Integrated Primary Care .pptx

Co-Morbid Behavioral Health Problems
with Common Medical Diagnoses:
Lunch Trainings for Medical Personnel
in Primary Care
The Center for Cognitive and Behavioral Therapy, Inc.
4624 Sawmill Rd.
Columbus, OH 43220
Offices in Westerville & Gahanna, and Co-Located in Primary Care Offices
Co-Morbid Behavioral Health Problems with Common
Medical Diagnoses: Lunch Trainings for Medical
Personnel in Primary Care
© The Center for Cognitive and Behavioral Therapy, 2019, all rights reserved

• CoMorbidity with Anxiety and Depression (Rechenberg, Whittemore
& Grey, 2017)
• Kovacs et al. (1990)
• Mental Health Disorders: 47.6%
• Anxiety: 19.6%
• Depression: 26.1%
• Bernstein et al (2013)
• Mental Health Disorders: 34.7%
• Anxiety: 21.3%
• Depression: 11/3%
Behavioral Health Issues and Type 1 Diabetes (T1D)

• Frequent Cognitive and Behavioral Case Formulation Concepts
• Fear of Hypoglycemia
• Worry about Hypoglycemia
• Misattribution of Sxs
• Over-Monitoring of Physical Sensations
• Avoidance

• Diabetes Distress/The Wall
• Impact of Chronic + Acute
• Fatigue of Management Requirements

• Frequent Cognitive and Behavioral Case Formulation
Concepts: Distress vs Depression

Evidence-based Treatment Protocol Components
• Behavioral Targets:
• Dietary Modifications
• Glucose Monitoring
• Food Monitoring
• Medication (non-pump patients)
• Motivation Improvement through Meaning of Behavioral
Targets (Shift to Life Sustaining/Improving)
• Life Steps (Brief)
• Identification of Each Task for Behavioral Targets
• Reframe Meaning
• Set Goals, Identify Barriers, and Solutions to Barriers

Evidence-based Treatment
Protocol Components
• Managing Distress and
Depression
• Education of Parents and
Child on Reward Erosion

Protocol Components
Depression
• Behavioral Activation with
Goals
• Prompts
• Praise for Success
• Tokens and Contracts

OH 0-4 235 6.2 1.91 (3.4 – 11.2) 32,918 (12,828 –
53,007)
OH 5-9 295 15.2 3.64 (9.3 – 23.8) 95,543 (45,950 –
145,136)
OH 10-14 377 16.4 2.92 (11.5 – 23.0) 99,558 (61,145 –
137,971)
OH 15-17 338 17.5 3.38 (11.9 – 25.2) 71,281 (41,282 –
101,281)
State Age Group Sample Size Prevalence
(Percent)
Standard
Error
95% CI *
(Percent)
Prevalence
(Number)
95% CI *
(Number)
Source: CDC
Prevalence of Asthma
Behavioral Health Issues and Childhood Onset Asthma

Source: HHS
Co-Morbidity
No. with Disorder Co-Morbid Percentage
and 95% CI among
Children with Asthma
No. W/O Disorder No Co-Morbidity
Percentage and 95% CI
among Children with
Asthma
Depression 77 6.6 (4.7, 8.5) 261 2.5 (2.1, 2.8)
Difficulty
with
emotions,
concentration,
behavior, or
getting along
321 26.9 (23.6, 30.2) 1,608 16.9 (15.9, 17.9)
Frequently
anxious,
nervous, or
worriedb
167 13.5 (10.9, 16.2) 713 7.1 (6.4, 7.7)

• Common Behavioral Problems Affecting Disease Management or Medical
Treatment
• Beware Misdiagnosis of NSEs (Insomnia, Loss of Appetite, Mood Changes)
• Family Conflict Worsens Treatment Outcomes
• Impact in Teen Years to Peer Pressure
• Problems with Medication Adherence and Management of Allergen Exposure
• Breathing Retraining, Minimizing Thoughts re: Asthma Chronicity-–Nonadherence
• Evidence-based Treatment Protocol Components
• Breathing Retraining/Breathing Control
• Self-Management Skills
• Parental Anxiety Management
• Application of CBT Methods in the General Case
• MI, Development of Self-Management Skills, Breathing Retraining, Parental SOC
Strategies, Coping with Anxiety

