Psychology in Diabetes Care and Practice

Val Wilson

• Publisher: Routledge
• Year: 2022
• ISBN:
  9781000536959
• Edition: 1
• Topic: Psychology
• Subtopic: Applied Psychology
• Index: Psychology

This is an indispensable guide to diabetes care and practice, providing a thorough overview of the main issues that health professionals should keep in mind when treating someone with the condition, and how psychology plays a key role in diabetes self-management.

Based on the latest research evidence along with numerous patient perspectives, the book looks at a wide range of topics in diabetes health psychology, from mental health conditions to theories of behaviour change, with a focus on comorbidities. Chapters describe the emotional impact of a diabetes diagnosis; the psychosocial issues surrounding living with diabetes; theories of behaviour applied to diabetes self-management; the impact of diabetes and depression; diabetes and eating disorders; the psychological impact of diabetes complications, and potential stigma associated with having Type 2 diabetes, including the psychological impact of weight loss surgery.

Psychology in Diabetes Care and Practice enables the provision of support to reduce psychological distress and improve diabetes self-management. It helps patients to learn more about how best to manage their condition, as well as health professionals wanting to find appropriate ways to facilitate self-management.

1 Diagnosis, Diabetes, and Emotional Impact

DOI: 10.4324/9781003260219-2

Currently, the total number of individuals with diabetes worldwide stands at 415,000,000, which is 1 in every 11 adults; this figure is estimated to rise to 642 million people living with diabetes by 2040. It is also estimated that 46 percent of people presently have undiagnosed diabetes (diabetes.co.uk, 2019). In the UK alone, 3.5 million people have diabetes of one form or other, the majority being diagnosed with Type 2 diabetes due to a sedentary lifestyle and a diet rich in unrefined carbohydrates. For UK children and teens under 20 years of age, the National Institute for Health (2017) reported that 208,000 young people now have either Type 1 or Type 2 diabetes. These statistics show the rate at which diabetes is rapidly increasingly, with many more cases still undiagnosed. A diabetes diagnosis has far-reaching consequences, affecting every individual both physically and psychologically.

Impact of a diabetes diagnosis

‘It was a complete shock to be told I had Type 1 diabetes and what that would mean for the rest of my life. I didn’t take it all in for months’.

‘I couldn’t believe what my doctor was telling me – that this illness had to be managed for the rest of my life, with a high risk of blindness and kidney failure if I didn’t’.

‘I refused to believe it when I was told I now have Type 2 diabetes. I didn’t even feel ill and it was only found because of a routine blood test’.

Being diagnosed with diabetes may bring with it many negative emotions, such as shock, disbelief, fear, anger, distress and self-blame, although understanding what has been causing certain symptoms can also bring a sense of surprise and relief. It may be the case that there have been no symptoms at all, and the condition is discovered by chance. Similar to the bereavement response, the individual will go through stages such as anger, immobilisation, denial, bargaining, and acceptance as they come to terms with having a chronic, life-changing health condition. This realisation has been termed, ‘the beginning of a new reality’ (Diabetes UK, 2019).

Clinically, Type 1 diabetes onset – where there is ongoing autoimmune destruction of the insulin-producing cells of the pancreas – presents with acute hyperglycaemia, excessive thirst and urination. Often, ketoacidosis is present – where excess glucose cannot be used as fuel by the body and the blood becomes acidic, with the presence of ketone bodies. A diagnosis of Type 1 can follow other periods of illness, such as pancreatitis and more recently, COVID-19 with the diagnosis almost always being ‘considered devastating’ (Diabetes UK, 2019), despite the current availability of treatment technologies to enable a healthy life with the condition.

Type 2 diabetes presents far more slowly than Type 1, sometimes taking up to 12 years before the individual – perhaps after a long period of denial – reports symptoms such as increased thirst and urination to gain a diagnosis (Diabetes UK, 2008). Despite this slow onset, Type 2 diabetes is a complex metabolic condition caused by a variable degree of insulin resistance and/or defects in pancreatic insulin secretion, where complications such as heart disease and background retinopathy have already begun. It is wrong to think that Type 2 diabetes is not as serious as Type 1, nor that it only occurs in older people. There is a growing incidence of Type 2 diabetes in children and young adults, due to a diet high in refined carbohydrates and little or no exercise; Type 2 is also more predominant in children with a family history of the condition, and racial minorities such as Southeast Asians, Native Americans, Pacific Islanders or African Americans (Wilson, 2019).

Following a diabetes diagnosis, it is important that the individual:

• Understands the seriousness of their condition and the outcome if it is not properly managed.
• Is aware that if diabetes is managed as well as possible, complications are not inevitable. N.B. It should be noted that brittle Type 1 diabetes is not easy to manage, no matter how hard the individual tries.
• Know that having diabetes is accompanied by changeable emotions, such as depression, which can be treated if recognised and reported.

It is well known that individuals with either Type 1 or Type 2 diabetes mellitus experience a reduced feeling of psychological wellbeing because of the condition (Diabetes UK, 2019; Wilson, 2019). Perhaps as many as 50 percent of individuals being diagnosed with diabetes already have a feeling of adverse psychological wellbeing (Chew, et al., 2014; Walker, et al., 2012). This is due to high blood glucose levels creating chemical changes in the brain resulting in poor coping ability for other life events, such as work or family concerns disrupting the individual's daily routine prior to a diabetes diagnosis (Stuckey, et al., 2014).

