Psychotherapy in DCFY A psychologically orientated diabetes

service Webinar 22nd November 2018

Jackie Fosbury

Clinical Lead in Diabetes Psychotherapy

Supervisor in Psychotherapy

Diabetes psychology

• Integrated care

• Psychotherapists

• Depression

• Anxiety

• Binge Eating Disorder

• Sexual Dysfunction

• Psychological Insulin Resistance

• Working at ‘face value’ - top tips!

Integrating physical and emotional health

• We have to integrate physical and emotional health because of the rising levels and costs of complex multi-co-morbidity (Kings Fund 2016)

• 40% of patients in poor glycaemic control have psychological problems which affect their ability or willingness to manage their condition (Katon et al 2005)

• In the UK only 16% of these patients access psychological help ‘outside of the diabetes clinic’ (DUK

/DAWN study 2016 – 24% IN 2015)

• Not providing psychotherapy results in the unproductive over use of diabetes education (Fosbury et al 1996)

DCFY Psychotherapists

Jackie Fosbury, Psychotherapy Lead , Cognitive Analytic Therapy Mainly HWLH

Dahlia Maslin, Psychotherapist, Cognitive Analytic Therapy Mainly B and H

Abeni Luken, Psychological Wellbeing Practitioner, Low level CBT HWLH and B and H

(2.70 WTE)

Provide integrated care within DCFY

Provide virtual clinics to supervise staff within DCFY

Sit in on some clinics

Do short term, low intensity high output CBT

Do long term, high intensity low output CAT

Do not see patients already in therapy with other therapists or level 4 patients

Depression

• In the general population 1 in 5 women, 1 in 10 men are diagnosed with depression

• T2 patients are twice as likely to be depressed as the general population Anderson RJ, et al. Diabetes Care. 2001;24:1069–78.

• Depression can cause diabetes via reduced physical activity, over eating, under sleeping and insulin resistance

• Diabetes can cause depression because of the disease progression and increased treatment demands

• Painful neuropathy and sexual dysfunction creates a risk factor for developing depression

• So depression is bi-directional in T2 diabetes

Depression in Diabetes

6

0

5

10

15

20

25

Hermanns et al Li et al

Percentage

T1DM T2DM (no insulin) T2DM (insulin)

T1DM=Type 1 diabetes mellitus; T2DM=Type 2 diabetes mellitus.

Hermanns N, et al. Diabet Med. 2005;22:293–300; Li et al: Diabetes Care 2008. 31:105-107.

Anxiety

• Anxiety is normally a precursor to depression and is a fear based response that affects cognitive function and self care behaviours

• It can be accompanied by physical symptoms ….

• Patients ‘worry’ about hyperglycaemia and ‘fear’ hypoglycaemia

• Shame regarding weight/diet/exercise

• Stigma having/causing T2

• Insulin transfer – psychological insulin resistance (Given et al 2015)

• Long term complications

Daily life with

diabetes

Anxiety about complications

Impact on family

Frustration/

stress

Dislike/fear of hypos

Dislike of needles

Taking medication in

public

Shame/guilt

Relationship with medical team

Balancing competing demands

Telling others

Eating Disorders (1) Diabulimia

• T1 diabetes is a risk factor for developing diabulimia because of the constant vigilance regarding weight and food intake

• Diabulimia refers to the purging of calories via daily insulin omission

(Peveller et al Diabetes Care 1992, Colton et al Diabetes Care 2007, Nielsen S, 2002 European Eating Disorders Review), Jones et al BMJ 2000).

What does this look like to you? (Diabetics with Eating Disorders – DWED)

Recording weight Encyclopaedic knowledge of calories, carbohydrate and

fat content of foods. Continuous exercising. Restricting types of food Keeping a "food diary" or lists that consists of food and/or

behaviours Being Pre-occupied with thoughts of food (with thanks to DWED for their permission to use this slide)

(2) BED (Binge Eating Disorder)

• Is a psychiatric disorder

• Does not involve purging (unlike bulimia)

• 25-45% of T2 meet criteria for BED

• Affects males and females

• Involves eating without hunger, secret eating, continuous, disconnection, powerlessness, self loathing and disgust

• Strong association with depression

Frances – Ms Sensitive T2D Obesity, weight increasing ‘I am lazy’ ‘whatever you do, don’t send me to the dietitian’

Delicate child must not be upset (eats for comfort)

Mum says (1) leave her alone/let her have what she wants (2) I’ll do everything for you

Eating not regulated, becoming inactive (lazy)

Dad – unassertive Cannot challenge mum

Weight increases

Upset at school over weight, then T2D in adulthood

Sexual dysfunction

• Sexual problems can occur because of physical and emotional issues

• Sexual difficulties occur in men and women

• They occur more frequently in men and women with diabetes with high blood glucose levels

ERECTILE DYSFUNCTION • 15% males will experience ED between the age of 40-50. • Higher incidence in diabetic males than other medical condition (39%)

(Rosen RC et al, Curr Med Res Opin 2004) • Causes multi-factorial: Endothelial dysfunction (Phe V, Roupret M. Erectile Dysfunction and Diabetes: a review of the current evidence

based medicine and a synthesis of the main available therapies. Diabetes and Metabolism 2012)

Medication (anti-depressant and hypertensive medication) Lifestyle choices (smoking, alcohol) Psychological factors (stress, depression, anxiety) in > 20% of cases (American

Diabetes Association 2009).

