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A biopsychosocial treatment approach to the management of diabetes mellitus
A Biopsychosocial Treatment Approach to the Management of Diabetes Mellitus Lee S. Schwartz, M.D., Lewis Russell Coulson, M.D., David Toovy, B.S., John S. Lyons, Ph.D., and Joseph A. Flaherty, M.D.
Abstract: The relationship among recent life stress, social support, a patient’s locus of control, and thecontrol of bloodglucose is evaluated in persons with diabetes mellitus, using objective measures of these psychosocial variables. Short-term [fasting blood sugar (FBS)] and long-term [glycosylated hemoglobin (Hgb A-1C)l control measures are taken at two points in time in order to evaluate the effects of the psychosocial variables on change in diabetes control. For life euents, a significant positive association was found between the number of recent life events and blood glucose control. Decrease in social support predicted a worsening of longer-term (Hgb A-10 control over time. An external locus of control within the patient was associated both with poor short-term control at time one and prediction of poorer long-term control over time. The implications of these findings are discussed in support of a biopsychosocial approach to the management of diabetes mellitus.
Introduction Stress and susceptibility to illness have been linked for a variety of illnesses, including peptic ulcer disease, myocardial infarction [l-3], and various psychiatric disorders [4]. For diabetes mellitus, statistically significant links have been found between life stress and the onset of diabetes, both for the insulin-dependent [5,6] and non-insulindependent [7j types. Relationships have also been reported between life events and both the onset and change in the course of diabetes [8-151. Stressful life events, especially undesirable ones, have been linked to changes in the diabetic conFrom Northwestern University Medical School (L.S.S., J.S.L.); the University of Illinois, kollege of Medicine. (D.T., 1.A.F.k and the Universitv of Illinois/VA Westside Medical Center (L.R.C.), Chicago, Illkois. Address reprint requests to: Lee S. Schwartz, M.D., 259 E. Erie, Suite 452, Chicago, IL 60611.
General Hospital Psychiatry 13, 19-26, 1991 0 1991 Elsevier Science Publishing Co., Inc. 655 Avenue of the Americas, New York, NY 10010
dition [16], including increased glycosuria, changes in prescription, and changes in frequency of clinic appointments [17]. Insulin-dependent patients appear to have more problems with diabetes management in association with undesirable life events [17], which are linked to a worsening of control [17-231. Life events that are neutral or even positive have also been reported more by insulindependent persons in poor control [24]. Yet acute, artificially induced stressors do not seem to significantly affect blood glucose in insulin-dependent [25] or non-insulin-dependent [26] persons. The effect(s) of stress have also seemed to depend on specific aspects of the patient (271, including personality type [28]. Social support, that which leads one to believe that others care about and understand him/her, can influence the effect(s) of life stress. Lack of social support has been associated with poorer recovery from surgery [29], increased need for steroid treatment in adults with asthma [30], increased birth complications [31], and increased incidence of tuberculosis [32]. Likewise, increased social support has been associated with decreased morbidity following bereavement [33,34], retirement [35], termination of employment [36], and the threat of death [37-391. For persons with diabetes, family support has been recognized as important in the management of children [40-501, adolescents [51], and adults [52-561. Support groups are useful for parents of children with diabetes 1571 and for diabetic persons in general [58,59]. Nursing support has been recognized as important in maintaining the stability of the hospitalized pregnant diabetic woman [60], as is physician support to the elderly
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L. S. Schwartz et al.