Behavioral Health Issues and Encopresis
• Elimination Disorders: Constipation, Encopresis and Enuresis
• Prevalence of Elimination Disorder
• 2018 Meta-analysis of Ages 5-18 Years (Koppen, et al. 2018)
• Functional Constipation: .5% to 32%, Pooled 9.5%
• Functional Encopresis: Pooled .4%
• 2016 Study of Nocturnal Enuresis in School Aged Children (Sarici, et al. 2016)
• 9.52% Prevalence
• Boys: 12.4%, Girls 6.5%
• 48% of Enuresis Children did Poorly in School

Behavioral Health Issues and Encopresis
Treatment
• Avoidance of Bathrooms
• Hiding Soiling
• Parental Anger
• Elimination Disorders Function to Avoid Distress and Anxiety, Coupled with
Respondent Conditioning Problems
• Encopresis: Enhanced Toilet Training
• Psychoeducational Intervention
• Toilet Training
• Parent Training

Behavioral Health Issues and Enuresis
• Enuresis
• Collect Data on Time of Urination
• Coordination with Physician on Fluid Intake Patterns
• Awaken and Void
• Fade Prompts to Void
• Use of Electronic Alerting Systems

Behavioral Health Issues and Food Allergies
Peniamina, et al. 2016

Behavioral Health Issues and Food Allergies
Treatment Options
• Child Treatments: Exposure Based Interventions
• Coping Skills
• Recognizing the Difference Between Anxiety Physical Symptoms vs. Allergic Reactions
• Identifying Fear-Inducing Cognitions through Cognitive Therapy and Psychoeducational Interventions (e.g.,
actual risk of death from allergy)
• Use of Calming Strategies to Help in Discriminating Anxiety from Allergy
• Implementation of Graduated Exposure with Use of Coping Cognitions and Anxiety Tolerance
• Response (Avoidance) Prevention
• Self-Reward for Exposure and Response Prevention
• Parental Treatment (Parent Anxiety)
• Psychoeducational Interventions to Modify Catastrophic Cognitions
• Use of Parent Management Training to Reduce/Eliminate School Avoidance or Refusal
• Contingency Management through Ignoring or Non-Rewarding Outcomes for Calls to Parents
Source: Masia, Mullen & Scotti, 1998

Behavioral Health Issues and ADHD
Co-Morbidities with ADHD

• ADHD and Anxiety/Depression
Treatment
• Aggravation of Anxiety with Stimulants
• Medication Non-Compliance
• Parental Anxiety-Aggression Impact on Parenting
• Neurobiological Impact of ADHD on Emotional Regulation and Social Conflict
• Barkley Video 1
• Barkley Video 2
• Anxiety Learning through Unanticipated Failure or Punishment
• Difficulty Recognizing Problem Definition to Create Adaptive Strategies
• Exposure to Punitive Parenting and Peer Hostility/Rejection
• Creates Respondent Conditioning of Anxiety Response and Cognitions of Poor Capacity to
Cope

• ADHD and Anxiety/Depression
• Application of Coping + Exposure/Coping Opportunities
• Identify and Manage Catastrophic but Concrete Cognitions
• Education of Parents to Support Homework
• Application of CBT Methods
• Consult from Pediatrician on Medication Management for more Severe Cases
• Functional Analysis of Maladaptive Behaviors (Egression, Sock Shredding/Clothes
Picking, Avoidance)
• Contextual Skills Deficits (e.g., Academic, Social) and Psychoeducation Interventions
• Application of Modified Coping Cat plus Response Prevention

• ADHD and ODD
• Parent Management Training
• Understanding Behaviors and Role of Attention
• Management of Attention Contingencies and Planned Ignoring
• Use of Effective Prompts and Point-Chart Cost-Response Programs
• Effective Use of Time-Out for Temper Outbursts
• Practice Strategies in the Home
• Reprimands for Threatening Behaviors
• Application of CBT Methods
• Parental Anticipatory Anxiety: Sense of Competency Scale
• Modification of Catastrophic Ideas through Cognitive Therapy
• Overlearning through Repetitive Rehearsal of PMT in Anxiety Provoking Situations
• Tag-Teaming as Parents

Behavioral Health Issues and TICS (Breakthroughs on Stimulants)
Tics/TS with and
without ADHD
Across Other
Disorders
Source: Freeman, 2007

Behavioral Health Issues and TICS (Breakthroughs on Stimulants)
• Tics
• Habit based Repetitive Movements
• Eye Blinking
• Sniffing
• Throat Clearing
• Evidence-based Treatments
• Habit Reversal Therapy
• Development of Functional Understanding
• Development of Stress Management and Coping
• Introduction of Competing, Functional Behaviors
• Use of Contingent Rewards for Competing Behaviors
• Introduction of Tic Disruption Skills

FAMILY/INTERNAL ADULT
MEDICINE SLIDES

• CoMorbidity with Anxiety and Depression (R. T., Gelb, S., Suglia, S. F., Keyes, K. M., Aiello, A. E., Colombo, P. C., Galea, S., Uddin, M., Koenen, K. C., & Kubzansky, L. D. (2015). Sex
differences in the association between depression, anxiety, and type 2 diabetes mellitus. Psychosomatic medicine, 77(4), 467-77.

