A commentary on this article appears in this issue on page 269.

Health psychology is multidisciplinary, with researchers, practitioners, and policy makers finding themselves needing at least some level of competency in a variety of areas from psychology to physiology, public health, and others. Given this multidisciplinary ontology, prior attempts have been made to establish a framework for understanding the role of biological, psychological, and socio-environmental constructs in disease development, maintenance, and treatment. Other models, however, do not explain how factors may interact and develop over time. The aim here was to apply and adapt the 3P model, originally developed and used in the treatment of insomnia, to couch the biopsychosocial model in a way that explains how diseases develop, are maintained, and can be treated. This paper outlines the role of predisposing, precipitating, and perpetuating factors in disease states and conditions (the 3Ps) and provides examples of how this model may be adapted and applied to a number of health-related diseases or disorders including chronic pain, gastrointestinal disorders, oral disease, and heart disease. The 3P framework can aid in facilitating a multidisciplinary, theoretical approach and way of conceptualizing the study and treatment of diseases in the future.

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Based on its distinctive innervation between the brain and body, the vagal nerve has long been considered to play an important role in explaining how exposure to stress leads to numerous psychiatric disorders and cardiac diseases. In contrast to activation of the sympathetic nervous system during exposures to stress, the vagal nerve is responsible for parasympathetic regulation of visceral activity including cardiac functioning that often but not always co-occurs during periods of stress. Although methods exist to measure vagal nerve influences on the heart directly, most of the literature on both human and animal participants’ responses to stress employs the measurement of heart rate variability (HRV). HRV, the tendency for the heart rate to increase and decrease in adaptation to the changing physiological and external environment, can be easily detected using surface electrodes; several HRV parameters have been shown to be valid indicators of parasympathetic nerve activity. Theories of the evolutionary heritage of the vagal nerve, like Porges’ polyvagal theory and the subsequent neurovisceral integration perspective of Thayer and colleagues that traces the autonomic regulation of the heart into higher cortical regions, have served as important conceptual works to guide empirical work examining the effects of stress on both tonic and phasic vagal activity. A number of methodological approaches have been employed to evaluate whether exposure to stress affects vagal tone, including use of animal models, case-control samples of humans exposed to stressful living situations, and samples of humans diagnosed with a range of psychiatric disorders. Findings from studies comprising this literature support a relation between exposure to stress and reduced cardiac vagal tone. Both humans and animals typically exhibit reductions in daily HRV when exposed to a range of stressful situations or contexts. The relation between stress and phasic alterations in vagal functioning, the magnitude of the acute change in HRV in response to an acute stressor, is more complicated, likely involving significant moderating variables that have yet to be elucidated. In sum, considerable evidence supports an important neuroregulatory role of the vagal nerve in modulating the body’s response to environmental stress and potentially serving as an avenue for understanding how exposure to stress increases risk for psychiatric disorders as well as cardiovascular disease.

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Introduction Based on research showing the benefits of camp settings, our overnight, 5-day summer camp is designed to provide social support, acceptance, rehabilitation, and normative childhood experiences for our pediatric burn survivors (ages 7–17). Typical recreational activities (e.g., swimming, sports, crafts) and burn-specific programming (e.g., peer support discussions) are infused into camp. Despite this enriching opportunity, some individuals decide not to attend camp. The purpose of this quality improvement study was to better understand factors influencing decisions not to attend our summer camp and to identify strategies for overcoming these barriers to optimize attendance in the future. Methods Beginning in February 2019, we attempted to contact and interview 81 guardians of children who were eligible and invited to our summer camp but did not attend in 2017 and/or 2018. Attempts to contact were made via telephone by a trained burncamp staff member. Three attempts to contact were made per family unless otherwise reached. Our interview guide elicited reasons that led to their decision not to attend camp. Interviews were completed in approximately 30 minutes or less. Results Sixty-four contacts were unsuccessful, resulting in a 79% failure to contact rate. Only 17 individuals (21%) were successfully contacted. Thirteen caregivers (16%) completed the interview via telephone, while 4 (5%) refused to take part in the interview. Principal reasons for non-attendance included school attendance, parental beliefs about camp (e.g., child being away from home), other conflicting activities (e.g., other camps, vacations), and perceived lack of need for support (e.g., my child is doing well/does not need to go to a burn camp). Conclusions Despite the positive psychosocial outcomes observed among survivors who attend camp, large numbers of families and youth are not attending. While the purpose of the study was to explore factors influencing decisions not to attend camp, we also learned that it is important to address barriers to successfully contacting families. Challenges in planning the logistics of camp, specific strategies for engaging families over time, and ideas for addressing reported barriers to attendance (e.g., empowering well-adjusted survivors to attend to support others) will be discussed in this presentation. Applicability of Research to Practice Results from this quality improvement project have impacted camp planning and recruitment strategies. Findings may lead to increased enrollment rates and enhanced awareness of camp and its benefits.

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Introduction For those experiencing neurological symptoms and being evaluated for multiple sclerosis (MS), it is important to assess whether sleep disturbance is primary or secondary to neurological disease. In this case, CBT-I was initiated to rule out a sleep disorder as an underlying cause of neurological symptoms. Report of case(s) The patient is a 61-year-old, White, female with chronic insomnia, excessive daytime sleepiness, and mild OSA comorbid with abnormal brain MRI (significant non-specific lesions). Patient is followed by neuroimmunology for management of neurological symptoms with unclear etiology (fatigue, paresthesia, neuropathic pain, and impaired cognition). She was referred to sleep medicine by her neurologist who suspected severe fatigue and sleepiness may be contributing to complex medical presentation. Patient endorsed a history of sleep-maintenance insomnia associated with drowsy driving (1 MVA and 3 near-misses). Of note, patient discontinued CPAP use for mild OSA in spring 2022 due to device recall. Her sleep physician recommended CBT-I to increase TST prior to OSA re-evaluation. Patient presented as anxious and distressed regarding safety while driving. She initiated CBT-I and engaged in stimulus control, cognitive restructuring, sleep diaries, relaxation, motivational interviewing, and supportive therapy. Baseline sleep diaries showed average WASO=146 minutes, SE=58%, and TST=4.1 hours. At week 7, average WASO=60 minutes, SE=86%, and TST=6.0 hours. Though no baseline measure was obtained, sleep disturbance (PROMIS Sleep T Score) was WNL (T=54) at week 7. Depression, anxiety, and pain-related disability decreased: PHQ-9 (11-moderate to 8-mild), GAD-7 (6-moderate to 4-mild), PDI (41 to 33). Measures of daytime sleepiness remained in the severe range (ESS 20 to 18), suggesting the need for OSA re-evaluation. Although sleep quality improved, patient reported new and worsening neurological symptoms including dysphagia and falls at home. CBT-I treatment is ongoing. Conclusion As individuals diagnosed with MS and other neurological disorders are more likely to experience insomnia than the general population, assessment of sleep disorders and evidenced-based treatments should be part of comprehensive neurological evaluation. In this case, the patient’s sleep parameters improved with CBT-I, but neurological symptoms persisted and worsened, suggesting the need for continued assessment and follow-up with neurology and sleep physicians. Support (if any) None.