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:
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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:
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Knowledge
Perception bias/accuracy
Stress
Self-efficacy
Barriers:
• Psychological (cont’d):
▫ Grief/Adjustment
 Time
 Stages:
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Denial
Anger/Shame
Bargaining
Sadness
Acceptance
▫ Actions lack immediate reinforcement
Barriers:
• Social:
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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:
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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
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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:
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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?
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Precontemplation
Contemplation
Preparation
Action
Maintenance
Termination
Transtheoretical Model
• Processes of change:
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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:”
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Problem recognition
Expression of concern
Intention to change
Optimism about change
Motivational Interviewing
• “Roll with resistance.”
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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 1051
Decatur, GA 30030
404-378-0441