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rf_o LE- 17
SEMINAR ON

Psyc holo gical Inte rven t ion in the Man agem ent of
Diab et es

Chairperson- Prof. J. Mahto

Presentee- Irish Sheikh

Date-15.09.2016
Time -3:00 PM

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POST GRADUATE INSTITUTE OF BEHAVIORAL AND

MEDICAL SCIENCES
fs yc ho lo gi ca l ln tc rvent1·on •·n th e Management of
-
.Diabetes
-
-
Int rod uc tio n

d' d b up of disorders. All forms are

Diabetes mellitus is not a single tsor er ut a heterogeneous gro
metabolism
erglyc em ia and disturbance of carbohydrate, fat, and protein
characterized by hyp ·msulm· acti·on and/or insulin
1 · d ti · ·
vhich are associated with absolute or re ahve e 1c1enc1es of · cat1· on
\ · ely accepted class1fi
He alth Org aniz t· (W HO ) develops a now wid
Secretion. The Wo
rld a ion
classical characteristics.
of the disorder, largely based on
e and either
olic dis ord er tha t is cha rac terized by high blood glucos
Diabetes is a metab of frequent
e ins ulin . Th is hig h blo od sugar produces the symptoms
insufficient or ineffectiv se many
st, and inc rea sed hun ger . Untreated, diabetes can cau
urination, increased thir erosmolar
pli cat ion s inc lud e dia bet ic ketoacidosis and nonketotic hyp
complications. Ac ute com
ure, and damage to the
s lon g-t erm com pli cat ion s include heart disease, kidney fail
coma. Seriou
ause cells of the
e to eit her the pan cre as not producing enough insulin, or bec
eyes. Diabetes is du
most common
per ly to the ins uli n tha t is produced.Diabetes is the third
body do not res pon d pro
ters for Disease Control
in thi s cou ntr y and on e of the leading causes of death (cen
chronic illness
the roughly 18
Ne arl y 6.3 % of the U.S . population has diabetes, and of
and Prevention, 2001). es
5.2 mi llio n car es rem ain undiagnosed (American Diabet
e it,
million ind ivi dua ls wh o hav
stroke as well
ple wit h dia bet es are at high risk for hypertension and
Association, 200 2a) . Peo
r in medical costs, not
abe tes cos ts the Un ite d Sta tes more than $132 billion a yea
{Roan.2003). Di betes
t res ult fro m dis abi lity and work loss (American Dia
tha
including the ind ire ct cos ts
diabetes.
on, 200 3: Dia mo od, 200 3). Th ere are three main types of
Associati
 ilJlt l •ndh er l Ol•hc.tu;
1''r~ nf ch11lx tr•
n111hc1c, mdluu, ,~ cJa.,-,ified inM four hroail cotcizone~ type I, type 2. ge•uat,onal dia~ ~,, 1
''c,1h1.:i ~cllic type.~ 1he "other ~pec1fic type, arc a collection of a few dr,zen ~•
'"drv,1,,.
ro:use~ The term "diabdcs' without qualrficat,on, u~ually refers to d1abete1 mellitus ,

Type t
Diabetes type I

T)"'C I diabetes mellitus 1s characterized by loss of the insul in-producing beta cells of the ,,1 .
,,

►
of Langerhans in the pancreas, leading to insulin deficiency. This type can be further cl !:ii
. . . . . a.s,,ft~
as immune-mediated or idiopathic. The maJonty of type I diabetes 1s of the unmune-rn...1·
'"•"at~
nature m which beta cell loss is a T-cell-mediated autoimmune attack. It causes appro;q
, rnatel•1
10% of diabetes mellitus cases in North America and Europe. Most affected people are oth ·
erw,,e
healthy and of a healthy weight when onset occurs. Sensitivity and responsiveness to insulin are
usually nonnal, especially in the early stages. Type I diabetes can affect children or adults b
• Ut
was traditionally tenned 'Juvenile diabetes" because a majority of these diabetes cases we
re ,n
children.