patient [61]. Research with children has demonstrated associations between poor family functioning and poorer diabetes control [62-651. Various measures of family functioning have shown the following to be related to better control for insulin-dependent diabetes: increased support offered [66], lesser incongruence between parents [67], increased cohesion with less conflict [56,6870], orientation toward achievement [70], and increased caring as perceived within the family [71]. Of 233 patients with insulin-dependent diabetes, those that received regular feedback from a nurse practitioner showed improved glycohemoglobin (Hgb A-1C) results, which are a measure of longterm control [72]. Good family functioning was also found to be significantly higher for patients in good short-term control, as measured by fasting blood sugar (FBS) [73]. Another psychosocial variable studied in connection with diabetes mellitus is locus of control. Locus of control refers to the extent to which an individual feels able to control the events and/ or circumstances in his or her life. There is an internal-external dimension that refers, respectively, to the degree to which the person perceives things that happen to him or her as a result of his or her own action, as opposed to occurring as a result of chance, fate, or powers beyond one’s control and understanding [74]. Results have been inconsistent in examining the relationship between locus of control and control of diabetes. An internal locus of control has been linked to both poorer control [75-771 and better control [78]. Findings of no apparent relationship to control of diabetes have been demonstrated as well when a measure of health locus of control was used [79]. Patients in poor metabolic control were found to use “wishful thinking” and “avoidance/help seeking behavior, ” both related to an external locus, more than patients in good metabolic control [80]. Yet, children with an external locus have also shown a trend toward good control, possibly due to strict family rules that enhance compliance [81]. Adult patients trained to negotiate with their physicians regarding treatment options showed better control than an uncoached reference group [82]. Such coaching may be considered an enhancement of a patient’s internal locus of control characteristics. In a pilot study by the principal author, using objective measurements of life events and social support, it was demonstrated that a higher number of life events was associated with a higher per20
centage of abnormal Hgb A-1C and FBS results. Also, higher social support was associated with a smaller percentage of abnormal Hgb A-1C scores [83]. Overall, persons with high life events and low social support had the highest percentage of abnormal Hgb A-1C results. This earlier study, however, lacked statistical significance due to small sample size. The current investigation was undertaken to statistically substantiate the earlier findings and to investigate the effect(s) of locus of control on control of diabetes. We set out to measure blood glucose control at two points in time, 3 months apart, using objective measures of recent life events, social support, and locus of control. Diabetic control was measured with both short-term (FBS) and longterm (Hgb A-1C) methods. We postulated that: (1) high life events would predict worsening of diabetes control; (2) low social support would predict disturbance in diabetic control; and (3) an increase in life events and/or decrease in social support over time would predict a decline in control of diabetes. We set out also to examine the relationship between an individual’s locus of control and control of his or her diabetes.
Methods Over a period of approximately 14 months, 112 diabetic patients from a Veterans Administration Hospital outpatient general medicine clinic volunteered for this study. All subjects received their treatment from the same internist. The subjects were all (1) male, (2) over 18 years of age, (3) diabetic for at least 3 months, and (4) ambulatory. Patients were excluded only if there was a past history of excessive missed clinic appointments or gross noncompliance, as evidenced by refusal to take medications. The patients’ ages ranged from 38 to 80 years (mean 63 years), were diabetic for a minimum of 3 months and a maximum of 45 years (mean 16 years), and were treated with insulin (54 subjects), oral hypoglycemic agents (43 subjects), diet alone (12 subjects), or a combination of insulin and oral hypoglycemic agents (3 subjects). Seventy-five were married and 37 were unmarried. Informed consent was obtained from each patient after the nature of the procedures had been fully explained. At each clinic visit blood was drawn for Hgb A-lC, to measure control during the previous 3 months, and for FBS, which measured short-term control. During each visit the patient was interviewed
Biopsychosocial
using four different instruments. All the questions were read to the subject and recorded by a single interviewer. The practice of reading and recording every questionnaire served to eliminate the bias due to poor vision and/or differences in patient literacy. The interview began with questions of demography, diabetic treatment regimen, and other medical care information. Each patient completed the Paykel Scale of Recent Life Events, which asks the patient about specific events that may have occurred in his or her life during the previous 3 months. Of the 61 events listed, at the top end of the scale are catastrophic and highly distressing events such as death of a child or spouse. At the bottom are events that are desirable and nondistressing. This instrument has demonstrated moderate individual reliability and high agreement across groups [84]. Each patient also completed the Social Support Network Inventory (SSNI), which asks the individual to list key support individuals and/or groups in his or her support network and to rate each of them on variables, including practical support, emotional support, availability, and reciprocity. This instrument measures perceived social support and identifies the providers of it. The SSNI has been shown to have high test-retest reliability (r = 0.87), internal consistency (alpha coefficient = 0.89), and concurrent validity [85]. Lastly, the patient completed a modified version of the Rotter Locus of Control Scale, which measures individual differences in generalized expectancy for internal/external control. For this scale, item analysis and factor analysis show that internal consistency is relatively high, test-retest reliability is satisfactory, and discriminant validity is established [86]. We used a shortened (12-item) version of the original 29-item scale. Of the initial 112 patients, 102 provided data at a second clinic visit approximately 3 months later. Of the ten patients who were lost to follow-up, five missed their appointments, four refused a second interview, and one was hospitalized. There were, therefore, 102 subjects included for purposes of data analysis.
of Diabetes
Table 1. Means and standard deviations variables at times 1 and 2 Time 1
for all
Time 2
Variable
Mean
Standard deviation
Mean
Standard deviation
Hgb A-1C FBS Life events score SSNI Locus of control score
10.29 194.66 28.59 4.05
3.17 76.24 24.03 0.61
10.50 190.84 27.59 4.01
3.87 81.74 25.68 0.57
3.53
1.59
3.46
1.57
-
higher the score, the more external the locus). For diabetes control, short- and long-term control were measured by FBS and Hgb A-lC, respectively, higher values indicating poorer control. Table 1 summarizes the means and standard deviations of these variables at times 1 and 2. To study the relationship between life events, social support, locus of control, and control of diabetes, regression analyses were done, using Hgb A-1C and FBS as dependent variables. Separate regression analyses were used in order to attempt to predict FBS and Hgb A-1C at times 1 and 2 by the level of life events, level of social support, and by locus of control. In addition, regression analyses were used to predict change in Hgb A-IC and FBS over time by life events, social support, and locus of control. Table 2 summarizes the intercorrelations discovered.