Mortality Risk for Type 2 Diabetes
“Three clear patterns emerged from this large, population-based study of mortality risk associated with type 2
diabetes and comorbid depression and anxiety.
• First, mortality risk was lowest for affective symptoms alone, higher for diabetes alone, and highest for both
combined.
o Highest Mortality Risk for Affective Symptoms with T2D
• Second, excess mortality among those with diabetes was observed to be lowest for anxiety alone, higher for
combined depression and anxiety, and highest for depression alone.
o Highest Mortality Risk for Those with T2D is Co-Morbid Depression
• Third, the effects of mental health symptoms appeared to be stronger in men with diabetes than in women.
Overall, the highest risk of death was observed in men with diabetes and concurrent symptoms of depression
alone. (p. 355)“
o Highest Mortality Risk for Men with T2D and Depression Alone
Naicker, K, Johnson, JA, Manuel, D, Skogen, JC, Overland, S, Siversten, B. & Colman, I. (2017). Type 2 Diabetes and comorbid

Behavioral Health Issues and Diabetes
Source:
https://www.lark.com/blog/depr
ession-and-diabetes

• Fear of Hypoglycemia
• Worry about Hypoglycemia
• Misattribution of Sxs
• Over-Monitoring of Physical Sensations
• Avoidance
• Distress vs Depression

Behavioral Health Issues and Type 2 Diabetes
• Behavioral Targets:
• Dietary Modifications
• Glucose Monitoring
• Food Monitoring
• Medication (non-pump patients)
• Motivation Improvement through Meaning of Behavioral
Targets (Shift to Life Sustaining/Improving)
• Life Steps (Brief)
• Identification of Each Task for Behavioral Targets
• Reframe Meaning
• Set Goals, Identify Barriers, and Solutions to Barriers

Protocol Components
Depression
• Education of Parents and
Child on Reward Erosion

Protocol Components
Depression
• Behavioral Activation with
Goals
• Prompts
• Praise for Success
• Tokens and Contracts

Adults: ADA 2019 Guidelines (Diabetes Care Supplement 1, Vol. 41)
Diabetes: Behavioral Patient-Centered Collaborative Care
• Setting Goals:
• Specific, Measurable, Achievable, Realistic, Time-limited (ADA 2019
Guidelines)
• Assessment of Co-Morbidities
• Screening for Depression, Anxiety and Disordered Eating (All have
Valant Instruments)
• Initial Visit and Annually
• Depression: PHQ-9, Anxiety: GAD-7; Eating Problems: Eating
Disorders Examination Questionnaire (EDE-Q)
• Screen for Cognitive Impairment (Valant MSE)

Behavioral Health Issues and Obesity

Baumeister, H & Harter, M (2007)

Obesity: Behavioral Patient-Centered Collaborative Care
• Behavior Therapy Targets
• >5% Weight Loss: Setting Realistic Goals through Psychoeducational Information on 5% Loss
• Modification of Energy Deficiency to 500-700 KCAL/Day
• Motivational Interviewing and Readiness to Lose Weight: Seeking to use Empathy to Obtain
Agreement
• Calorie Reduction or Meal Replacement
• Self-Monitoring of Weight, Food Intake, Exercise-Energy Expenditure
• Behavioral Change Planning
• Assess Food Intake and Types of Foods Eaten (Dense Calorie vs. Less Dense)
• Daily Calorie Monitoring with a Food Diary
• Focus on Simple Changes to Foods Eaten (Small changes, concrete changes) e.g., 500 C
reduction
• Modification of Eating Habits (See Handout Modifying Eating Habits)

Adults
• Obesity and Exercise
• Asking Patient if They Need to Change
• Psychoeducation on 30 minutes of moderate activity 5 days per week
• How To Change Plan
• Find FUN Activities
• Set Short and Long Term Goals (Attainable, Measurable, and Concrete)
• Start Slow and Build Up
• Track Progress (use self-monitoring forms or apps)
• Have a Plan B—What if I Can’t Do my Plan?
• Self-Reward Every Day!