"Brittle" diabetes, also known as unstable diabetes or labile diabetes is a tenn that was
traditionally used to describe the dramatic and recurrent swings in glucose levels, often occurring
for no apparent reason in insulin-dependent diabetes. This tenn, however, has no biologic basis
and should not be used. There are many reasons for type I diabetes to be accompanied by
irregular and unpredictable hyperglycaemia, frequently with ketosis, and sometimes serious
hypoglycaemia, including an impaired counter regulatory response to hypoglycaemia, occult
infection, gastroparesis (which leads to erratic absorption of dietary carbohydrates}, and
endocrinopathies (e.g., Addison's disease). These phenomena are believed to occur no more
frequently than in I% to 2% of persons with type !diabetes.

Type !diabetes is partly inherited, and then triggered by certain infections, with some evidence
pointing at Coxsackie B4 virus. A genetic element in individual susceptibility to some of these
triggers has been traced to particular HLA genotypes (i.e., the genetic "self' identifiers relied
upon by the immune system). However, even in those who have inherited the susceptibility,

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,iiJ .
~c},
~iP .
·¢<·
~JJf//")
,0

o;~·\
 . .
e ·
I DM seems to require an enviro The onset of type I diabetes 1s unrelated to
nmental trigger.
tYP
lifestyle.

fyp e2
Diabetes type 2

· · · may be combine · ·
e 2 diabetes mellitus is char act · d bY msu· lm resistance, which d with
Typ enze · 1s·
· es to ·msulm
The defiect·1ve responsi·veness of body tissu
elatively reduced insulin secretion ·
r etes
th ever, the specific defects are not known. Diab
believed to involve e insulin receptor. How
most
classified separately. Type 2 diabetes is the
mellitus cases due to a known defect are
insulin
mon type .In the early stag e of type 2, the predominant abnormality is reduced
com
s and
can be reversed by a variety of measure
sensitivity. At this stage, hyperglycaemia
or reduce glucose production by the liver.
medications that improve insulin sensitivity
factors
factors and genetics. A number of lifestyle
Type 2 diabetes is due primarily to lifestyle
ed by a
ent of type 2 diabetes, including obesity (defin
are known to be important to the developm
stress, and
mas s index of greater than thirty), lack of physical activity, poor diet,
body
Japanese
d with 30% of cases in those of Chinese and
urbanization. Excess body fat is associate
a Indians
pean and African descent, and 100% of Pim
descent, 60-80% of cases in those of Euro
obese often have a high waist-hip ratio .
and Pacific Islanders . Those who are not

n of sugar-
of developing type 2 diabetes. Consumptio
Dietary factors also influence the risk
the diet is also
with an increased risk. The type of fats in
sweetened drinks in excess is associated
turated and
fatty acids increasing the risk and polyunsa
important, with saturated fats and trans
play a role in
Eating lots of white rice appears to also
monounsaturated fat decreasing the risk.
eved to cause 7% of cases.
increasing risk. A lack of exercise is beli

Gestational diabetes
, involving a
mbles type 2 diabetes in several respects
Gestational diabetes mellitus (GD M) rese
about 2-
tion of rela tive ly inad equ ate insulin secretion and responsiveness. It occurs in
combina
etes is fully
or disappear after delivery. Gestational diab
S¾ of all pregnancies and may improve
treatable, but requires careful medical supervision throughout the pregnancy. About 0....
2 50
affected women develop type 2 diabetes later in Ii fe. \ ~r

Though it may be transient, untreated gestational diabetes can damage the health of h
tq
mother. Risks to the baby include macrosomia (high birth weight), congenital cardiac et~ (1
1

nervous system anomalies, and skeletal muscle malformations. Increased fatal .

anct ce
111ta1
. . . . . insulin
tnh1b1t fetal surfactant production and cause respiratory distress syndrome. HYPerb·i· tiia1
• I 11'1.lbine .
may result from red blood cell destruction. In severe cases, pennatal death may tli1a
occur
co1mnonly as a result of poor placental perfusion due to vascular impainnent. Labou . ' ll\o,t
r inctu
may be indicated with decreased placental function. A Caesarean section may be Pert Clion
there is marked fatal distress or an increased risk of injury associated with macrosom· Ofrne(j if
ia, such
shoulder dystocia as

