Transcript Dealing with the Stress of Chronic Disease – with an

Frank McDonald
Consultation–Liaison Psychologist
The Townsville Hospital
Queensland, Australia
March 2008
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
2
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
3
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
4
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
5
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
6
etc
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 hypo’s 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
7
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
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Risks and interventions
 What’s Depression and what’s 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.
Beck’s Depression Inventory (BDI)
9
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
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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
11
Risks and interventions
 When diabetic symptoms increase, always check for
Depression
 Don’t assume physical and behavioural symptoms
directly relate to diabetes. May be the result of
undetected Depression
12
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;
who’ll stick by you over the long run; who believes in
you?”
13
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. 1:1) interventions 17
14
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
15
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
16
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
17
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
18
Risks and interventions
 Issues: attention, information processing speed
(with effects then on memory encoding), and
“executive functioning” (Use Luria’s ‘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
19
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 (“I’ll 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 didn’t let it get to me. I refused to think about it
too much.”
20
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.”)
 Don’t 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.”)
 Don’t rely on behavioural avoidance/escape (Efforts to
avoid stress by overeating, over-drinking, excessive
smoking, overuse of medication.)
21
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)
22
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.”
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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
individual’s glycaemic control
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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
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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
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Additional
 See author’s website www.fmcdonald.com for a copy of
this presentation and related paper “Coping with
Psychosocial Effects of Chronic Illness on Individuals
and Families”
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