Dealing with the Stress of Chronic Disease

1
Dealing with the Stress of Chronic Disease with
an accent on Diabetes

• Frank McDonald
• ConsultationLiaison Psychologist
• The Townsville Hospital
• Queensland, Australia
• March 2008

2
Overview

• The importance of psychological support for
  people with diabetes and their families
• Psychological and social factors to screen for in
  the management of diabetes
• Psychological and Primary Care interventions to
  improve clinical outcomes
• Conclusion/Recommendations

3
Importance of a psychological perspective
across conditions

• Everyone with a chronic health condition suffers
  psychologically
• Degree depends on number and intensity of
  challenges faced, and the quality of internal and
  external supports
• Problem for pts and carers is not just disease
  management (biomedical aspects) but pressure to
  cope

4
Importance of a psychological perspective in
diabetes mx

• Psychological issues can exert considerable
  influence on glycaemic control in diabetic pts,
  and raise risks of brittle diabetes and
  diabetic ketoacidosis 1, 2
• Diabetes is one of the most psychologically and
  behaviourally demanding of the chronic medical
  illnesses 3
• So health practitioners need to be alert to
  disruptions to psychological wellness. This
  usually requires regular screening for
  psychosocial issues. Many of these overlap with
  those of other long-term illnesses

5
Risks and interventions

• Distress/ high levels of stress (feelings of
  being overwhelmed) increase noradrenaline and
  cortisol which mobilise glucose and fatty acids.
  Not quickly used up in diabetes, requiring
  insulin increase4
• As well, stress impairs insulin release. So
  postulated as a risk factor in developing Type 1
  diabetes 5
• Clinical evidence cases of late onset diabetes
  after major stressors like cancer or heart
  surgery in pts who would probably have otherwise
  remained genetically dormant

6
Risks and interventions

• May explain brittle diabetes i.e. problems
  even when pt does everything right. Though
  relationship between it and stress not simple.
  May represent extreme end of adaption spectrum
  since such pts often present with more
  psychosocial risks6
• Stress management training (with its focus on
  frequent hormone holidays) over 5 weeks
  improves blood glucose control at 1 year f/u 7
• Onset distress a focus in some studies 8. An
  anxious, emotionally-demanding time for most
  sufferers of chronic conditions as wait for test
  results, get over shock etc

7
Risks and interventions

• Anxiety Disorder rates much higher in diabetics
  than non-diabetics. Up to 20 vs. 10 Worse when
  two or more chronic complications9 Common fears
  contribute e.g. of hypos or future complications
  
• May affect metabolic control indirectly by
  interfering with self-care. Direct effect on
  metabolism un-researched but probably similar to
  Distress mind-body effects
• Psychological anxiety management strategies can
  help here. These include standard cognitive,
  behavioural and physical relaxation strategies

8
Risks and interventions

• Depression is associated with poor outcomes in
  many chronic conditions. Higher prevalence (near
  double) and relapse in those w. diabetes than
  general population at least 1 in 5 10 and
  average 4 episodes over 5 years 11
• Associated with poor rx adherence,
  hyperglycaemia, cardiovascular disease and
  retinopathy 12
• Also associated with risky behaviours like food
  and alcohol binging and less attention to
  diabetic cues 13

9
Risks and interventions

• Whats Depression and whats Diabetes? Making
  distinction is important. Easy to mistake similar
  signs and symptoms as direct effects of diabetes.
  So, like other psychological conditions
  discussed, often goes unrecognised, with
  substantial impact on QoL and self mx.
• Depression less inevitable, more easily managed
  of two conditions
• Symptom overlap between them (both have physical
  symptoms) can be discriminated with screener e.g.
  Becks Depression Inventory (BDI)

10
Risks and interventions

• High number of psychological symptoms (e.g.
  crying, loss of social interest, indecision,
  senses of punishment or failure, suicidal
  thoughts, dissatisfaction) vs. Physical (e.g.
  fatigue, sick run down, libido loss) suggests
  Depression
• Seven psychological items above on BDI
  discriminate abnormally high levels of depression
  in groups of chronically ill people
• No BDI access? Use checklist (Behaviours,
  Thoughts, Feelings, Physical) on
  beyondblue.org.au What is Depression? page to
  separate psychological influences

11
Risks and interventions

• If confirmed, consider range of biopsychosocial
  options
• Pharmacological options. Evidence says they
  usually work better when combined with
• Psychosocial options e.g. Cognitive therapy,
  activity scheduling, environmental changes,
  (outline examples), and Interpersonal Therapy
  (focus on communication and interpersonal skills,
  like assertiveness). Because issues can involve
  conflict e.g. with health professionals that are
  felt as disempowering. High levels of conflict
  are associated with recurrent hypoglycaemia and
  ketoacidosis 14

12
Risks and interventions

• When diabetic symptoms increase, always check for
  Depression
• Dont assume physical and behavioural symptoms
  directly relate to diabetes. May be the result of
  undetected Depression

13
Risks and interventions

• Social Connectedness (degree of social, family
  and community support). In chronic illnesses
  generally, excellent outcome predictor at 12 or
  24 months - better than all traditional risk
  factors (like smoking, drinking, high
  cholesterol, diet and low exercise levels)
  combined15
• One way I assess this is to ask Is there at
  least one person - professional, family or friend
  - you can turn to, if you were ever overwhelmed,
  to help work things out wholl stick by you over
  the long run who believes in you?