Neurocognitive functioning and Diabetes: Studies indicate that children who develop ct·
iabetes
before 5 years of age and/or who have frequent episodes of hypoglycemia are at . k
ns fo1
neurocognitive deficits, particularly in visual-spatial functioning (Holmes & Richman
' 1985,
Rovet, Ehrlich &Hoppe, 1988; Ryan, Vega & Drash, 1985). Studies have also sho""' '
"II lhat
diabetic children, especially boys, are more likely to have learning problems (Holmes, Dunlap,
Chen & Cornwell, 1992). Other research has found poorer attentional functioning and
1ower
verbal intelligence in children with a history of significant hypoglycemia (Rovet & Alvarez,
1997). A longitudinal study of newly diagnosed children revealed declines in verbal intellige
nee
and school grades, predicted in part by memory dysfunction (Kovacs, Goldston & Iyengar,
1992; Kovacs, Ryan& Obrosky, 1994). Another study showed that 2 years after diagnosis
'
children exhibited mild neuropsychological deficits, including reduced speed of infonnation
processing, and decrements in conceptual reasoning and acquisition of new knowledge
(Northam, Anderson, Werther, Warne, Adler & Andrewes, 1998), which were predicted by both
recurrent hypoglycemia and hyperglycemia, as well as early onset of diabetes (before 5 years of
age) (Northam, Anderson, Werther, Warne & Andrewes, 1999). Neurocognitive deficits have
been observed in adults with type !diabetes, particularly those with at least five episodes of
severe hypoglycemia (Langan, Deary, Hepburn & Frier, 1991 ), and in patients with peripheral
neuropathy (Ryan, Williams, Orchard & Finegold, 1992). Among older adults with type 2
 . bctcs. cognitive deficits have been reported
din in associati on with poor g\ycemic contra\
(Rcoven. Thompson, Nahum & Haskins, \ 990) .

., ~,,ch <!lil't11olo gy and Diab etes :

Approximately one-third of patients with diabetes
~ have
. ,rnosable psychological problems at some point duri
dtae· · ng their lifetime.

~S tre ss is common in diabetes and is brought

on by ordinary daily hassles (e.g. , driving in
u-atlic, conflict with family members, work deadlines
), negative life events (e.g. , death of a loved
financial problems, divorce) , and the additional burd
0 ne, ens of coping with diabetes. Stress may
have direct effects on health via elevated blood
glucose values (Surwitt & Schneider, \ 992;
Auslander, Bubb, Rogge & Santiago , l 993) and
indirect effects on health via disruption in
behavioural patterns and routines (e.g., eating and
sleeping). Stress has been associated with an
increased risk of type 2 diabetes. When one is unde
r stress, his body signals its nervous system
and pituitary gland to produce epinephrine and
cortisol, known as "stress hormones." Whe n
cortisol and epinephrine are released, the liver prod
uces more glucose, a bloo d sugar.

-Affective disorder and Anxiety disorder: Affe

common diagnoses and occur significantly mor
ctive and anxiety disorders are the mos t
e often in patients with diabetes than in the
general U.S . population (Gavard, Lustman & Clou
se, 1993). The se disorders can lead to poo r
glycemic control through alterations in neuroho
rmonal and neurotransmitter functioning and
through disruption in diabetes self-care .

'Blood-injection-injury pho bia' and in the Inte

rnational Classification of Dise ases (lCD -\0)
as
'blood-injury pho bia' . The re is intense fear
asso ciat ed with seei ng bloo d or rece ivin g
an
injection. Whe ther the prev alen ce of DSM -IV or
lCD -l O need le pho bia is high er in pati ents with
diabetes than in the general pop ulat ion is not
kno wn. Des pite this , pho bic sym ptom s and
anxieties related to self -inje ctio n of insu lin and
self-mo nito ring of bloo d gluc ose are com mon
and asso ciat ed with difficulties in adh erin g
to diab etes self -car e and con sequent\ )' incr
ease d
glycemic leve ls (Be rlin et al. l 997 ; Bie nve nu &
Eato n l 998 ; Mol lem a et al. 200\) .

