Using the MBMD in Bariatric Surgery
Michael Antoni, Ph.D. and Anne-Marie Kimbell, Ph.D.
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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.
Using the MBMD in Bariatric Surgery
Michael Antoni, Ph.D. and Anne-Marie Kimbell, Ph.D.
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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
Using the MBMD in Bariatric Surgery
Michael Antoni, Ph.D. and Anne-Marie Kimbell, Ph.D.
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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
Using the MBMD in Bariatric Surgery
Michael Antoni, Ph.D. and Anne-Marie Kimbell, Ph.D.
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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.
Using the MBMD in Bariatric Surgery
Michael Antoni, Ph.D. and Anne-Marie Kimbell, Ph.D.
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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)
Using the MBMD in Bariatric Surgery
Michael Antoni, Ph.D. and Anne-Marie Kimbell, Ph.D.
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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
Using the MBMD in Bariatric Surgery
Michael Antoni, Ph.D. and Anne-Marie Kimbell, Ph.D.
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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
Using the MBMD in Bariatric Surgery
Michael Antoni, Ph.D. and Anne-Marie Kimbell, Ph.D.
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MBMD
Seven MBMD Domains
Negative Health Habits
(6 scales)Response Patterns
(3 scales)
Psychiatric Indications
(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.
Using the MBMD in Bariatric Surgery
Michael Antoni, Ph.D. and Anne-Marie Kimbell, Ph.D.
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MBMD
Negative Health Habits
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
Psychiatric Indications
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
Using the MBMD in Bariatric Surgery
Michael Antoni, Ph.D. and Anne-Marie Kimbell, Ph.D.
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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
Using the MBMD in Bariatric Surgery
Michael Antoni, Ph.D. and Anne-Marie Kimbell, Ph.D.
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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
Treatment Prognostics
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.
Using the MBMD in Bariatric Surgery
Michael Antoni, Ph.D. and Anne-Marie Kimbell, Ph.D.
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MBMD
Treatment Prognostics
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.
Using the MBMD in Bariatric Surgery
Michael Antoni, Ph.D. and Anne-Marie Kimbell, Ph.D.
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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.
Using the MBMD in Bariatric Surgery
Michael Antoni, Ph.D. and Anne-Marie Kimbell, Ph.D.
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MBMD
Bariatric Surgery Patient Norms
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
Bariatric Surgery Patient Norms
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%)
Using the MBMD in Bariatric Surgery
Michael Antoni, Ph.D. and Anne-Marie Kimbell, Ph.D.
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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.
Using the MBMD in Bariatric Surgery
Michael Antoni, Ph.D. and Anne-Marie Kimbell, Ph.D.
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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
Using the MBMD in Bariatric Surgery
Michael Antoni, Ph.D. and Anne-Marie Kimbell, Ph.D.
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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
Using the MBMD in Bariatric Surgery
Michael Antoni, Ph.D. and Anne-Marie Kimbell, Ph.D.
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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
Using the MBMD in Bariatric Surgery
Michael Antoni, Ph.D. and Anne-Marie Kimbell, Ph.D.
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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)
Using the MBMD in Bariatric Surgery
Michael Antoni, Ph.D. and Anne-Marie Kimbell, Ph.D.
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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
- Intervention Fragility
+ Psy Ref
Using the MBMD in Bariatric Surgery
Michael Antoni, Ph.D. and Anne-Marie Kimbell, Ph.D.
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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
- Intervention Fragility
- Info discomfort
- Problematic Compliance
Interpretation
Using the MBMD in Bariatric Surgery
Michael Antoni, Ph.D. and Anne-Marie Kimbell, Ph.D.
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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
Using the MBMD in Bariatric Surgery
Michael Antoni, Ph.D. and Anne-Marie Kimbell, Ph.D.
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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
Using the MBMD in Bariatric Surgery
Michael Antoni, Ph.D. and Anne-Marie Kimbell, Ph.D.
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MBMD
Sample Report
Name Female A
Age 34
Gender F
Race White
Marital Status Married
Education Bachelor’s Degree
MBMD
Response Patterns and
Negative Health Habits
Using the MBMD in Bariatric Surgery
Michael Antoni, Ph.D. and Anne-Marie Kimbell, Ph.D.
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MBMD
Psychiatric Indications and
Coping Styles
MBMD
Stress Moderators
Using the MBMD in Bariatric Surgery
Michael Antoni, Ph.D. and Anne-Marie Kimbell, Ph.D.
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MBMD
Treatment Prognostics and
Management Guides
MBMD
Bariatric Summary
Using the MBMD in Bariatric Surgery
Michael Antoni, Ph.D. and Anne-Marie Kimbell, Ph.D.
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MBMD
MBMD
Using the MBMD in Bariatric Surgery
Michael Antoni, Ph.D. and Anne-Marie Kimbell, Ph.D.
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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
Using the MBMD in Bariatric Surgery
Michael Antoni, Ph.D. and Anne-Marie Kimbell, Ph.D.
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MBMD
Training Opportunities
Online Training Available (earn up to 3 APA CE credits)
www.PearsonClinical.com/MBMD
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