Physical treatment for ED PDE5’s

• Limited success if neurological damage present. (Madani, Ali Hamidi et al, Journal of sexual medicine April

2013. This study excluded patients with psychological ED).

• Limited success if patient is anxious/depressed. Anxiety and depression reduce

desire and arousal. • PDE5’s work when there is arousal!!! (50% T2 report loss of desire) (DUK 2009)

• If erectile dysfunction is caused by neuropathy - interpersonal, supportive, or

behavioural therapy are often helpful for patients and their partners.

• All pharmacological therapies for ED have shown a decrease in efficacy in diabetic patients in comparison with non diabetic control.

(Effective therapy for the management of erectile dysfunction in men with DM: A review)

WOMEN

• Women experience decreased vaginal lubrication caused by hyperglycaemia (14%-45%) (Slob and Wincze), (Bargiota A et al (2011) sexual dysfunction in diabetic women.

Hormones 10 (3); 196-206)

• Lack of lubrication increases with age and drop in oestrogen.

• Lack of lubrication increases vaginal infections causing dyspareunia.

• Nerve damage affects female genitalia which impairs sexual response (Bargiota as above).

• Body image problems weight gain and injection sites affects sexuality and intimacy cause sexual distress . (Clare Shaban, Body Image, Intimacy and Diabetes, European Diabetes Nursing 2010)

Psychological Insulin Resistance (PIR)

• Improvements in glycaemic control often requires insulin transfer in T2 patients

• But 25% of tablet treated patients are unwilling to take insulin.

• Clinical inertia – extra time spent in clinic dealing with complexity and patients concerns around insulin

• Patient problems – lack of positive gain, poor confidence, fear of hypoglycaemia, ‘needle phobia’

• At risk groups – patients who have been started on insulin late!

Different ways to speak to patients

• I wonder why it feels as if it is difficult to remember your insulin? BGM? Tablets? Asking them to reflect and think

• Some people feel as if they have to resist or neglect their physical needs. Suggest self neglect and self sabotage – suggests harm

• What do you feel will happen to you if you care for yourself properly? Looks at snags to self care (diabetes management)

• How will things go right for you if you do not look after your diabetes? Suggests nothing can go right

The anxious patient

Top tips

- Use closed ended questions

- Keep the session focused and bring patient back to current topic

- Try not to get caught up in the content of their worries

- Try not to give too much reassurance - this can maintain worry as gives short term relief without the techniques to manage worry themselves

The depressed patient

Top tips

• Encourage them to stick to their usual routine rather than be lead by their mood

• Focus on small behaviour changes they can make to improve mood e.g. 10 minute walk, earlier bed time

• Start with behavioural focus which can bring about motivation by positive reinforcement

Motivation

• Looking at the pros and cons of not changing behaviour what’s wrong with feeling/getting better/looking after yourself?

• Try not to overwhelm patients with risk e.g. “If you do not take your insulin injections you’re at risk of blindness.” This can sometimes push a patient further away from engaging.

• Encourage short term goals patient could be working on whilst waiting for appointments/DCFY service e.g. test blood sugars twice a day then work up to 3, then 4 etc. Is there anything you think is possible to do?

• Specific Measurable Attainable Realistic Timely (SMART) Goals e.g. “ I aim to lose 4 pounds of weight within a month” - rather than - “I need to lose weight.”

Sent: 9 November 2011 11:14

To: Fosbury, Jacqueline

To whom this may concern my name is …… I am 41 and suffer with diabetes cardiomyopathy disk prolapse asthma depression and binge eating disorder which was consuming me out of control making me a physical mess since having all these medical predispositions you would expect a change of determination people would just be frustrated and say stop eating!!! If only what this experience has taught me is that I am my mother and father here is good and bad in that its not worth dying for which incidentally is a real possibility if you cut me in two like a stick of rock the dysfunctional upbringing is there for all to see that will never go away but I can deal with that with more awareness of the facts paranoia disappears this will never end I will take one day at a time I will have sad times of self pity but I will have a life worth living I have a life worth living I have reached a point where I can with this many thanks