L
Adiustmcnt dlsonl ers
• It of a psychosocial stresso r is in ex cess or
a resu
When a person ' s level of distress as th ""it;~ai
affe ctin g the per son 's abi lity to cop e or ~unct_ion, ey may be diagnoseq
expected and is
ma y ma nife st itse lf in a det enorat1on of self-management, behav ~~
adjustment disorder. This lfit~I
· and/or anxiety · . A d'~uStment d'isorders are sho
10n l"l-t, .
disturbances and sytnptoms of depress . h. '"ftii
· h an onset Of symptoms wit m I month of
nths), wit 11
(usually lasting no longer than 6 mo et of t~
dia bet es- rela ted dis tres s after diagnosis can trigger the ons
stressor. High lev els of e1
cas e-n ote sur vey, 28.5% of those referred to a liai son psYch1ai~
adiustme nt diso rde r- in a rec ent . . ti
., •
lvi et al, 200 8). Predictor s of dia betes-related ct·1 ~
this dia gno sis (Da Stte-i
diabetes clinic received hr ~
C
es nts·
management ; negative life eve 'C O .
plic atio ns; setb ack s in dia bet
include diabetes com n,c
and pre vio us history of dep res sio n.
stress in daily life

dep res sion aff ect s app rox imately one of every five patients .
Depressive disorder: Major :Ith
imp airs qua lity of life and all aspects of functioning (Gavard, Lustnia
diabetes and severe ly
n &:
It has add ed imp orta nce in dia bet es because of its association with treatme t no
Clouse, 1993).
vascular ct· n.
nce , poo r gly cem ic con trol , and increased risk for micro- and macro ISe¾:
adhere
s unrecognizect
plications (Lu stm an, Gri ffith & Clouse, 1997). Depression remain
com H illld
ma jori ty of cas es des pite its spe cific relevance to diabetes (Lustman &
untreated in the arper,
1987).
.
betes is psychogenic in its origins has been suggested for many centunes I
The notion that dia ·n
iety or stressful Jives Id
th th
was a theory that anx cou cause
the 19 and early .20 century, there
.
emotional glycosuna (Meninger 1935).

ressive disorder me asu red by the diagnostic interview schedule w~

In 1981 major dep
. es f
associated with mo re tha n a two fold increase in the incidence of cas o self.
prospectively
.
ton et al.1996).
report type 2 diabetes 13 years later (Ea
~
• 11 disorders ore clinicnlly importa t b . assoc1.at1,on with · contro\
• poor glycem1c
€01111., n ccause of their
11d 011 incrcnscd 1i~k for relinopathy (Rydall . Rod'in , 0 1msted , Oeveny1· & oaneman, 1997).
11
6,Jting disorder~ can be cfTectively treated with psychotherapy.

mellitus and an
1i,e particular clinical problems that occur when patients have both diabetes
eating diso rd er have been highlight in case reports since the 1970s. Anorexia nervosa (AN),
bulimia nervosa (BN) and the milder fonns of eating disorder have all described; in the main the
clinical features seen in such patients resemble closely those of non-diabetic patients, with one
important exception.

The first step in successful management of such disorders is detection, but this can be difficult as
111any patients may be secretive or ashamed of their behavior
and unwilling to divulge details in
the clinic setting. Poor glycemic control, repeated episodes of ketoacidos is or hypoglycemia or
fluctuation in body weight are all important clues. Sensitive but direct enquiries about attitudes
10 body shape and weight and method of weight management should be
made. Eating Attitude
Test may help but are not diagnostic. Specific forms of treatment such as cognitive -behavioral
therapy are likely to be of benefit, but practitioners providing such treatments need to have a
good understanding of the management of diabetes if they are to be effective.