https://www.move.va.gov

Behavioral Health Issues and Pain
Source: Hooten, WM
(2016)—Mayo Symposium
on Pain

Adults
Pain: Assessment & Treatment
DoD Chronic Pain BPS Assessment (Hunter, Supplement 2)
1. Pain Symptom Description
2. Location of Pain in Body
3. Onset, Frequency, Duration
4. Subjective Rating 10 = Worst, 0 = Absence
A. Average 2 Weeks
B. Worst 2 Weeks
C. Lowest 2 Weeks
D. Current Level
5. Factors Associated with Increased/Decreased Pain
6. Medical Conditions Related to the Pain
7. Pain Meds and Use Patterns
8. Psychological Changes Co-occurring with Pain Event
9. BPS Assessment of Functioning Across Domains of Life Functions/Roles

Adults
• Treatment Factors/Components (Hunter et al., 2017)
• Psychoeducational Resources
• Pain Diary/Monitoring
• Activity Pacing
• Behavioral Activation
• Relaxation Training
• Skills Training (Intense Episode)
• Cognitive Reframing
• Decreasing Pain Behaviors
• Nutrition and Sleep (with Referral to Specialists of Needed)
• Improving Medication Adherence
• Improving Use of Ambulatory Devices
• Collaboration with PCP

Adults
• Pain Pathway Conceptualization
(Hunter et al., 2017)
• Pain Gate Openers
• Depression
• Anxiety
• Fear
• Focused Attention on Injury
• Sense of No Personal Control
• Negative Thinking Patterns
• Social Withdrawal
• Pain Gate Closers
• Emotional Control/Regulation
• Relaxation
• Mental Distraction (Mindfulness)
• Positive Thoughts
• Sense of Personal Control
• Engaging in Pleasurable Activities (Pleasure
Scheduling)

Adults
• Common Pain Beliefs (Hunter et al., 2017)
• Pain Must Be a Serious Disease or Injury
• False: Pain is a neurologic process not
related 1:1 to the severity of any physical
harm
• It’s Best to Rest and be Inactive
• False: Rest until the injury has healed, then
build strength and return to being active with
PCP oversight
• Other People Must Understand How Bad this
Hurts
• False: This goal will keep you focused on
your pain, can lead you to be disappointed,
and build resentment from others. Try
having a small group of confidants, cope as
best you can, and keep others as unaware as
possible.
• Pain means I’m broken
• False: Negative self-statements make things
worse. Find ways to know your goals, be sure to
work to meet your goals as much as possible,
and find ways to do what gives your life
meaning.
• My Goal is to be Pain Free
• False: A realistic goal is to find things than give
life meaning while accepting some pain.

Adults
• Five Steps of Pain Management for Intense Episodes(Hunter et al., 2017)
• Management of self-talk.
• Use Point-Counterpoint Strategy
• Use Relaxation Strategies to Maintain Maximum Relaxed State
• Create Imagery that Promotes Distraction of Attention from Pain Cues to Help Close Gates
• Effectively Use Pain Medication, Particularly at Onset through Early Warning Signal Monitoring
• Communicate with Supports and Express both What is Helpful and What is Harmful

Behavioral Health Issues and COPD
Co-Morbidities (Yohannes,
Baldwin, & Connolly, 2000)
• 40% Depression
• 36% Anxiety
Baker, et al., 2018

Shortness of Breath Cycle COPD/Asthma (from Hunter et al., 2017)
Shortness of breath
Anxiety or Panic
Increased Resp. Rate
of Breathing Effectiveness
Increased Oxygen Use by Muscles
Increased Shortness of Breath
Perpetuation of Cycle Worsening

Areas of Suggested Assessment by PCP
• Breathing Symptoms
• What affects your breathing and what happens after an episode?
• Medication
• Do you ever not take your medicine?
• Social Functioning
• Wat types of changes from COPD have occurred at Work, Home, Socially
• Emotional and Cognitive
• Describe any changes in mood or fearfulness since COPD
• What are some of the thoughts you have when you are short of breath?
• Health Related Behaviors
• Describe your exercise routines
• Interventions
• Are you doing any coping strategies like relaxation or relaxed breathing?

