Overview

• Psychological problems are common in people with diabetes but most can be overcome with support and education

• Diabetes is commoner in those with chronic mental illness

• Problems range from those of adjustment to more serious depressive illness and maladaptive coping behaviours

• Screening for depression using validated assessment tools should be part of routine surveillance

• Psychological health is key to successful self-management

• Family cohesion and agreement about management responsibilities improves metabolic control

Introduction

Earlier chapters have discussed some of the psychological issues that people with diabetes may encounter, issues with which clinicians should be familiar. There may be positive aspects such as self-efficacy, autonomy and empowerment. But there may also be more negative aspects such as the 'learned helplessness' that was mentioned in Chapter 10. Here, we discuss these in more detail including more serious disorders of psychological adjustment. We will first of all cover some of the less serious issues that most patients may encounter to some degree, before considering the serious problems that affect a small minority.

Adjusting behaviourally to the diagnosis

Diabetes may happen to anyone, and occurs no less commonly in those with pre-existing psychological or psychiatric disorders, some of which may predispose to diabetes. In type 1 patients, usually presenting in childhood, the personality is still in the developmental stage when the need for dietary discipline, frequent self-injection and blood glucose monitoring arise, all potentially disrupting this formative process (Figure 16.1). It is, therefore, not surprising that adjustment behaviours may become maladaptive, and sometimes frankly self-destructive. There is some evidence that children with diabetes are more likely to have difficulties with information processing and learning problems, particularly those with very early diagnosis or history of severe hypoglycaemia. Poor metabolic control is associated with greater risk of a psychological diagnosis, and frequent hospital admissions lead to recurrent school absence, further disrupting education.

However, there is no one 'personality type' typical of type 1 diabetes, and most adjust remarkably well to these potential stresses, given sufficient family and peer support, as well as that of their health professionals. In fact, empowered type 1 individuals benefit from the fact that their behaviour is still flexible enough to adapt to the new requirements. This is something that older, type 2 patients typically find difficult, and in their cases it is behavioural inertia and inflexibility that are the obstacle to successful management.

Multidisciplinar^ behavioural interventions involving the family have been shown to improve regimen adherence and glycaemic control in type 1 children (Box 16.1), but are usually most effective when introduced soon after the diagnosis.

Box 16.1 Components of effective behavioural interventions in children with diabetes

Goal setting

Self-monitoring

Positive reinforcement

Behavioural contracts

Supportive parental communications

Appropriately shared responsibility for diabetes management

Needle phobia

A reluctance to pierce the skin with a sharp foreign body is of course a perfectly natural response in childhood, and also affects quite a proportion of adults. Education over the safety of injections, the use of short 6 mm needles, and a lot of practice, overcome this in the majority of patients young and old. Type 1 individuals, who rapidly become insulin-dependent, usually solve the problem fairly quickly through repeated exposure to the trigger as there is no alternative. But in older type 2 individuals it may become an unspoken reason why insulin therapy is repeatedly deferred, adding to other sources of inertia.

Demonstrating modern insulin injection technique often overcomes needle phobia, along with supportive encouragement.

Figure 16.1 Diabetes takes some getting used to even for robust personalities.

Familiarity with the device and the injection technique on the part of the clinician is important to foster an atmosphere of confidence building. If the clinician appears under-confident or clumsy then this will amplify any anxiety on the patient's side.

A minority of patients remain excessively anxious about insulin injections. Children may become dependent on their parents administering the insulin, a pattern that is, of course, necessary if diabetes occurs in early childhood, but in older children should be resisted to promote eventual independence.

Dishonesty in recording blood glucose results

The tendency of patients to fabricate blood glucose results to placate their clinician is now well known, and there is evidence that this behaviour occurs among widely differing patient subgroups. One celebrity patient made it his New Year's resolution to not invent quite so many self-monitored results. Some patients wish to disguise the fact that they have not taken any readings at all, or only a few. In these cases the give-away may be the use of the same pen or pencil to write all of the results down at the same time, although some may have appropriately accessed the meter's memory and written all the results out in one go for the clinician's benefit. A check on the meter's memory may confirm this, or may reveal that the reported results on the profile are a selected sample. Before confronting a patient for abusing time and trust, it is worth stepping back and in each individual's case trying to work out why it has happened from their perspective.

In the case of the person who is not self-monitoring despite advice to do so, why are they not sufficiently motivated? The missing link here may be their ability to make sense of the patterns, resulting in the 'learned helplessness' phenomenon described in Chapter 10. A discussion needs to take place over the purpose of the self-monitoring, whether it is for the clinician's or the patient's benefit, who should be responsible for analysing the results and making adjustments, and the extent to which this should be done using the retrospective rather than prospective approach (see Chapter 10). Time invested in teaching the patient some simple rules for interpreting the data and making dose adjustments, provided they are able to learn these skills, goes much further than a simple reprimand that will further damage their feelings of self-efficacy as well as the clinician-patient relationship.

Patients may have hidden agendas that only come to light on active questioning. Driving safety, employment issues and health insurance are all plausible and understandable (if not excusable) bases for deceptive behaviour. The answer, again, is to keep 'on the same side' and avoid the 'Armande' response (Chapter 3), where even adults may occasionally develop a juvenile rebelliousness that is uncharacteristic of the rest of their behaviour.

'Food addiction'

The pre-existing psychological or psychiatric history of the individual may be very relevant to the patient's adjustment to the diabetes diagnosis, and their coping mechanisms. Type 2 diabetes occurs more often in overweight people. Many of these have simply developed bad eating habits in a culture that is increasingly sedentary and in which high calorie foods are widely available. Such people may have little or no psychological pathology, but nevertheless have a serious physical problem that must be overcome by psychological means. A few are obese because of an abnormal attitude towards food, and in some the term 'food addiction' might be appropriate.

Food addiction has been defined as 'eating types and amounts of foods that seem to contrast with a person's intentions to make moderate and 'sensible' food choices.' However, it is a matter of controversy whether this term is appropriate to people who eat excessively. Nevertheless, those in the severely obese category may benefit from psychological referral, to explore and address underlying reasons for their eating behaviour, including body image, the meaning of food in their lives, and their response to hunger and satiety.

Depression and diabetes

Whilst all patients are likely at times to feel burdened by the prognostic implications of their diagnosis, a significant proportion will develop potentially serious depressive illnesses. This problem is common enough that it should be actively sought by questioning during regular diabetes reviews, as should some of the issues that may contribute to it, such as erectile dysfunction. These problems, unlike biochemical indices, are difficult to measure but represent a large component of the person's quality of life.

Depression is a common finding in chronic disease generally, but in the case of diabetes has a particularly significant impact on the mean health score (Figure 16.2).

Depression screening has been introduced into regular diabetes surveillance in the UK through the Quality and Outcomes Framework (see Chapter 18). It uses a validated screening tool involving two questions, following any positive responses with a more detailed questionnaire to assess severity. Three such questionnaires are available. The most commonly used is the PHQ-9 (Table 16.1).

'Self-defeating' behaviour

This psychological condition can affect anyone with or without diabetes. In the case of the insulin-treated individual the situation

Table 16.1 Patient Health Questionnaire (PHQ-9).

PATIENT, HEALTH QUESTIONNAIRE (PHQ-9) NAME: DATE:

Over the last 2 weeks, how often have you been bothered by any of the following problems? (use V" to indicate your answer)

1. Little interest or pleasure in doing things

2. Feeling down, depressed, or hopeless

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