Hgb A-IC For Hgb A-1C at time 1, the overall regression model was significant [F(3,106) = 2.86, p < 0.051. Specifically, the number of life events was posi-
Table 2. Pearson product moment correlations between Hgb A-lC, FBS, life events, social support, and locus of control at two time points Time 1
Results Scores were obtained on the Paykel Scale of Life Events (the higher the score, the higher the life stress expected), the SSNI (the higher the score, the greater the degree of perceived social support), and the modified Rotter Locus of Control Scale (the
Management
A-1C Life events Social support Locus of control
0.23 0.10 0.11
FBS 0.28” 0.06 0.25”
-
Time 2 A-1C
FBS
0.23 0.11 0.14
0.21 0.16 0.06
ap < 0.05.
21
L. S. Schwartz et al.
tively associated with Hgb A-1C [F(1,106) = 6.45, p < 0.011. That is, subjects with more life events had worse control as measured by Hgb A-1C. There was no association found between social support or locus of control and Hgb A-1C at time 1. The results at time 2 closely replicated the findings at time 1. For Hgb A-1C at time 2, the overall regression model was nearly significant [F(3,93) = 2.56, p < 0.061. Again a high life events score was significantly associated with poorer control of blood glucose [F(1,93) = 3.72, p < 0.051. There was no association between social support or locus of control and Hgb A-1C at time 2.
FBS The overall regression model was significant for FBS at time 1 [F(3,100) = 6.75, p < O.OOl], higher life events being associated with worse control. Life events were significantly associated with FBS at time 1. [F(l,lOO) = 10.43, p < 0.011, higher life events being associated with worse control. No relationship was found for social support scores and FBS at time 1. Locus of control was positively associated with FBS at time 1 [F(l,lOO) = 10.24, p < 0.011. The more external the locus of control, the higher was the FBS. The model at time 2 was not significant.
Change in Hgb A-ZC For change in Hgb A-1C over time, the overall regression model was also significant [F(3,91) = 4.21, p < 0.011. Specifically, the SSNI score at time 2 was significantly negatively associated with change in Hgb A-1C from time 1 to time 2 [F(1,90) = 6.81, p < 0.011. The SSNI score at time 2 reflected the patient’s perception of available support during the preceding 3 months. It showed that decreased social support at time 2 predicted a worsening of control over time as measured by an increase in Hgb A-1C. In addition, locus of control at time 2 was significantly associated with change in Hgb A1C at time 2 [F(1,90) = 6.00, p < 0.011. The persons with a more external locus of control showed worsening of glucose control over time.
Discussion The findings of this study demonstrated that stress in the life of a person with diabetes can predict negative effect on the control of his or her illness. 22
Although a high life events score was associated with poorer short-term (FBS) and long-term (Hgb A-1C) control of blood glucose, this relationship did not appear as stable for FBS. For Hgb A-lC, however, the findings were present both initially and 3 months later. Stressful life events can lead to poor attention to glucose and/or urine testing, as well as altered eating behaviors, decreased exercise, etc., all of which can have a negative effect on blood glucose levels. All can impair short-term and, if these event(s) continue unresolved, longterm control. Of additional importance is the finding that a decrease in social support predicted worsening of control, as measured by an increase in Hgb A-1C at time 2. Support from others is something that is always evolving; it is not static. The same is true for the Hgb A-1C control measure, which demonstrates blood glucose control over the preceding 3 month period. FBS is a measure of control at only one point in time. It would not be as likely to be affected by perceived support as is Hgb A-lC, and in this study, FBS was not so affected. As persons develop and/or more effectively utilize support networks to deal with stress, a positive cumulative effect might be expected to exert control on diabetes. Support from important others can help with the stress of coping with chronic illnesses like diabetes as well as stressors associated with life in general. Our support system findings substantiate the findings of the previous pilot study [83] and those of other studies which have demonstrated the importance of social support on the control of diabetes [49,62-66,71-731. Previous investigations have not been consistently able to demonstrate a relationship between locus of control and the control of diabetes. Results have been varied, some connecting improved control to an external locus [Bl] and some to an internal locus [78,82]. Poorer control has also been linked both to an external [BO] and an internal [75-771 locus of control. The present study is unique in finding that for persons with an external locus of control, there was predicted a worsening of control of the diabetes over time. These people see things and/or persons outside themselves as responsible for what happens to them. Persons with an external locus can be influenced positively or negatively by external events or persons, and therefore, they would be more subject to high life stress and/or decreases in social support. The latter could then contribute to poorer diabetes control. That external locus of control was positively associated with
