Psychological Implications of Diabetes & Chronic Disease

1. Psychological Implications of Diabetes & Chronic Disease Anne Bartolucci, Ph.D., C.B.S.M. Atlanta Insomnia & Behavioral Health Services, P.C.

2. Disclosures: • No commercial bias or influence • Sources: • Textbooks • Articles from peer-reviewed journals • Dr. Google (N.I.H. & reputable sources) • My own clinical practice • Only one diabetic family member:

3. My Diabetic Family Member:

4. Objectives: • Identify and be able to problem-solve barriers to self-management of diabetes in children and adults both immediately after diagnosis and long-term. • Increase awareness of clinical and subclinical psychological disorders that can arise from diabetes and other chronic conditions. • Introduce time-limited techniques to identify psychological problems and increase compliance with treatment.

5. Biopsychosocial Model • Engel (1977) • Multifactorial • Patient context: “conditions of life and living” • History/Early experiences • Biomedical markers vs. symptom onset & adoption of sick role • Social & cultural context • Trust in physician & medical system • When to seek care • Compliance

6. Biopsychosocial Model • Biological • Physiological • Symptoms • Psychosocial • Cognitive • Social support • Identity as patient • Medico-Legal • Insurance • Coordination of care (e.g., PCP & specialists)

7. Objective: • Identify and be able to problem-solve barriers to self-management of diabetes in children and adults both immediately after diagnosis and long-term.

8. Barriers • Illness affects many areas of a patient’s life • Psychological: • Knowledge • Perception bias/accuracy • Stress • Self-efficacy

9. Barriers: • Psychological (cont’d): • Grief/Adjustment • Time • Stages: • Denial • Anger/Shame • Bargaining • Sadness • Acceptance • Actions lack immediate reinforcement

10. Barriers: • Social: • Family environment (children & adolescents) • Context of social support • Negative social influences • Self-care autonomy / Desire for independence

11. Barriers: Problem-Solving • Knowledge: • Patient-centered • Revisit • Training • Hypoglycemia prevention • Self-monitoring • Stress management • Family intervention • Social/Coping skills training

12. Barriers: Problem-Solving • Social: • Include family members in treatment planning • Use as coparticipants or coaches • Communication • Training of school personnel (e.g., teachers, school nurse)

13. Objective: • Increase awareness of clinical and subclinical psychological disorders that can arise from diabetes and other chronic conditions.

14. Psychological Disorders • Depression: • At least three times more prevalent in diabetics than general population • Bilateral influence • Associated with other psychosocial stressors • Challenges: nonspecific effects of illness vs. depression related to diabetes?

15. Psychological Disorders • Eating Disorders • Poorly studied, prevalence unknown • Young women • Diabetes occurs first • Signs: • Severe emaciation • Poor glycemic control without reason

16. Psychological Disorders • Generalized Anxiety Disorder • Specific Phobia • In children: • Aggression • Learning disabilities • Subclinical • Poor coping with stress • Sleep problems

17. Objectives: • Introduce time-limited techniques to identify psychological problems and increase compliance with treatment.

18. Assessment: Depression • Formal/Structured: • Beck Depression Inventory • SIGECAPS: • Sadness • Loss of interest • Feelings of guilt or being punished • Low energy • Concentration problems • Appetite changes • Psychomotor agitation/retardation (observed) • Sleep problems • Suicidal or homicidal ideation, intent, plan

19. Assessment: Stress • Multifactorial: • Situational stressors • Interpretations/reactions • Cognitive • Emotional • Behavioral • Coping skills • Resources • Self-efficacy

20. Transtheoretical Model • Stages of Change: Where is the patient? • Precontemplation • Contemplation • Preparation • Action • Maintenance • Termination

21. Transtheoretical Model • Processes of change: • Consciousness raising • Dramatic relief • Self-reevaluation • Environmental re-evaluation • Self-liberation • Social liberation • Counterconditioning • Stimulus control • Contingency management • Helping relationships

22. Transtheoretical Model • Most patients will be in contemplation and precontemplation • To move forward… • Precontemplation: increase pros • Contemplation: decrease cons • Pros need to increase twice as much as cons decrease

23. Transtheoretical Model • To move from precontemplation to contemplation, need to engage in: • Consciousness raising • Dramatic relief • Environmental reevaluation • To move forward from contemplation, need: • Self reevaluation • In preparation, person is engaging in: • Self-liberation

24. Compliance: Making Allies • Don’t “should” on your patients! • What can/will they do? • Some compliance is better than none • How do we make this work for you? • What gets in the way of adherence? • Instead of “why aren’t you…?” • Takes defensiveness away • Specific action plan • Revisit what will get in the way? • Building on small & large victories

25. Motivational Interviewing • Identify problem • Resolve ambivalence • Listen for “change talk:” • Problem recognition • Expression of concern • Intention to change • Optimism about change

26. Motivational Interviewing • “Roll with resistance.” • Simple reflection • Amplified reflection • Double-sided reflection • Shifting focus • Agreement with a twist • Emphasizing personal choice • Reframing

27. Maintaining Change: • Lapses vs. Relapses vs. Collapses • Lapse = temporary slip-up • Relapses = larger slip-up • Collapse = back to square one and a half • What can we learn from this? • Tracing sequence of events back to emotional, situational, & behavioral antecedents • What can you do differently next time?

28. Conclusions: • Diabetes is a disorder that affects many aspects of a patient’s life and therefore requires a multifactorial treatment strategy. • The Biopsychosocial Model can help with patient case conceptualization, identification of barriers to compliance, and potential motivators to move through the Stages of Change. • Motivational Interviewing techniques can aid clinicians with moving through resistance to compliance both early in the process and later when the patients slip up.

29. Contact • anne@sleepyintheatl.com • www.sleepyintheatl.com • Office address: • 315 West Ponce de Leon Avenue Suite 1051 Decatur, GA 30030 404-378-0441