~bstance misuse-

Alcohol is hypothesized to be diabetogenic. Some well-designed large population-based

prospective cohort studies in men have shown an inverse association between amount alcohol
consumption and incident cases of diabetes although other similarly well-designed studies have
found a positive association. One of the reasons for these discrepancies may relate to the more
general observation that there is a U-shaped association between alcohol intake and mortality.
Most of the studies have used lifetime self-report measures of alcohol which are likely to
underestimate alcohol consumption, especially in women where the stigma is the greatest.

The prevalence of problem drinking does not appear to be raised in diabetes population patients
but even so alcohol consumption is associated with reduced diabetes self-care behaviors and
 1
worse glycoemic control and it may be an independent ri sk factor for developin ct·
g 'abet
complicati<ms ( Adler et 11 I. 1997: Kohner cl al.1998 ). '1

Personality disorder-

In the 19 ,h century medicine when psychogenic factors were considered in the onset of ct· b
ia et
(Menninger 1935 ) no personality trait has been consistently identifie~ to be ~ sociated wllh :
1
onset of. or co-exist with, diabetes. A follow- up study of I 05 patients with tyPe 2 ctiabet
participating in a randomized controlled trial showed that in the Revised NEO persona1·e-i
. . ity
inventorv the neuroticism domain was associated with batter glycaem1c control at baseli
·J ne but
associations with different personality domains and glycaemic control were inconsistent at 6_and
J2- month follow up. Research in this area in other chronic disease is hampered by the
rnore
complex question of reverse causality, that is to what extent does the life experience of diabetes
affect personality development.

Treatment:

Healthy eating: Contrary to popular perception, there's no specific diabetes diet. However, it's
important to center patient's diet on high-fiber, low-fat foods: Fruits, Vegetables, Whole grains.
The patient needs to eat fewer animal products, refined carbohydrates and sweets. Low glycernic
index foods also may be helpful. The glycemic index is a measure of how quickly a food causes
a rise in your blood sugar. Foods with a high glycemic index raise blood sugar quickly. Low
gJycemic foods may help achieve a more stable blood sugar. Foods with a low glycemic index
typically are foods that are higher in fiber.

Physical activity: Everyone needs regular aerobic exercise, such as walking, swimming and
biking. What's most important is making physical activity part of the patient's daily routine.

Monitoring blood sugar: Depending on the treatment plan, the patient may check and record
his blood sugar level every now and then or, if he is on insulin, multiple times a day. Sometimes,
blood sugar levels can be unpredictable. With help from the diabetes treatment team, the patient
will learn how blood sugar level changes in response to food, exercise, alcohol, illness and
medication.
j\1cdicntlon: Most commonly used medication in Type 2 diabetes are Metformin,
s ulfonylnrcns, Mcglltlnldcs, Thln7.olldlncdloncs, DPP-4 lnhlhlton, GLP-1 receptor agonlsts

insulin thcrnpy: Some people who have type 2 diabetes need insulin therapy as we\\. In the
pn!;I. insulin therapy wns used as last resort, but today it's o~en prescribed sooner because of its
t,encfits. Because nonnal digestion interferes with insulin taken by mouth. insulin must be
injected. Depending on the patient' s needs, doctor may prescribe a mixture of insulin types to
use throughout the day and night. Often, people with type 2 diabetes start insulin use with one
tong-acting shot at night.

-
Role of psycholog ist in diabetic care: Ideally, diabetes treatment is provided by a team of
health care professionals that consists of a physician, diabetes nurse educator, dietician, and
psychologist (Lorenz, Bubb, Davis, Jacobson, Jannasch, Kramer, Lipps, Sch\undt, 1996). The
psychologist provides direct services to the patient via promotion of health behaviors and
treatment of psychological problems, and also provides consultation to the medical team on how
to incorporate psychological principles into patient care to enhance clinical outcomes.

Diagnoses and Assessment: Clinical psychologists are an appropriate resource to the diabetes
treatment team for the diagnosis, assessment, and treatment of mental health problems of patients
with diabetes. Psychologists with expertise in reinforcement strategies, learning principles, and
behavior modification are highly desirable given the usefulness of these skills for developing
health behaviors. While not all psychologists are trained in diabetes, it is recommended that
clinical psychologists working with diabetic patients have training in health and/or pediatric
psychology and be licensed by the state in which they work. This will provide some degree of
quality assurance and will increase the chances that services rendered by a psychologist will be
reimbursed by insurance companies.