Biopsychosocial Management of Diabetes
higher FBS is also consistent with this hypothesis. This type of person would be more adversely affected by distressing events occurring during the short period before the FBS is measured. On the other hand, persons with a more internal locus of control might be expected to find resources within themselves to deal with the variables that affect diabetes control. Why such inconsistency between these and previous results? We postulate that the answer may lie in the role of the health care professional in helping the patient use his or her own coping style to deal with the diabetes. Early life conflicts over control, as far back as the toddler stage, when the child begins to establish a sense of autonomy over his or her body, have been implicated in problems with diabetes control [87]. The latter can emerge in conflicts with the physician as well. In addition to studying how external or internal is a patient’s locus of control, it is important to consider the match between the patient’s locus of control and the care-giver’s style. The individual with an internal locus is unlikely to derive much support from a physician who dictates the treatment, rather than involving the patient, who in this case wants to be responsible for what happens to him or her. Likewise, an individual who looks to others for direction might find it stressful to work with a physician who expects the patient to make his or her own adjustments in diabetes management. In either case, control of the diabetes will be more difficult. Studying the patient alone, without examining the match between patient and caregiver, might be the basis for previous inconsistencies in locus of control findings. We acknowledge some inconsistencies in these findings as well. First, there was no association found between social support or locus of control and Hgb A-1C. However, both a decrease (i.e., change) in social support and an external locus of control predicted a worsening of control over time. The regression model for change in Hgb A-IC was significant. As social support is not static over time and persons more affected by external events might be more affected by decrease in support, it may be that the significant findings here are reflected best in changes over time. In addition, although high life events were significantly associated with poorer long-term control at time 1 (p < O.Ol), the same association reached only trend significance at time 2 (p < 0.06). External locus of control was significantly positively associated with poor FBS at time 1, but not at time 2. Obviously these findings
are not unambiguously positive. Acknowledged are the potential confounding effects of variables like changes in diet, exercise, and outside factors like infection. Nevertheless, such variables are a part of the life of a person with diabetes and should not diminish the importance of the psychosocial variables studied here. In addition, these findings are limited to an allmale sample. Two previous studies of non-insulindependent patients found satisfaction with supportive relationships to correlate positively with control for women but negatively for men [88,89]. Findings from those studies suggested that social support may operate differently for men than for women who have diabetes. Our study demonstrates for men a significant relationship between decreased social support and poorer diabetes control over time. Unlike the previous studies [88,89], the present one (1) included insulin-dependent as well as non-insulin-dependent patients and (2) examined change in control over time. It is not possible to know which of these differences (or perhaps others) accounted for the difference in findings. However, if social support does work differently for men, then a more sensitive way to examine the relationship between support and control is needed. In this study, by measuring support in relationship to glucose control at two points in time, and, hence, to change in control over time, we feel we have provided one.
Implications
for Diabetes Health Care
Most people with diabetes are not strangers to the fact that stress and lack of support affect their lives and their diabetes. But they can benefit from acknowledgment by their physician and/or nurse that those things have valid effects on their control. Both physicians and nurses, who treat diabetic persons over an extended period of time, can help create an environment in which the patient feels comfortable discussing events perceived as psychological in nature. The health care provider can let the patient know that stress can disturb control and that wanting to discuss the stressor is not cause for concern. Time may be used to help the patients discuss their reactions to stressful life events, along with options for coping. A physician treating a diabetic patient over months to years can be a powerful force in providing helpful support and reassurance, especially during times of increased stress. Supportive treatment requires a provider who is perceived as em23
