When considered from an experiential perspective, type 1 diabetes (Type 1 diabetes mellitus) represents a significant stressor for individuals and their families. A comprehensive understanding of psychological factors related to Type 1 diabetes mellitus requires investigation of (/) the impact of Type 1 diabetes mellitus upon psychological adjustment and (ii) the impact of psychological adjustment upon medical outcomes for diabetes mellitus 1. Both of these directions of influence are reviewed below regarding each of the most prevalent and/or problematic psychological adjustment problems for adults with Type 1 diabetes mellitus.
When comparing with other chronic health conditions, from an experiential perspective, it is important to consider:
• disease factors, including disease onset, disease progression;
• regimen factors, including the complexity, the intrusiveness, the cost and the accessibility, and the side-effects that affect regimen adherence;
• individual factors, including health beliefs and coping; and
• comorbidpsychopathology.
Disease, regimen, and individual factors specific to Type 1 diabetes mellitus, although reviewed more comprehensively elsewhere, will be reviewed briefly in this chapter. Several psychological problems that are prevalent and problematic among individuals with Type 1 diabetes mellitus, depression, anxiety, and dysregulated eating, will each be reviewed in detail in the post.
The disease onset of Type 1 diabetes mellitus may vary in several ways. Some individuals may experience the vague and mildly distressing symptoms of increased thirst and urination, hunger, fatigue, and weight loss, and subsequently seek medical attention at which time they receive the diagnosis of Type 1 diabetes mellitus. In such cases, the symptoms are not extreme or greatly distressing, and the individual may perceive the news of the diagnosis and demand for ongoing treatment to be more distressing than the symptoms. In contrast, other individuals may develop diabetic ketoacidosis (diabetic ketoacidosis) (e.g., a serious and dangerous condition of high levels of ketones, which can result in coma and/or death) prior to diagnosis, and therefore experience the disease onset as more distressing and fear inducing. Additionally, many adults with Type 1 diabetes mellitus have been diagnosed as children or adolescents, and time since diagnosis is an important consideration. The regimen factors are likely to be more important than the disease factors regarding both coping and self-management success among individuals with Type 1 diabetes mellitus. The Type 1 diabetes mellitus self-management regimens, as described in more detail in other chapters, are reviewed here with respect to the specific demands they place on patients. Regardless of which exact regimen an individual uses, the Type 1 diabetes mellitus treatment is complex, multifactorial, and requires ongoing consistency. The exact regimen, in turn, poses particular challenges and offers particular benefits. In Table 1, the typical current Type 1 diabetes mellitus regimens are compared and contrasted regarding the factors involved in patient self-care.
Table Specific Self-Management Activities and Lifestyle Factors Relevant to Current Insulin Regimen
| Type of regimen | Injection therapy with intermediate insulin and rapid insulin (but not at every meal) (e.g., Twice daily NPH [morning and dinnertime, possibly bedtime] with Regular, Aspart or Lispro injections prior to breakfast and dinner) | multiple daily insulin regimen;
basal/bolus therapy by injections, with bolus taken at every meal (e.g., Glargine with Aspart or Lispro injections each time you eat) |
CSII; pump therapy |
| Frequency of injection (or needle insertion) | Fewer, 2-3/day | More injections | Only infusion set changes, 1/every third day |
| Need for consistency in mealtimes | High | Low | Low |
| Flexibility in mealtimes | Low | Moderate | High |
| Flexibility regarding amounts of food eaten/meal | Low | High | High |
| Need for carbohydrate counting | Varied, but can accomplish control without carbohydrate counting | High | High |
| Demand to execute arithmetic for meal insulin-to-carbohydrate ratios | Varied, but low if patient is not carbohydrate counting | High | High, but low with newer pump models, in which ratios can be entered into pump. |
| Ability to dose with insulin for effects of dietary Fats upon blood glucose | Low, very difficult | Low, very difficult | High, ease with use of temporary basal rates. |
| Ability to achieve euglycemia with exercise/sports activity | Low | Moderate | High |
Within the literature addressing Type 1 diabetes mellitus treatment among adolescents and children, an important distinction has been made between adherence and self-management with accompanying activities and goals relevant to blood glucose management. Adherence represents the patient’s following of treatment instructions by medical providers, and self-management involves an active self-directed process, with elements divisible into process to execute the activities to reach self-management goals. This distinction emphasizes that, although self-management is a process collaborative with medical providers, it truly requires the patients and families to understand the factors that affect blood glucose [e.g., food intake (carbohydrates, fats), insulin dosage, timing of food intake and insulin dosage, blood glucose monitoring, exercise, stress], factors that affect prevention of complications (foot care, ophthalmologic screening), and actively manage these activities in their ongoing life. As highlighted in Table 1, the evolution of regimen, development of newer preparations of insulin (e.g., Glargine), and application of newer delivery methods (e.g., continuous subcutaneous insulin infusion [CSII] pumps) over the past 10 to 15 years, has greatly affected the self-management behaviors required for patients. As a result, many of the old stereotypes among the public, such as Type 1 diabetes mellitus management requiring the elimination of simple carbohydrates and/or severe restriction of carbohydrates, has become an obsolete assumption. For example, those using basal/bolus multiple daily injections (multiple daily insulin) or CSII pumps, who are accurate in their carbohydrate counting and appropriate use of insulin-to-grams of carbohydrate bolus ratios, may not need to limit carbohydrate intake at all. Although regimen such as multiple daily insulin and CSII pumps have reprieved some patients from requirements of older regimen, successful management continues to require the consistent process of active blood glucose monitoring, use of insulin boli to correct high blood glucose, counting of carbohydrates and use of insulin-to-gram of carbohydrate ratio boli, and other demanding activities to maintain optimal blood glucose.