Psychological Techniques/Intervention in Diabetes:

Research shows that psycholog ical interventi ons can be used to treat mental health problems and

people with diabetes. Research has focused mainly on depressio n and suggests psychothe rapy

has a greater effect on depressive symptom s and glycemic control than antidepressant treatment,
especially when combined with self-mana gement education (van der Feltz-Cor nelis and
Nuyen,2010). Psychotherapy. counseling and psychological interventions are urnbrel)
, . a tel'lli~
people referred for psychologica l therapy may receive different types of verbal therapies. ·~
• Psycho-education Psych-educational programs for youths and family-based
have shown 10be effective in improving psychosocial and diabetes-related Prograh\, 1
. . . . OU\to
Psycho-educa tional programs provide education, behavioural skills and p ll\e,
. .. . ' sychos ..
support for young people and their famthes to learn how to optimally mana ~1~
ge a ch
illness. However, disseminating and translating research-based programs i ton1t
nto ct·1 .
care has been challenging because of provider and fam ily ti me constraints n1~•1
cost.The lntemet and other Health technologies offer a platform for imp'as we11 . <t1
rov 1n
dissemination and accessibility of psycho-educational programs for youth With g the
. mcreasmg
. . 1y ava1.1abl e . 1
diabetes. Access to the Intemet 1s nahonw1.de, with 94<>;; TY\le 1
o of y
online regularly. Approximately 90% of young people of all demographic oU\h \
socioeconomic categories have access to the Internet. Thus, e-Health interventi ¾d
ons hai,,
the potential to reach a diverse group of youths. Programs provided on the lnte e
met can
include psycho-educational content, interactive learning, immediate feedback and .
' soc1a1
networking. Psycho-educational programs delivered via computer-based Intemet
access
have demonstrated efficacy in youths with various chronic illnesses, leading to imp
roveq
knowledge, symptoms, health outcomes, and quality of life. With respect to youths .
W1th
Type 1 diabetes, an e-Health self-management program with a focus on problem sol .
v1ng
and social networking demonstrated improved self-management and problem solvi·n .
gIn
youth who completed the program compared to a control group. An Internet copingskills
training program, developed by our research team, did not demonstrate differential
improvements in metabolic control and diabetes-related outcomes compared to an
Internet diabetes education program, but youths in both groups reported significantly
increased self-care autonomy, higher diabetes self-efficacy, and improved overall quality
of life over time. The Internet, therefore, represents a potentially efficient and effective
delivery platform for psycho-educational programs for youths with Type 1 diabetes and
other chronic illnesses. When evaluated, high satisfaction with e-Health programs have
also been reported.
• Supportive therapy focuse .
s on increasing the individual' s self-esteem and adaptive
ski11s and identifies unhelpf b h .
1
u e av1ors by exploring the person's interpersonal patterns
(Woller et al. 1996) Famil d .
· Y an social support are important aspects of adherence to
diabetes management Nume .
· rous correlntlonal studies have shown a positive and
significant relationship bctw .
een social support and adherence to diabetes treatment.
Future research should ident'1f lh
Y e many types of social support interventions that
promote adherence· in do' d' b . .
' ing so, la et,c patients are given the ability to seek social
support that is most conduciv d · · ·
e an appropnate for their lifestyle. Lastly, further empirical
evidence is needed to address th h · b · · ·
e mec anisms y which social support works to directly
influence health outcomes, health care utilization, and behaviour change.