L. S. Schwartz et al.
pathic and available for what might be weekly visits. Diabetes can make the patient feel isolated, as he or she reacts to the need for a special diet, insulin injections, oral medication, and/or daily finger sticks for glucose monitoring, by feeling “different.” With the help of the American Diabetes Association, referral to a support group can help patients to know that their problems are not necessarily unique and to see how others cope with those problems. Likewise, helping someone else with a similar problem may actually help the patient to feel more in control of his or her own diabetes. If the patient is not receiving support at home, this too needs to be examined. Family units are easily disrupted by the guilt of a parent or sibling of the family member with diabetes. Guilt can result both in overindulgence of the family member with diabetes and/or distancing of that person from the rest of the family. Fear of developing diabetes is possible in family members and can make the family avoid even the mention of a diabetic treatment routine like injections, thus diminishing support that the diabetic person needs. If a family was dysfunctional even before the diabetes appeared, without intervention, stress might be further heightened. Sometimes the health care provider will need the help of a mental health professional. Selfimposed isolation, brought about by a person who does things to keep other people away, if due to a chronic personality disorder, will result in poor available support to deal with the diabetes. Usually for such individuals, there is evidence of interpersonal difficulties that preceded the diabetes. Good control is also harder to achieve for the diabetic person who has chronic difficulty dealing with stress, or who continually creates situations that add stress to his or her life. For all of these problems, psychotherapy can be helpful in altering such self-destructive tendencies. Likewise, underlying anxiety or depressive disorders can alter control by negatively affecting the patient’s usual means of coping. In summary, these findings suggest potential psychosocial contributions to the control of diabetes, a chronic medical condition. In discussing these findings, we postulate a way to improve control as well as impart optimism in the patient coping with the chronicity of the disease. The authors wish to express appreciation to Dr. Dean Rosset, M.D., whose assistance in recruitment and testing of subjects made this study
24
possible, and to Mary Pittman, M.S.W., for her help with data compilation and analysis. Dr. Schwartz’s work was supported by the Medical Research Service of the United States Department of Veterans Affairs.
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unteer support group for parents of children with diabetes. Diabetes Educ 10(2):53-54, 1984 Denney L: I’m not the only one: Report on a diabetic support group. J Vis Impair Blind 77(5):215, 1983 Rotholz T: The single session group: An innovative approach to the waiting room. Sot Work Group 8(2):143-146, 1985 Merkatz RB, Budd K, Merkatz IR: Psychologic and social implications of scientific care for pregnant diabetic women. Semin Perinatol 2(4):373381, 1978 Holvey SM: Psychosocial aspects in the care of elderly diabetic patients. Am J Med SO(Supp1 5A):6163, 1986 Grey MJ, Gene1 M, Tamborlane W: Psychosocial adjustment of latency-aged diabetics: Determinants and relationship to control. Pediatrics 65(1):69-73, 1980 Koski K, Kamento A: The inter-relationship between diabetic control and family life. Pediatr Adolesc Endocrinol3:41-45, 1977 White K, Kolman ML, Wexler P, et al: Unstable diabetes and unstable families: A psychosocial evaluation of diabetic children with recurrent ketoacidosis. Pediatrics 741749-755, 1984 Minuchin S, Baker L, Rosman B, et al: A conceptual model of psychosomatic illness in children: Family organization and family therapy. Arch Gen Psychiatry 32:1031-1038, 1975 Schafer LC, McCaul KD, Glasgow RE: Supportive and nonsupportive family behaviors: Relationships to adherence and metabolic control in persons with type 1 diabetes. Diabetes Care 9(2):179-184, 1986 Standen PJ, Hinde FRJ, Lee PJ: Family involvement and metabolic control of childhood diabetes. Diabetic Med 2:137-140, 1985 Anderson BJ, Miller JP, Auslander WF, et al: Family characteristics of diabetic adolescents: Relationship to metabolic control. Diabetes Care 4(6):586-593, 1981 Cerreto MC, Mendlowitz DR: Relationship of family functioning to metabolic control in juvenile diabetes. Clin Res 31:905A, 1983 Edelstein J, Linn MW: The influence of the family on control of diabetes. Sot Sci Med 21(5):541-544, 1985 Waller DA, Chipman JJ, Hardy BW, et al: Measuring diabetes-specific family support and its relation to metabolic control: A preliminary report. J Am Acad Child Psychiatry 25(3):415-418, 1986 Graber AL, Wooldridge K, Brown A: Effects of intensified practitioner-patient communication on control of diabetes mellitus. South Med J 79(10):205209, 1986 Cardenas L, ValIbonae C, Baker S, et al: Adult onset
