psychological implications of diabetes & chronic disease anne bartolucci, ph.d., c.b.s.m....
TRANSCRIPT
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
•www.sleepyintheatl.com
•Office address:▫315 West Ponce de Leon Avenue
Suite 1051Decatur, GA 30030404-378-0441