help identify high risk situations for return to smoking and help develop coping strategies
  • provide reinforcement–promote confidence and self-efficacy

Question 7

describe the maintenance stage in the stages of change model

Answer 7

• person now able to successfully resist temptation to return to smoking
• greater confidence
• able to anticipate risky situations and prepare coping strategies in advance
• with smoking behavior, relapse is the rule

Question 8

Answer 8

preparation

if she was in the contemplation stage, she wouldn’t be ready to set a date; “I’m thinking about quitting, but…”

Question 9

describe indicators of physicial dependence

Answer 9

• the presence of withdrawal symptoms
• difficulty of previous cessation attempts
• number of cigarettes smoked daily and their level of nicotine

Question 10

describe why smoking in the morning is an indicator of physical dependence

Answer 10

• physical dependence on nicotine involves some degree of withdrawal during sleeping hours
• thus, upon awakening there is an increased need for nicotine and it is particularly enjoyable to smoke at this time

Question 11

describe FDA approved products for smoking cessation

Answer 11

• the FDA has approved several nicotine replacement products (NRTs)
  
  • gum
  • transdermal patch
  • nasal spray
  • vapor inhaler
• NRTs double long-term cessation rates and relieve withdrawal and craving

Question 12

describe FDA-approved drugs that help with smoking cessation

Answer 12

• sustained release bupropion (Zyban)
  
  • AD with dopaminergic and noradrenergic activity
• varenicline (Chantix): partial agonist
  
  • eases withdrawal by stimulatin nicotine receptors, blocks them if patient takes up smoking again
  • Chantix has been associated with suicidal ideation–banned in 2008 by FAA for use among pilots and air traffic controllers

Question 13

describe psychological and social determinants of smoking

Answer 13

• smoking is a learned behavior
• cigarettes often become associated with certain events such as social occasions, eating, relaxing, sexual encouters, drinking alcohol, etc.
• these situational discriminative stimuli trigger the desier to smoke (classical and operant conditioning)

Question 14

describe why smoking is a negative reinforcement

Answer 14

• cigarettes are commonly used to handle stress, anxiety, depression and anger
• such unpleasant states = internal discriminative stimuli leading to the behavior of smoking
• smoking tends to relieve such states (negative reinforcement)

Question 15

describe stress management and assertiveness training in smoking cessation

Answer 15

• stress management: many different approahces–progressive muscle relaxation, yoga, meditation, qigong, biofeedback, guided imagery, tai chi, biofeedback, self-hypnosis
• assertiveness training: designed to help patients resist social pressures to smoke–i.e. to empower them to speak up for themselves and say “no, thanks”

Question 16

describe when NRTs are not recommended

Answer 16

• few withdrawal symptoms
• relapse > 2 weeks
• low FTND (Fagerstrom Questionnaire of Nicotine Dependence)

Question 17

describe when NRTs are recommended

Answer 17

• history of withdrawal symptoms
• relapse < 1 week
• high FTND

Question 18

describe the different types of therapies for the different types of psychological dependences

Answer 18

Question 19

describe social support and therapies

Answer 19

Question 20

Answer 20

she wants to quit, BUT she is stressed, therefore contemplation

Question 21

Answer 21

she is stressed –> relaxation training

she started again because all of her friends smoke –> group therapy needed

FTND low, low physical dependence, quit for a month –> NO NRTs

Question 22

describe the abstinence violation effect (AVE)

Answer 22

• AVE is often seen following unplanned return to use
  
  • self-blame
  • guilt
  • loss of confidence
• physician needs to help patient refram this as a “slip” or “lapse” as opposed to a “relapse”
  
  • “slips are normal and to be expected”
  • “that wasn’t a failure, it was that a short success”

Question 23

describe the weight gain barrier to smoking cessation

Answer 23

• smokers weight 5-10 lb less than nonsmokers
• when smokers quit, 80% of them gain weight
• a nicotine-related decrease in metabolic rate and possibly increases in foot intake appear significant
• weight gain may be a trigger to relapse in some cases
• clinician response: reassurance that gain won’t be as much as feared; encourage vigorous exercise

Question 24

describe depression as a barrier to smoking cessation

Answer 24

• there is a strong association between smoking and mood disorders
• depressed smokers are less likely to stop smoking than non-depressed smokers
• if depression is present, it should be treated before cessation is attempted

Question 25

describe substance abuse as a barrier to smoking cessation

Answer 25

• there is a high rate of smoking among users of alcohol, cocaine and heroin
• even among smokers who do not abuse alcohol, drinking is commonly associated with smoking relapse

Question 26

describe social support as a barrier to smoking cessation

Answer 26

• smokers with nonsmoking spouses are more likely to be successful in quitting
• smokers whose efforts to quit are supported by significant others and friends have greater success
  
  • involving significant others in treatment is beneficial
• group therapy: good source of support

Question 27

describe motivational interviewing (MI)

Answer 27

• theory of reactance: people are strongly motivated to maintain a sense of autonomy and to resist and defend their behavior when criticized
• MI is based on the premise that it is much better to build on the patient’s self-motivation to change
• MI involves an interview style emphasizing empathy, curiosity, self-determination and acceptance

Question 28

name the 4 main principles of motivational interviewing

Answer 28

• roll with the resistance
• develop discrepancy
• express empathy
• enhance self-efficacy

Question 29

describe the method of roll with the resistance during MI

Answer 29

• expect resistance: it’s natural–change is difficult
• don’t fight against it: flow with it
• patient must come to own conclusion that it’s best to change–goal is not to impose new view/goal
• the “righting reflex”: it can be difficult for the clinician to resist telling patient she/he is doing something wrong and to resort to direct persuasion

Question 30

describe the method of “develop discrepancy” during MI

Answer 30

• the patient is stuck and needs your help to move along
• help patient see the discrepancy between where they want to be and where they are now
• if they accept your invitation of assistance it will be becuase of their own reasons

Question 31

describe the method of “express empathy” during MI

Answer 31

• accept patients for who they are–judging or blaming is counterproductive
  
  • this does not necessarily imply condoning their behavior
• the paralyzing ambivalence clinicians see in their patients with regard to changing health behaviors that appear to clearly damaging can be better understood through clinician self-reflection and self-awareness

Question 32

describe the method of “enhace self-efficacy” during MI

Answer 32

• “self-efficacy” (self-confidence) is critical for behavior change
  
  • you’ve got to believe you can do it
• be supportive, get creative–help patient see what a difference behavior change will make in her life