Post on 22-Jan-2016
description
How Psychological How Psychological Assessments Can Help Assessments Can Help
You With Those You With Those Puzzling PatientsPuzzling Patients
Add Your Name HereAdd Your Name Here
What Percent of Primary Care What Percent of Primary Care Visits Are Driven By Visits Are Driven By
Psychological Factors?Psychological Factors?
60%
40%
Medical Reason
Psychological Reason
Cummings & VandenBos, Cummings & VandenBos, 19811981
Of The 10 Most Common Physical Of The 10 Most Common Physical Complaints In Primary Care, Complaints In Primary Care,
What Percent Were Explained What Percent Were Explained Organically ?Organically ?
85%
15%
Organic Basis Found
No Organic Basis Found
Kroenke & Mangelsdorff, Kroenke & Mangelsdorff, 19891989
Primary care MDs Primary care MDs treat more patients treat more patients with psychological with psychological conditions than do conditions than do
mental health mental health professionals professionals
In The Fast Pace of Primary In The Fast Pace of Primary Care, Many Mental Health Care, Many Mental Health Patients Fall Through the Patients Fall Through the
CracksCracks Patients with psychological problems Patients with psychological problems
are difficult to treat in the primary are difficult to treat in the primary care systemcare system
As a result, psychiatric disorders are As a result, psychiatric disorders are overlooked by primary care overlooked by primary care physicians between 33% and 79% of physicians between 33% and 79% of the time (Higgins, 1994).the time (Higgins, 1994).
You Order Tests You Order Tests All Of The TimeAll Of The Time
X-rays, MRIs, Blood Tests,EKGs, X-rays, MRIs, Blood Tests,EKGs, etc.etc.
Ironically, what you see so oftenIronically, what you see so often
— Stress and Psych Problems —— Stress and Psych Problems —
is the one thing you cannot is the one thing you cannot order a test for.order a test for.
Until now.Until now.
True or False?True or False?
Since pain and depression are Since pain and depression are subjective states, they cannot be subjective states, they cannot be measured scientifically.measured scientifically.
FalseFalse
Psychometrics is the Psychometrics is the scientific method used scientific method used
to assess subjective to assess subjective states, such as pain, states, such as pain,
depression or anxiety.depression or anxiety.
How Good Are How Good Are Psychometric Tests?Psychometric Tests?
A review based on 125 meta-A review based on 125 meta-analyses and 800 studies concluded analyses and 800 studies concluded good psychometric tests are good psychometric tests are comparable to good medical tests in comparable to good medical tests in their ability to diagnose and predict their ability to diagnose and predict outcome (Meyer, et al, 2001)outcome (Meyer, et al, 2001)
Psychological factors are more Psychological factors are more reliable predictors of back pain than reliable predictors of back pain than imaging and diagnostic disc injection imaging and diagnostic disc injection (Carragee et al, 2004)(Carragee et al, 2004)
What is the Value of What is the Value of using Psychological using Psychological
TestsTests How much more difficult would you How much more difficult would you
life be if you didn’t have tests like x-life be if you didn’t have tests like x-rays or blood tests?rays or blood tests?
In the same way, psychometric tests In the same way, psychometric tests can help you assess subjective can help you assess subjective experiences, and identify experiences, and identify psychosocial complicationspsychosocial complications
New psychological tests, New psychological tests, like the BHIlike the BHI™™ 2 and BBHI 2 and BBHI™™
2, have been developed 2, have been developed specifically use with specifically use with medical patients…medical patients…
and can help to answer and can help to answer many of your questions.many of your questions.
Is This Patient’s Level Of Pain High?Is This Patient’s Level Of Pain High?
Is this pain higher than Is this pain higher than the average patient?the average patient?
Is it higher than the Is it higher than the average healthy person?average healthy person?
What is the patient’s pain What is the patient’s pain percentile rank?percentile rank?
A BHI 2 could answer A BHI 2 could answer these questionsthese questions
10 = Bad Pain
0 = No Pain
8
9
7
5
6
3
1
2
4
Rate Your PainRate Your Pain
What Psych Conditions What Psych Conditions Bring Patients into Bring Patients into
Primary Care?Primary Care?
Chronic Pain/ Somatization
25%
Family Problems
10%
Job Stress 10%
Anxiety20%
Depression 20%
Misc 15%
Tulkin and Gordon, Tulkin and Gordon, 19981998
Miscellaneous includes substance abuse & personality disorders
Only The BHI 2 Assesses All Of These Variables
The BHI 2 was designed The BHI 2 was designed to help psychologists and to help psychologists and
physicians collaboratephysicians collaborate It can help to answer a physician’s It can help to answer a physician’s
questionsquestions
It points out to the psychologist what It points out to the psychologist what info is needed from the physicianinfo is needed from the physician
The Health PsychologyThe Health PsychologyArrow of Causality:Arrow of Causality:Which Comes First?Which Comes First?