Areas of Possible Behavioral Interventions (Hunter et al., 2017)
• Exercise Training
• Diaphragmatic Breathing
• Anxiety-Dyspnea Cycle
• Psychoeducational Intervention on Physical—Cognitive—Emotional Triad
• Provide Handouts with Permission (MI)
• Cognition Modification
• Assess Cognitive Distortions
• Develop Alternative Coping Thoughts
• Employ a Stop-Rest-Relax-Rethink Template for Coping

Behavioral Health Issues and Cardio-Vascular Disease
Comorbidity with Anxiety and Depression
• 84M US, 2200 Deaths/day, Heart Attack Victims have an 18-
20% Chance of Developing Depression, HA with Depression
puts Likelihood of Death within 6 Months 3-4 Times Greater
(https://www.healthyplace.com/depression/articles/co-
occurrence-of-depression-with-heart-disease)
• Coronary Heart Disease has 25-25% Comorbidity with Anxiety,
Anxiety Increases Likelihood of Sudden Cardiac Death
• Some Data Support Hostility/Anger as a Risk Factor for CVD

Source:
https://www.cfrjourna
l.com/articles/depressi
on-patients-heart-
failure

• Common Behavioral Problems Affecting Disease
Management or Medical Treatment
• Tobacco Use, Obesity/Poor Diet Habits, Physical Inactivity,
Alcohol Consumption, Medication Compliance
• Frequent Cognitive and Behavioral Case Formulation
Concepts
• Emotional Stress Factors, Depression & Anxiety, Hostility and
Anger
• Targets include Weight/Diet, Smoking/Alcohol, Anger
Outbursts, PCP Guided Exercise

• MI Informed Assessment and Consult on Unhealthy Behaviors
and CBT Weight Reduction
• Relaxation and Stress –oriented Cognitive Restructuring, BP
Pre-Post
• Depression CBT Informed by Catastrophic Death Thoughts
• Anger/Hostility: CBT of Anger, Use of Constructivist
Intervention, Assertiveness Training

From https://www.medscape.org/viewarticle/749924

Behavioral Health Issues and Sleep Disorders
From Downloaded from https://academic.oup.com/sleep/article-abstract/35/10/1367/2596067

Common Behavioral Problems Affecting Disease
Management or Medical Treatment
• Nicotine/Alcohol Use, Non-Sleep Behaviors in Bed, Poor Activity
Levels
Frequent Cognitive and Behavioral Case Formulation
Concepts
• Target Substance Use Reduction/Cessation, Stress Reactions to
Sleeplessness, Cognitive-based Anxiety Induction, Stress from
Secondary Sources

• CBT-I
• Creation of a Sleep Hygiene
• Relaxation Therapy
• Mindfulness/staying Present
• Use of Deep Breathing and Guided Imagery
• Stress Mgt/Resilency
• Creation of Coping Strategies and Problem Solving Orientation
• Cognitive Modification
• Identification and Restructuring of Beliefs and Unhealthy Cognitions
• Stimulus Control Strategies
• Creating Bedroom Stimulus Control of Sleep Onset

CBT for Insomnia Effects
[From Abstract: Davidson, J. R., Dawson, S., & Krsmanovic, A. (2019). Effectiveness of Group Cognitive
Behavioral Therapy for Insomnia (CBT-I) in a Primary Care Setting. Behavioral Sleep Medicine, 17(2), 191–201.]
• Sleep onset latency, wake after sleep onset, total sleep time, sleep
efficiency, and ISI scores improved significantly (p <.001).
• Mood ratings also improved (p <.001).
• Use of sleep medication decreased (p <.001).

[From Abstract: Davidson, J. R., Dawson, S., & Krsmanovic, A. (2019). Effectiveness of Group Cognitive
Behavioral Therapy for Insomnia (CBT-I) in a Primary Care Setting. Behavioral Sleep Medicine, 17(2), 191–201.]
• Eighty-eight percent of patients no longer had clinically
significant insomnia (ISI score ≤ 14) by the last session
• 61% showed at least "moderate" improvement (ISI score reduction >
7)
• Wait-list data from 42 patients showed minimal sleep and mood
improvements with the passage of time.
• Number of visits to the family physician six months postprogram
decreased, although not significantly (p =.108).

From LUND, H. G. et al. The Discrepancy between Subjective and Objective Measures of Sleep in Older Adults
Receiving CBT for Comorbid Insomnia. Journal of Clinical Psychology, [s. l.], v. 69, n. 10, p. 1108–1120, 2013.

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