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diabetes mellitus: Glycemic control and family function. Am J Med Sci 293(1):28-32, 1987 Strickland, BR: Internal-external expectancies and health-related behaviors. J Consult Clin Psycho1 461192-1211, 1978 Edelstein J, Linn MW: Locus of control and the control of diabetes. Diabetes Educ 13(1):51-54, 1985 Brand AH, Johnson JH, Johnson SB: Life stress and diabetic control in children and adolescents with insulin-dependent diabetes. J Pediatr Psycho1 11(4):481-495, 1986 Peyrot M, McMurray JF: Psychosocial factors in diabetes control: Adjustment of insulin treated adults. Psychosom Med 47(6):542-557, 1985 Hamburg BA, Inoff GE: Relationships between behavioral factors and diabetic control in children and adolescents: A camp study. Psychosom Med 44(4): 321-339, 1982 Gross A, Delcher H, Snitzer J, et al: Personality variables and metabolic control in children with diabetes. J Genet Psycho1 146(1):19-26, 1985 Delamater AM, Kurtz SM, Bubb J, et al: Stress and coping in relation to metabolic control of adolescents with type I diabetes. J Dev Behav Pediatr 8(3):136140, 1987 Evans CL, Hughes IA: The relationship between diabetic control and individual and family characteristics. J Psychosom Res 31(3):367-374, 1987 Greenfield S, Kaplan SH, Ware JE, et al: Patients‘ participation in medical care: Effects on blood sugar control and quality of life in diabetes. J Gen Intern Med 3448-457, 1988 Schwartz LS, Springer J, Flaherty JA, et al: The role of recent life events and social support in the control of diabetes mellitus. Gen Hosp Psychiatry 8:212-216, 1986 Paykel ES, Prusoff BA, Uhlenhuth EH: Scaling of life events. Arch Gen Psychiatry 25:340-347, 1971 Flaherty JA, Gaviria M, Pathak D: The measurement of social support: The social support network inventory. Comp Psychiatry 24(6):521-529, 1983 Rotter JB: Generalized expectancies for internal versus external control of reinforcement. Psycho1 Monogr Gen Appl SO(l):l-28, 1966 Viederman M, Hymowitz P: A developmentalpsychodynamic model for diabetic control. Gen Hosp Psychiatry 10(1):34-40, 1988 Heitzmann CA, Kaplan RM: Interaction between sex and social support in the control of type II diabetes mellitus. J Consult Clin Psycho1 52(6):1087-1089, 1984 Kaplan RM, Hartwell SL: Differential effects of social support and social network on physiological and social outcomes in men and women with type II diabetes mellitus. Health Psycho1 6(5):387-398, 1987
Abstract: The relationship among recent life stress, social support, a patient’s locus of control, and thecontrol of bloodglucose is evaluated in persons with diabetes mellitus, using objective measures of these psychosocial variables. Short-term [fasting blood sugar (FBS)] and long-term [glycosylated hemoglobin (Hgb A-1C)l control measures are taken at two points in time in order to evaluate the effects of the psychosocial variables on change in diabetes control. For life euents, a significant positive association was found between the number of recent life events and blood glucose control. Decrease in social support predicted a worsening of longer-term (Hgb A-10 control over time. An external locus of control within the patient was associated both with poor short-term control at time one and prediction of poorer long-term control over time. The implications of these findings are discussed in support of a biopsychosocial approach to the management of diabetes mellitus.
Introduction Stress and susceptibility to illness have been linked for a variety of illnesses, including peptic ulcer disease, myocardial infarction [l-3], and various psychiatric disorders [4]. For diabetes mellitus, statistically significant links have been found between life stress and the onset of diabetes, both for the insulin-dependent [5,6] and non-insulindependent [7j types. Relationships have also been reported between life events and both the onset and change in the course of diabetes [8-151. Stressful life events, especially undesirable ones, have been linked to changes in the diabetic conFrom Northwestern University Medical School (L.S.S., J.S.L.); the University of Illinois, kollege of Medicine. (D.T., 1.A.F.k and the Universitv of Illinois/VA Westside Medical Center (L.R.C.), Chicago, Illkois. Address reprint requests to: Lee S. Schwartz, M.D., 259 E. Erie, Suite 452, Chicago, IL 60611.
General Hospital Psychiatry 13, 19-26, 1991 0 1991 Elsevier Science Publishing Co., Inc. 655 Avenue of the Americas, New York, NY 10010
dition [16], including increased glycosuria, changes in prescription, and changes in frequency of clinic appointments [17]. Insulin-dependent patients appear to have more problems with diabetes management in association with undesirable life events [17], which are linked to a worsening of control [17-231. Life events that are neutral or even positive have also been reported more by insulindependent persons in poor control [24]. Yet acute, artificially induced stressors do not seem to significantly affect blood glucose in insulin-dependent [25] or non-insulin-dependent [26] persons. The effect(s) of stress have also seemed to depend on specific aspects of the patient (271, including personality type [28]. Social support, that which leads one to believe that others care about and understand him/her, can influence the effect(s) of life stress. Lack of social support has been associated with poorer recovery from surgery [29], increased need for steroid treatment in adults with asthma [30], increased birth complications [31], and increased incidence of tuberculosis [32]. Likewise, increased social support has been associated with decreased morbidity following bereavement [33,34], retirement [35], termination of employment [36], and the threat of death [37-391. For persons with diabetes, family support has been recognized as important in the management of children [40-501, adolescents [51], and adults [52-561. Support groups are useful for parents of children with diabetes 1571 and for diabetic persons in general [58,59]. Nursing support has been recognized as important in maintaining the stability of the hospitalized pregnant diabetic woman [60], as is physician support to the elderly