Severe Physical
Symptoms
Extreme Anxiety
Only the BHI 2 and BBHI 2 Only the BHI 2 and BBHI 2 interpret both possibilitiesinterpret both possibilities
The BHI 2 and BBHI 2 The BHI 2 and BBHI 2 allow you to track allow you to track
changes in painchanges in pain
The BHI 2 Was Designed to The BHI 2 Was Designed to Assess Common Psychological Assess Common Psychological
ConcernsConcerns
DepressionDepression AnxietyAnxiety Family DysfunctionFamily Dysfunction Survivor of ViolenceSurvivor of Violence Borderline personalityBorderline personality Etc.Etc.
They Were Also Designed to They Were Also Designed to Assess Common Medical Assess Common Medical
Concerns.Concerns. PainPain
Including percentile rank, variability and Including percentile rank, variability and distributiondistribution
FunctioningFunctioning SomatizationSomatization Satisfaction with medical careSatisfaction with medical care Prescription abusePrescription abuse Muscular Bracing Muscular Bracing
Tension headaches, myofascial pain, TMJTension headaches, myofascial pain, TMJ Etc.Etc.
For Those Patients Who For Those Patients Who Are Especially PuzzlingAre Especially Puzzling
60%
40%
Medical Reason
Psychological Reason
40%
60%
Medical Reason
Psychological Reason
A certain percentage of psychologically-involved patients may be difficult for you to figure out. A referral for a BHI 2 test might shed some light on the matter.
Case HxCase Hx
39 Year old female. Somatization?39 Year old female. Somatization? diffuse physical symptomsdiffuse physical symptoms no objective medical findingsno objective medical findings resists examinationresists examination noncompliant with PTnoncompliant with PT no response to any treatmentno response to any treatment
QuickTime™ and aTIFF (LZW) decompressor
are needed to see this picture.
On the BHI 2 On the BHI 2 bidirectionalbidirectional scales, the scales, the length of the bar shows length of the bar shows
how far the score how far the score deviates from the mean.deviates from the mean.
QuickTime™ and aTIFF (LZW) decompressor
are needed to see this picture.
Case History 1: ValidityCase History 1: Validity
These validity scoresgive no indication of
biased responding
Validity Scales
QuickTime™ and aTIFF (LZW) decompressor
are needed to see this picture.
Case History 1: Physical Sx ScaleCase History 1: Physical Sx Scale
Unusually high level of diffuse somatic symptoms, coupled with
great difficulties functioning
Physical Symptom Scales
QuickTime™ and aTIFF (LZW) decompressor
are needed to see this picture.
Case History 1: Affective scalesCase History 1: Affective scales
Reports of depression Reports of depression are are higherhigher than 87% of than 87% of
patientspatients
Affective Scales
Very Very lowlow level of anger. Total absence of anger, level of anger. Total absence of anger, or difficulty expressing angry feelings?or difficulty expressing angry feelings?
(Somatization often involves denied feelings)(Somatization often involves denied feelings)
QuickTime™ and aTIFF (LZW) decompressor
are needed to see this picture.
Case History 1: Psychosocial ScalesCase History 1: Psychosocial Scales
Psychosocial Scales The patient reports a history of
trauma and abuse. Is that why she hates being examined?
The patient views the workplace and medical setting as being supportive.
QuickTime™ and aTIFF (LZW) decompressor
are needed to see this picture.
Case History 1: Character ScalesCase History 1: Character Scales
Character Scales Symptom Dependency High =
using symptoms to meet dependency needs
Perseverance High = still showing some
determination and optimism
TreatmentTreatment
During examination and procedures, During examination and procedures, be sensitive to her Hx of traumabe sensitive to her Hx of trauma
Initiate treatment for depressionInitiate treatment for depression Psychotherapy and Rx Psychotherapy and Rx
Assertiveness training for Assertiveness training for appropriate expression of anger appropriate expression of anger
TreatmentTreatment
Work to improve support systemWork to improve support system Decrease family conflicts if possibleDecrease family conflicts if possible
Set up behavioral plan to help her to Set up behavioral plan to help her to increase her level of functioning increase her level of functioning
Encourage Encourage occasionaloccasional medical visits medical visits its an important part of her support systemits an important part of her support system overall work to decrease medical overall work to decrease medical
utilization by addressing underlying psych utilization by addressing underlying psych problemsproblems
The Results?The Results?
A satisfied patient who gets the care A satisfied patient who gets the care she needs…she needs…
And for you, the satisfaction of And for you, the satisfaction of effectively treating a challenging effectively treating a challenging case.case.