• Motivational interviewing (MI) involves helping the individual identify and resolve
discrepancies between their goals, values and current behavior (Williams et al, 1998).
People with diabetes often struggle to make healthy choices and stay on top of
managing their illness. Filling a vital need, this is the first book to focus on the use
of motivational interviewing (MI) in diabetes care. The uniquely qualified
authors-ph ysician Marc P. Steinberg has devoted much of his career to diabetes
care, and renowned clinical psychologist William R. Miller is the co-developer of
Ml-presen t proven counseling techniques that can make any conversation with a
patient more efficacious and motivating. Numerous sample dialogues illustrate
specific ways to elicit patients' strengths and help them overcome barriers to
change in such areas as eating habits, physical activity, medication use, insulin
treatment, substance abuse, psychological issues, and more. A non-manualized,
individually tailored therapy defined as "a collaborative, goal-oriented style of
communication with particular attention to the language of change. It is designed to
strengthen personal motivation for and commitment to a specific goal by eliciting and
exploring the person' s own reasons for change within an atmosphere of acceptance and
. ,,
compassion.
• Psycho dynamic (or psychoanalytic) therapy focuses more on understanding current
behavior through past experiences (Pusch et al, 2012).
• Behaviornlthernpy uses techniques such as goal-setting and reinforcement (Pusch
.
and inte et qi,
2012) and interpersonal therapy focuses on copmg strategi cs
relationships (Wil fley, 200 I). This was followed by piecemeal incl usion of behav·
l'])ers\\~al
1
cognitive psychological techniqu es. such as relaxation therapy and b'i01eedb r \\ra10
t
t· ack , ~
coping strategies resulting in the theoretical foundation of many interven tons b . t
eing\i
blurred or combined that a distinction cannot always be made.

• Client-Centered Therapy: A non-directive and supportive counsel ing a

. PProach
' the
goals of CCT are increased self-esteem and openness to expenence.. Additi onal!y, C:
. . . . .
C't
aims to mcrease self-understandmg; reduce defensiveness, guilt, and msecuritY., estab\i
. . . . 8h
more positive and comfortable relat10nsh1ps with others; and mcrease capacity
to
experience and express feelings.
the .
Cognitive Behavioral Therapy (CBT): CBT is a generic term referring to rap1es th
•
. at
incorporate both behavioral interventions (direct attempts to reduce dysfunett\\
na\
emotions and behavior by altering behavior) and cognitive interventions (direct attetn
p~
to reduce dysfunctional emotions and behavior by altering individual appraisaIs anct
thinking patterns). In the present study, techniques, such as cognitive restruC,unn
h• .

rel . ~
emotional adjustment/rational emotive therapy, relaxation, biofeedback axatton
sot .
training, music relaxation therapy, goal setting, stress management, and problem Ytng,
th
were classified as components of CBT. The most commonly used psychological erapy
behaviorat
in the treatment of adjustment disorders, depression and anxiety is cognitive
adjustment
therapy (CBT), although not one specific psychotherapy is recommended for
feelings and
disorders. CBT examines the relationship between a person' s thoughts,
e element
behaviors, and focuses on practical solutions to current problems. The cognitiv
into more
involves identifying and modifying dysfunctional cognitions, or thoughts,
ral element
realistic and helpful ones; this is called "cognitive restructuring". The behavio
and positive
refers to the use of behavior change strategies such as cueing, goal-setting
es. CBT has
reinforcement. as well as activity scheduling and stress management techniqu
diabetes, as
been shown to be effective at treating depression and anxiety in people with
HbA
well as improving self-care behaviours and having long- term effects of lowering
(Snock et al, 2008).
 change the
• Mi nd fulness-bnsed cognitive therapy (MBCT) is specifically developed to
about the
way people perceive their experien ce of life, rather than attending anxieties
teaches
future or attaining a sense of identity through past events, Mindfulness
nt and
individuals lo experience life on a moment by moment basis, avoiding judgme
of dealing
desire for change. Mindfulness is the cultivation of a radically different way
constantly
with adversity, negative memories, thoughts and experiences. Rather than
uals with
battling to remove oneself from discomfort, Mindfulness provides individ
by default,
teclmiques to accept and let things be as they are in the present moment,
n in
Mindfulness practices are accompanied by peace, relaxation and the reductio
significantly
symptoms of depression. More precisely, Mindfulness has been shown to
systems
reduce ruminative thinking patterns, affective symptoms and dysfunctional belief
by nice to
associated with depression. Mindfulness is the therapy of choice recommended
episodes
address recurrent major depression. People who have experienced three or more
effective
of depression will be offered MBCT as it has been found to be the most
depression is
treatment in preventing relapse.Using mindfulness to address symptoms of
will be no
also seen as more appropriate for a person with diabetes as it means there
conflicting side effects with their nonnal diabetes treatment.