19 ISSN 016%8343/91/$3.50
L. S. Schwartz et al.
patient [61]. Research with children has demonstrated associations between poor family functioning and poorer diabetes control [62-651. Various measures of family functioning have shown the following to be related to better control for insulin-dependent diabetes: increased support offered [66], lesser incongruence between parents [67], increased cohesion with less conflict [56,6870], orientation toward achievement [70], and increased caring as perceived within the family [71]. Of 233 patients with insulin-dependent diabetes, those that received regular feedback from a nurse practitioner showed improved glycohemoglobin (Hgb A-1C) results, which are a measure of longterm control [72]. Good family functioning was also found to be significantly higher for patients in good short-term control, as measured by fasting blood sugar (FBS) [73]. Another psychosocial variable studied in connection with diabetes mellitus is locus of control. Locus of control refers to the extent to which an individual feels able to control the events and/ or circumstances in his or her life. There is an internal-external dimension that refers, respectively, to the degree to which the person perceives things that happen to him or her as a result of his or her own action, as opposed to occurring as a result of chance, fate, or powers beyond one’s control and understanding [74]. Results have been inconsistent in examining the relationship between locus of control and control of diabetes. An internal locus of control has been linked to both poorer control [75-771 and better control [78]. Findings of no apparent relationship to control of diabetes have been demonstrated as well when a measure of health locus of control was used [79]. Patients in poor metabolic control were found to use “wishful thinking” and “avoidance/help seeking behavior, ” both related to an external locus, more than patients in good metabolic control [80]. Yet, children with an external locus have also shown a trend toward good control, possibly due to strict family rules that enhance compliance [81]. Adult patients trained to negotiate with their physicians regarding treatment options showed better control than an uncoached reference group [82]. Such coaching may be considered an enhancement of a patient’s internal locus of control characteristics. In a pilot study by the principal author, using objective measurements of life events and social support, it was demonstrated that a higher number of life events was associated with a higher per20
centage of abnormal Hgb A-1C and FBS results. Also, higher social support was associated with a smaller percentage of abnormal Hgb A-1C scores [83]. Overall, persons with high life events and low social support had the highest percentage of abnormal Hgb A-1C results. This earlier study, however, lacked statistical significance due to small sample size. The current investigation was undertaken to statistically substantiate the earlier findings and to investigate the effect(s) of locus of control on control of diabetes. We set out to measure blood glucose control at two points in time, 3 months apart, using objective measures of recent life events, social support, and locus of control. Diabetic control was measured with both short-term (FBS) and longterm (Hgb A-1C) methods. We postulated that: (1) high life events would predict worsening of diabetes control; (2) low social support would predict disturbance in diabetic control; and (3) an increase in life events and/or decrease in social support over time would predict a decline in control of diabetes. We set out also to examine the relationship between an individual’s locus of control and control of his or her diabetes.
Methods Over a period of approximately 14 months, 112 diabetic patients from a Veterans Administration Hospital outpatient general medicine clinic volunteered for this study. All subjects received their treatment from the same internist. The subjects were all (1) male, (2) over 18 years of age, (3) diabetic for at least 3 months, and (4) ambulatory. Patients were excluded only if there was a past history of excessive missed clinic appointments or gross noncompliance, as evidenced by refusal to take medications. The patients’ ages ranged from 38 to 80 years (mean 63 years), were diabetic for a minimum of 3 months and a maximum of 45 years (mean 16 years), and were treated with insulin (54 subjects), oral hypoglycemic agents (43 subjects), diet alone (12 subjects), or a combination of insulin and oral hypoglycemic agents (3 subjects). Seventy-five were married and 37 were unmarried. Informed consent was obtained from each patient after the nature of the procedures had been fully explained. At each clinic visit blood was drawn for Hgb A-lC, to measure control during the previous 3 months, and for FBS, which measured short-term control. During each visit the patient was interviewed
Biopsychosocial
using four different instruments. All the questions were read to the subject and recorded by a single interviewer. The practice of reading and recording every questionnaire served to eliminate the bias due to poor vision and/or differences in patient literacy. The interview began with questions of demography, diabetic treatment regimen, and other medical care information. Each patient completed the Paykel Scale of Recent Life Events, which asks the patient about specific events that may have occurred in his or her life during the previous 3 months. Of the 61 events listed, at the top end of the scale are catastrophic and highly distressing events such as death of a child or spouse. At the bottom are events that are desirable and nondistressing. This instrument has demonstrated moderate individual reliability and high agreement across groups [84]. Each patient also completed the Social Support Network Inventory (SSNI), which asks the individual to list key support individuals and/or groups in his or her support network and to rate each of them on variables, including practical support, emotional support, availability, and reciprocity. This instrument measures perceived social support and identifies the providers of it. The SSNI has been shown to have high test-retest reliability (r = 0.87), internal consistency (alpha coefficient = 0.89), and concurrent validity [85]. Lastly, the patient completed a modified version of the Rotter Locus of Control Scale, which measures individual differences in generalized expectancy for internal/external control. For this scale, item analysis and factor analysis show that internal consistency is relatively high, test-retest reliability is satisfactory, and discriminant validity is established [86]. We used a shortened (12-item) version of the original 29-item scale. Of the initial 112 patients, 102 provided data at a second clinic visit approximately 3 months later. Of the ten patients who were lost to follow-up, five missed their appointments, four refused a second interview, and one was hospitalized. There were, therefore, 102 subjects included for purposes of data analysis.
