add colomns: TOTAL:

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10. If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?

Not difficult at all Somewhat difficult Very difficult Extremely difficult is serious, as the patient has control of a potentially lethal weapon among their self-sabotaging behaviours. It is a pattern that is usually established by early adulthood and may require intensive psychological treatment with close liaison between the psychologist and the diabetes team. Behavioural treatments are available, which may involve residential behavioural retraining, but the availability of such programmes is limited.

Milder forms of self-sabotage may occur in many patients, at times of disillusionment or under stressful circumstances. For some people, awaiting a forthcoming diabetes review may be stressful. It may be necessary to take this into account when assessing recent profiles. Such people typically require support to improve their self-efficacy and autonomy.

It is important to distinguish patients displaying the more benign forms, or those whose behaviour reflects an underlying depressive illness, from those whose self-defeating behaviour is a more serious primary problem affecting other areas of their lives, as the treatment approach in each case will be quite different.

Figure 16.2 Global mean health by disease status. Reproduced with permission from Moussavi S, Chatterji S, Verdes E, et al. Lancet 2007;370:851-8.

Figure 16.2 Global mean health by disease status. Reproduced with permission from Moussavi S, Chatterji S, Verdes E, et al. Lancet 2007;370:851-8.

Eating disorders in diabetes

We have mentioned above the problem of 'food addiction', in which excessive calorie intake continues way beyond energy requirements leading to severe obesity and its complications. Diabetes may often be a result rather than a cause of this abnormal behaviour.

In addition, people with established anorexia or bulimia nervosa may later develop diabetes, compounding their disordered nutritional status. These problems require co-ordinated, multidis-ciplinary input from physicians, diabetes nurses, psychiatrists or psychologists, and dieticians.

Therapeutic inertia

In the past, reluctance to accept insulin therapy in people with type 2 diabetes was often attributed to patient-centred issues, including their reluctance to engage in a new life pattern of daily or more frequent injections.

More recently, it has been recognised that the problem is compounded through an interaction between patient- and practitioner-centred factors. Recognising our own complicity in this process is important. We may be responsible for amplifying anxiety through our own lack of confidence with managing insulin, or simply by referring to it as if it is a desperate, last resort measure. Similarly, patients and clinicians may vacillate for months over blood pressure treatment or the addition of second or third drugs in the regimen. Patients may pick up signals from the clinician reinforcing the assumption that the need for medication simply results from failure of life-style change. Whilst life-style change is effective and should be actively promoted, such an assumption is unfair, as the majority will also need medication to achieve ideal targets (Box 16.2).

Box 16.2 To avoid therapeutic inertia:

• Mention the range of possible treatments early on including insulin (using positive language), preferably at one of the early appointments after the diagnosis

• Discuss the fact that whilst not needed now, insulin is often required at a later stage in type 2 diabetes, as blood glucose levels tend to become more difficult to control

• Emphasise the benefits of tight blood pressure control in diabetes, mentioning early on that two or three different drug classes are usually required to achieve this

• It will therefore not be 'their fault' if the patient eventually requires insulin and several different antihypertensive medications

• Reassure the patient that there are several different classes and many different individual antihypertensive drugs available - it is therefore likely that a suitable combination will be found for them

Figure 16.3 With support from family, friends, and health professionals many of the psychological challenges of diabetes can be overcome.


Even the most robust personalities will find diabetes a challenge, particularly type 1 patients who must adapt behaviourally over a short timescale to develop new habits and daily practices, including insulin injections. Others may feel the burden of long-term complications or a fear of them developing in the future. Many simply feel out of control, and it is through addressing this feeling that the greatest impact can be made. The empowered patient who has 'ownership' of their diabetes is likely to have improved quality of life and lower psychological morbidity (Figure 16.3). Health professionals should nurture self-efficacy in all patients whilst remaining aware of the possibility of more serious psychological problems. Depression is common in diabetes and the combination is very detrimental to quality of life. For children with diabetes, behavioural interventions should be family-centred, and preferably started soon after diagnosis where the need is evident.

Further reading

Delamater AM. Psychological care of children and adolescents with diabetes.

Pediatr Diabetes 2007;8:340-8. Lloyd CE, Dyer PH, Barnett AH. Prevalence of symptoms of depression and anxiety in a diabetes clinic population. Diabetic Med 2000;17:198-202. Moussavi S, Chatterji S, Verdes E, et al. Depression, chronic disease, and decrements in health: results from the World Health Surveys. Lancet 2007;370:851-8.

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