.9>nclusion-

lly ill individuals has

The importance of the mental health expert in the management of medica
or. The mental health
grown with the proliferation of information linking health and behavi
thful behaviors' in a\l
professional intervenes to develop healthful behaviors' and remove unheal
patients with evident
medically ill patients and to relieve emotional distress in the subset of
where applications of
psychopathology. There are several general medical conditions
medical management
psychological techniques or services appear to affect the outcome of
positively.

one another is complex,

Mental health issues are common in diabetes, and their relationship with
ed prevalence of mental
bidirectional and not fully understood. Theories explaining the increas
mic control consider
health issues in diabetes populations and their relationship with poor glycae
 hmJr-rlcal fl8-'h"'•'".Cl· JJ.l:l well ~ rw('M~/t!O II vr.rl «W'l \ ' f.,clt'\N M ool'l <li'll'Wtler"
# µ~~,r, ~
l'flt\ ..

l'.!n~, c,f d ,Jth..t~ q11fl.11 rh,~ l<I ('l'Jf" .,...,,,,nv t,r,~•n-oo hy hrc"tvle (rtcM'"" '\UQJt~,1111R :i

t,Jt"U\!!ft".aJ Ntr.h1t ., IN 11t11ht't{'.Cl ( h1rh l',J('<o(f ~hn~(~) ,\T'll'.1 m(),,1<1 tlt~<ii-dcr, Dl:1hcie" I , ~,, ,
ti'\\ "Ii
a~ a UiJ;U!CJ ll"t nwnu,J hen/th r,rr,Mcm~ ,n V\1lnc.rahtc ind,v,du:\l 'I ind mc11101 heo1th ••1,
,~~\!~
•ntcrn:n "' 1111 or,.t1m1tl t111N:-1,_c: 1:clf-man11~cmcnt lc.' \din(( to poor glycne111ic co ntro1 ·~ .,
~ l ! ! i hJtvc ll"l(l~OO Ct Cl("l('111 I 111cto~. out they are important nonethe le"" Finn11c[a1
''
"11,11
anr,r.-, ,'TDcnt swrur,. JI\ mp. cond!llons. wc1al suppor1 and access to communitv 'lervice
"ltan :irr
an md" ,duru s nh1l11v to manage
·
the1r diabetes IY'
c11cch\;e >'·
I S
1m1 ar
·1 I
y. d·1nbetes corn 1 ~.
p ICat1"·,n,
L •
7 1t, e negat1\'e effect on a person 'l soc,a1situation. .:i,,

The ;qJe of psychological tnlCJVe11t1ons for people with di abetes and mental hea.Ith 'SS
11
unemployment social 1s0Jal1on and a lack of autonomy; all of which are associated ~ ',
With ni.
health zssue.o. The complex relationship of diabetes, mental health and social fact ors highrertt~
1
the need to treat people holistically and to promote interdisciplinary collaboration. &h1,

References

• Anderson RJ. Freedland KE, Clouse (2001) The prevalence of comorbid d

.Lh . epress1on 1
aduJts w i diabetes. Diabetes Care 24: J069- 78 n

• .
Atian1..ts E. Vogelzangs N, Cashman K (2012) . Common mental disorders .
assoc·
2-year diabetes incidence. J Affect Disorder 142: S30-35 iated With

• Bourdel-Marchasson I D t C H I
!r • F , rue , e mer C (2013) Correlates of health-related qua!"
1ze tn rench people with 1 2 d. . 1ty of
• . ype iabetes. Diabetes Res Clin Pract l Ol: 226-35
Kovacs M, Ho V, Pollock MH (199 . .
adjustment disorder Am J p h' 5) Cntenon and predictive validity of the diagnosis of
· syc 1atry 152: 523-8

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