Having diabetes can have a negative impact on the individual and their life, not just regarding disease self-management. The Diabetes Attitudes, Wishes and Needs second survey – DAWN2 – assessed the level of depression in 1,600 individuals with diabetes as 13.8 percent; diabetes-related distress as 44.6 percent; and perceived quality of life as 12.2 percent (Nicolucci, et al., 2013). The researchers reported that 20.5 percent of the individuals in the DAWN2 study agreed diabetes adversely affected their relationship with family and friends; 60.2 percent mentioned that diabetes negatively affected their physical health; and 40.0 percent felt diabetes medication disrupted their life to the extent that it was a problem. As a result, many people relied on negative coping strategies – such as smoking or over-eating – with the perception that their diabetes would definitely cause them problems in the future. If psychological issues go untreated, there is a marked association with poor physical health as a consequence (Bener, et al., 2012); cardiovascular disease (Laake, et al., 2014); and depressive symptoms (Diabetes UK, 2019).

Depression – whether diabetes-related or not – may lead to cognitive decline and can adversely affect the individual's ability to carry out diabetes self-care activities, so many studies have focused on major depressive disorder in diabetes (Park, et al., 2013; Sullivan, et al., 2013). However, psychological symptoms such as anxiety, stress and distress are more prevalent than major depressive disorder (Diabetes UK, 2019). These psychological disorders are associated with increased disability; steadily declining health; an increased use of healthcare facilities such as hospital appointments for eye and foot clinics, and a greater risk of early death (Goldney, et al., 2004). Older people with diabetes often have comorbidities that impair cognitive functioning, such as dementia, hypertension and cardiovascular disease. Age, duration of illness, diabetes complications, and poor glycaemic control may further complicate the relationship between cognitive function and diabetes.

‘At my last diabetes clinic appointment, I told them I’d been diagnosed with depression and that I was taking an anti-depressant [Amitriptyline] with the side effect of increased blood sugar levels. There was absolutely no understanding or practical advice about this whatsoever’.

‘My diabetes consultant and nurse don’t have the time to offer any support. I’m just weighed, have my blood pressure and blood glucose measured, then a quick five-minute chat with the consultant for him to ask if anything's changed. I then get told to come back in a year’.

‘I’ve never received any information from my diabetes team, not even a leaflet’.

The NHS Plan (NHS, 2000) states that too many patients feel talked about, rather than listened to. This suggests that many people do not consider themselves to be part of their diabetes team, their needs remaining uncommunicated and unmet. While those with diabetes are now invited to participate in diabetes care decisions, this should also address emotional, social, behavioural and psychological, as well as medical challenges. The National Service Framework (NSF) priorities for diabetes care document (Department of Health, 2002) states that ‘all individuals with diabetes should be provided with educational and psychological support with the aim of facilitating and supporting self-management’. It is clear from the previous recent examples that this is not necessarily the case in practice.

What Diabetes Care to Expect (Diabetes UK, 2000) suggests that the individual should work with their healthcare team as an equal to achieve the best diabetes management. This implies ability and opportunity to communicate in a two-way discussion about diabetes management so the individual can make decisions and ask for what they need; additionally, the individual spends less than two hours a year with their diabetes team – everything else is self-management.

The What Diabetes Care to Expect patient information pamphlet gives a list of diabetes care team members including a psychologist, ophthalmologist, chiropodist, and dietician. Although being able to request emotional and psychological support is one of the 15 health checks in diabetes care (Diabetes UK, 2018), it may not be the norm – in practice, there is a distinct lack of available psychological support for individuals with diabetes due to NHS budgeting. A 2003 survey of 200 individuals across the UK with Type 1 diabetes showed that only 12 – representing 8 percent of participants – agreed that they could be referred to a psychologist or counsellor if needed (Wilson, 2003). Furthermore, just over half of the participants were unaware they could ask for psychological support if they had mental health issues affecting diabetes self-management. Little has changed in recent times.

‘A mental health specialist should be part of the [diabetes] team to provide emotional support. I recently asked for this, but was told no support was available. I’ve never received any mental health support from my diabetes team – I’m not sure it ever existed. I only see the consultant and the nurse and that's the extent of my care team’.

‘I was told that if my depression affected my blood glucose levels, then I could see a psychologist through my diabetes team. I was assessed by the nurse as managing OK because I still tested my blood regularly for my own benefit with complications, so my depression was labelled as non-diabetes related. I was advised to pay to see a counsellor privately, i.e. not an NHS mental health specialist with diabetes expertise’.

Diabetes and altered brain function

Brain function is modified by a number of significant factors, such as education, mood, age, blood flow, and metabolic fluctuations (Cranston, 2005), meaning this function differs within the individual and across populations over time. Research shows that having diabetes alters the brain both structurally and functionally (Chew, et al., 2014). Neurochemical changes in the regions of the brain controlling cognition increase the risk of depression in people with either Type 1 or Type 2 diabetes (Lyoo, et al., 2012). Impairment of neurons has been seen in people with diabetes mellitus due to abnormal glucose metabolism, resulting in poor maintenance of memory and learning, and an inability to control the expression of emotions (Giacco and Brownlee, 2010).

While there are many negative associations between diabetes and poor self-care, not all emotional consequences are negative; many individuals report a developed ability for self-awareness, self-confidence, hope and humour. Identifying and reflecting on good experiences can have imme...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Dedication
• Contents
• Introduction
• 1 Diabetes, Diagnosis, and Emotional Impact
• 2 Diabetes and Psychosocial Issues
• 3 Theories of Behaviour Applied to Diabetes
• 4 Diabetes and Depression
• 5 Diabetes and Eating Disorders
• 6 Diabetes and the Disease Process
• 7 Diabetes, Stigma and Weight Loss Surgery
• Glossary
• References
• Index