David Levy, MD, FRCP
That there is a close link between long-term conditions and psychological functioning is to state the obvious. But the complexity of the relationship, especially in a condition that spans a lifetime, such as diabetes, has only relatively recently been explored. In addition, the therapeutic options, once the often very subtle problems have been identified, are only just emerging. Finally, the literature is full of studies describing cross-sectional associations, many of them expected or unsurprising, but only longitudinal studies can uncover causality; fortunately, detailed and validated measures of psychological function are now routinely included in many current large-scale RCTs, and the next few years should give us a much clearer understanding of the dynamics of psychological aspects of diabetes and, more importantly, an insight into therapies. Because the fundamental processes at work in type 1 and type 2 diabetes are different, it is worthwhile discussing them separately, especially in relation to the intimate association between family functioning and type 1 diabetes in young people.
Type 1 diabetes
The literature on the effect of psychological and psychosocial stresses on people with type 1 diabetes has rapidly increased since DCCT published, and there is a view that family stresses, particularly over the imperative for ‘good’ glycemic control, established by the DCCT, have increased since then, especially in relation to questions of blood glucose testing, disordered eating and the closely linked problem of omitting insulin doses.
Events around the time of diagnosis
About one-third of children develop a clinically significant adjustment disorder in the 3–12 months following the diagnosis of type 1 diabetes; although this usually resolves, if it persists it is associated with later psychological difficulties. Although less common, major depression and generalized anxiety disorder are at their peak in the year following diagnosis; parents also respond to the diagnosis with a form of post-traumatic stress disorder, twice as commonly in mothers than fathers. The theme of increased psychological problems in mothers, usually the main carers in young people with diabetes, is recurrent. There is little evidence from retrospective studies that psychological events are more frequent in the run-up to clinical diagnosis, but hospital admission or serious illness, unrelated to diabetes, is much more common, a finding that ties in with clinical experience and also with the concept of a physical stressor precipitating the final autoimmune insult to residual [3-cell function.
Eating disorders in type 1 diabetes (Box 13.1)
These are difficult to diagnose (standard questionnaires are too complicated for routine use), but repeated sensitive questioning based on the clues in the box may help. Formally diagnosed eating disorders are rare in type 1 diabetes, but they carry a high mortality and are frequently associated with characteristic advanced complications, especially retinopathy, peripheral neuropathy (though rarely with foot ulceration) and visceral autonomic neuropathy, especially gastroparesis. Because of the very poor control often associated with gastroparesis (see Chapter 10) this is likely to be a factor accelerating the progression of other microvascular complications. Disordered eating behavior is much more common than formal eating disorders.
Missing insulin is an early learned method for weight control and loss, and repeated sensitive questioning is required to assess it in individu- als. Nearly 40% of patients between 15 and 30 years old report intentional insulin omission. Overall, up to age 60, one-third omit insulin, and it is surprisingly common even in older women aged between 45 and 60. More extreme omission, effectively stopping insulin treatment entirely for up to 2 weeks at a time, is common during adolescence and early adulthood. Taking more daily injections is associated with insulin omission – again no surprise – so there is no point suggesting more injections for people in poor control if the current injections are not being taken. Try to fix the underlying problem first.
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