The individual factors, such as intelligence, knowledge, culture, patient’s trust in medical profession, health beliefs, and coping, constitute the variables that interact with the disease and regimen factors overviewed above. For a full review of these issues, the reader is referred to Boyer. Here, a brief review of diabetes-specific knowledge and coping are provided.
Diabetes-Specific Knowledge
Since the treatment for Type 1 diabetes mellitus involves a complex regimen of self-management, the amount and accuracy of knowledge is imperative for patients’ adherence to treatment and glycemic control. The literature on knowledge among the pediatric Type 1 diabetes mellitus population becomes relevant, since those diagnosed as children or adolescents may receive most of their self-management training at diagnosis. Data indicates, however, that individuals show decrease in their maintenance and application of diabetes-specific knowledge over time, and reeducation becomes important. Although knowledge is related to self-management and glycemic control, it has also been found not to predict management outcome, as other factors interfere with the application of this knowledge over time. Some of these factors are discussed throughout the remainder of this chapter.
Coping
Due to the demand for active and strategic self-management of blood glucose among all treatments for Type 1 diabetes mellitus, the coping dispositions of patients and their families are of crucial importance. Empirical investigations regarding coping among those with Type 1 diabetes mellitus, and the relationship of coping to medical outcomes, have generally implied that active, approach-oriented coping dispositions show a better match with diabetes mellitus 1 self-management demands than passive, avoidant coping. Active coping corresponds with better quality of life among adults with diabetes, and better metabolic control among adolescents with Type 1 diabetes mellitus. Although much of the research investigating samples of patients with Type 1 diabetes mellitus are adolescent samples, these data are relevant to our discussion, as most adults with Type 1 diabetes mellitus have had the condition across their adolescent years, and may have developed coping dispositions that persist into adulthood. While some studies have shown that coping training interventions for adolescents produced reductions in diabetes-specific stress but not improvements in glycemic control, others have produced improvements in self-efficacy as well as metabolic control that maintained for 6 months following therapy. Simply put, it appears that individuals who manage stress by approaching the stressful condition, attempting to control the condition, and find the process of exerting strategic control to be distress-reducing are likely to be more easily successful managing Type 1 diabetes mellitus than those who reduce stress by avoiding the stressful condition, employing avoidant strategies to reduce the sense of threat and distress, and experience greater distress when approaching the stress-inducing context.
While the factors reviewed above, knowledge, coping, and self-management difficulties are relevant to any and all individuals with Type 1 diabetes mellitus, several psychological disorders have been shown to be more prevalent in those with Type 1 diabetes mellitus, and particularly problematic for self-management and glycemic control.
DEPRESSION
ANXIETY
DYSREGULATED EATING
CONCLUSION
Type 1 diabetes mellitus is a complicated disease, which can represent a significant stressor for the individual and his/her family. A comprehensive understanding of how this disease impacts psychological factors, and the impact of psychological factors on medical outcomes is crucial in understanding and managing this disease. A well-developed literature has investigated the comorbidity between Type 1 diabetes mellitus and several psychiatric diseases, and has shown that individuals with diabetes mellitus have a disproportionately higher rate of psychiatric disorders. Depression, anxiety, and dysregulated eating appear more prevalent among those with Type 1 diabetes mellitus, interfere with important outcomes such as quality of life, self-management, and glycemic control. In addition, psychological factors interact with adjustment to Type 1 diabetes mellitus, self-management, and metabolic control, even at subdiagnostic levels of symptomatology. Indeed, it appears nearly impossible to optimize medical outcomes without addressing the role of knowledge, coping, anxiety and mood, and dysregulated eating in the adult Type 1 diabetes mellitus population. Diabetes treatment teams must maintain a high suspicion for these factors among adults with Type 1 diabetes mellitus, screen carefully, and treat aggressively, so as to prevent these nonpathophysiological factors from rendering treatment ineffective.