14
Risks and interventions

• If No epidemiologists predict poorer outcomes
  across conditions
• Diabetes research generally endorses
  encouragement of family support and improving
  family climate in everyday mx of diabetes to
  aids its control, especially with adults but less
  so adolescents16
• May be better to pair adolescents with peers than
  family in group (vs. 11) interventions 17

15
Risks and interventions

• Need to screen for social support, practical and
  emotional. Check quality and quantity of ties
  with family, friends, community, church,
  professionals
• Generally families that cope better are flexible
  about roles rather than rigid and traditional.
  With diabetes more cohesive, expressive and
  organised, less conflicted families are
  associated with less deterioration in glycaemic
  control and less severe acute complications 18
• Results on effectiveness of family therapy
  interventions are mixed 19

16
Risks and interventions

• Life events and environmental factors (such as
  poor housing, stressful jobs, unemployment
  stress, indigenous pts being out of country)
  can have practical and emotional impacts on mx.
  These raise risk of distress, anxiety and
  depression and their effects
• For Self-destructive behaviours (periodic or
  chronic serious mismanagement), common in
  adolescents, sometimes nothing short of
  residential treatment with group, individual and
  family therapy, education and medical supervision
  reduces diabetes-related hospitalisations 20

17
Risks and interventions

• Group therapy for these pts often targets life
  coping strategies like social problem solving,
  cognitive behaviour therapy (e.g. for depression
  and worry and identifying attitudes and beliefs
  underlying problems with self-care) and conflict
  resolution skills

18
Risks and interventions

• Neuropsychological function in depressed
  diabetics is usually more impaired than in
  healthy controls 21
• Milder for non-depressed, a (not statistically
  significant) trend towards worse functioning than
  in general population

19
Risks and interventions

• Issues attention, information processing speed
  (with effects then on memory encoding), and
  executive functioning (Use Lurias attend -
  plan - monitor verify sequence to guide
  compensations)
• Compensate with repetition, usual aide-memoires
  (like diaries, Webster-paks), environmental
  cues/prompts, more visual/less verbal educational
  material

20
Risks and interventions

• General coping skills may be poor
• Better copers
• Seek social support (I can talk to someone to
  find out more about this disease.)
• Can problem-solve (Ill find out how others deal
  with the effects of the disease.) Not so much
  emotional responders who advance little beyond
  worry, anger, denial etc
• Use distancing (Try to detach from stressful
  situations) e.g. I didnt let it get to me. I
  refused to think about it too much.

21
Risks and interventions

• Develop a positive focus (efforts to find meaning
  in the experience by focussing on personal growth
  e.g. I came out of the experience better than
  when I went in.)
• Dont rely on mental escape/avoidance.
  (Associated with Fatalism, passive acceptance,
  withdrawal from others, self-blame, efforts to
  forget disease, lots of 'escape fantasies' or
  wishful/magical thinking e.g. I wish that the
  situation would go away.)
• Dont rely on behavioural avoidance/escape
  (Efforts to avoid stress by overeating,
  over-drinking, excessive smoking, overuse of
  medication.)

22
Risks and interventions

• Have helpful self-management beliefs e.g. I
  control many effects of illness not just doctors
  and nurses while open about impact of remediable
  psychological issues on self-mx
• Engage in less self-blame, helplessness or angry
  expression of emotion (blaming others)

23
Risks and interventions

• Have more constructive attitudes, such as found
  in other chronic illness sufferers It's not my
  fault that this has happened to me. Factors
  outside my control lead to this illness but I do
  have a responsibility to help in my
  rehabilitation and care as challenging as that
  will be. I can exert some control over the
  effects of this illness.

24
Conclusion/Recommendations

• Research and clinical experience says no doubt
  that psychological factors adversely affect
  glycaemic control
• Given evidence for high prevalence of issues, and
  their impact on outcomes, individuals with
  diabetes should be regularly screened for
  distress, depression anxiety disorders by
  clinical interviews or questionnaires (e.g. the
  K10 available on the Net)
• Or screen via open-ended questioning about stress
  (family stress especially), social support,
  beliefs about their disease, coping style and
  behaviours that may impair individuals glycaemic
  control

25
Conclusion/Recommendations

• Interventions could include ongoing psychosocial
  support and encouragement and others listed, such
  as coping skills training, family therapy plus
  team and community responses to larger
  environmental issues22

26
Conclusion/Recommendations

• Management of diabetes requires teamwork
• Guidelines endorsed by International Diabetes
  Federation and WHO23 state that ideally both
  healthcare professionals and pts would have
  access to a Psychologist as an integrated team
  member or as an accessible team resource e.g. via
  GP mediated Medicare subsidy

27
Additional

• See authors website www.fmcdonald.com for a copy
  of this presentation and related paper Coping
  with Psychosocial Effects of Chronic Illness on
  Individuals and Families