psychological implications of diabetes & chronic disease

Psychological Implications of Diabetes & Chronic Disease

Anne Bartolucci, Ph.D., C.B.S.M.

Atlanta Insomnia & Behavioral Health Services, P.C.

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:

My Diabetic Family Member:

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.

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

Biopsychosocial Model•Biological

▫Physiological▫Symptoms

•Psychosocial▫Cognitive▫Social support▫Identity as patient

•Medico-Legal▫Insurance▫Coordination of care (e.g., PCP & specialists)

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.

Barriers

•Illness affects many areas of a patient’s life

•Psychological:▫Knowledge▫Perception bias/accuracy▫Stress▫Self-efficacy

Barriers:•Psychological (cont’d):

▫Grief/Adjustment Time Stages:

Denial Anger/Shame Bargaining Sadness Acceptance

▫Actions lack immediate reinforcement

Barriers:•Social:

▫Family environment (children & adolescents)

▫Context of social support▫Negative social influences▫Self-care autonomy / Desire for

independence

Barriers: Problem-Solving

•Knowledge:▫Patient-centered▫Revisit

•Training▫Hypoglycemia prevention▫Self-monitoring

•Stress management•Family intervention•Social/Coping skills training

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)

Objective:

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

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?

Psychological Disorders •Eating Disorders

▫Poorly studied, prevalence unknown▫Young women▫Diabetes occurs first▫Signs:

Severe emaciation Poor glycemic control without reason

Psychological Disorders•Generalized Anxiety Disorder•Specific Phobia•In children:

▫Aggression▫Learning disabilities

•Subclinical▫Poor coping with stress▫Sleep problems

Objectives:

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

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

Assessment: Stress•Multifactorial:

▫Situational stressors▫Interpretations/reactions

Cognitive Emotional Behavioral

▫Coping skills▫Resources▫Self-efficacy

Transtheoretical Model•Stages of Change: Where is the patient?

▫Precontemplation▫Contemplation▫Preparation▫Action▫Maintenance▫Termination

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

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

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

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

Motivational Interviewing

•Identify problem•Resolve ambivalence•Listen for “change talk:”

▫Problem recognition▫Expression of concern▫Intention to change▫Optimism about change

Motivational Interviewing

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

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?

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.

Contact

•anne@sleepyintheatl.com

•www.sleepyintheatl.com

•Office address:▫315 West Ponce de Leon Avenue

Suite 1051Decatur, GA 30030404-378-0441