of Diabetes
Table 1. Means and standard deviations variables at times 1 and 2 Time 1
for all
Time 2
Variable
Mean
Standard deviation
Mean
Standard deviation
Hgb A-1C FBS Life events score SSNI Locus of control score
10.29 194.66 28.59 4.05
3.17 76.24 24.03 0.61
10.50 190.84 27.59 4.01
3.87 81.74 25.68 0.57
3.53
1.59
3.46
1.57
-
higher the score, the more external the locus). For diabetes control, short- and long-term control were measured by FBS and Hgb A-lC, respectively, higher values indicating poorer control. Table 1 summarizes the means and standard deviations of these variables at times 1 and 2. To study the relationship between life events, social support, locus of control, and control of diabetes, regression analyses were done, using Hgb A-1C and FBS as dependent variables. Separate regression analyses were used in order to attempt to predict FBS and Hgb A-1C at times 1 and 2 by the level of life events, level of social support, and by locus of control. In addition, regression analyses were used to predict change in Hgb A-IC and FBS over time by life events, social support, and locus of control. Table 2 summarizes the intercorrelations discovered.
Hgb A-IC For Hgb A-1C at time 1, the overall regression model was significant [F(3,106) = 2.86, p < 0.051. Specifically, the number of life events was posi-
Table 2. Pearson product moment correlations between Hgb A-lC, FBS, life events, social support, and locus of control at two time points Time 1
Results Scores were obtained on the Paykel Scale of Life Events (the higher the score, the higher the life stress expected), the SSNI (the higher the score, the greater the degree of perceived social support), and the modified Rotter Locus of Control Scale (the
Management
A-1C Life events Social support Locus of control
0.23 0.10 0.11
FBS 0.28” 0.06 0.25”
-
Time 2 A-1C
FBS
0.23 0.11 0.14
0.21 0.16 0.06
ap < 0.05.
21
L. S. Schwartz et al.
tively associated with Hgb A-1C [F(1,106) = 6.45, p < 0.011. That is, subjects with more life events had worse control as measured by Hgb A-1C. There was no association found between social support or locus of control and Hgb A-1C at time 1. The results at time 2 closely replicated the findings at time 1. For Hgb A-1C at time 2, the overall regression model was nearly significant [F(3,93) = 2.56, p < 0.061. Again a high life events score was significantly associated with poorer control of blood glucose [F(1,93) = 3.72, p < 0.051. There was no association between social support or locus of control and Hgb A-1C at time 2.
FBS The overall regression model was significant for FBS at time 1 [F(3,100) = 6.75, p < O.OOl], higher life events being associated with worse control. Life events were significantly associated with FBS at time 1. [F(l,lOO) = 10.43, p < 0.011, higher life events being associated with worse control. No relationship was found for social support scores and FBS at time 1. Locus of control was positively associated with FBS at time 1 [F(l,lOO) = 10.24, p < 0.011. The more external the locus of control, the higher was the FBS. The model at time 2 was not significant.
Change in Hgb A-ZC For change in Hgb A-1C over time, the overall regression model was also significant [F(3,91) = 4.21, p < 0.011. Specifically, the SSNI score at time 2 was significantly negatively associated with change in Hgb A-1C from time 1 to time 2 [F(1,90) = 6.81, p < 0.011. The SSNI score at time 2 reflected the patient’s perception of available support during the preceding 3 months. It showed that decreased social support at time 2 predicted a worsening of control over time as measured by an increase in Hgb A-1C. In addition, locus of control at time 2 was significantly associated with change in Hgb A1C at time 2 [F(1,90) = 6.00, p < 0.011. The persons with a more external locus of control showed worsening of glucose control over time.
Discussion The findings of this study demonstrated that stress in the life of a person with diabetes can predict negative effect on the control of his or her illness. 22
Although a high life events score was associated with poorer short-term (FBS) and long-term (Hgb A-1C) control of blood glucose, this relationship did not appear as stable for FBS. For Hgb A-lC, however, the findings were present both initially and 3 months later. Stressful life events can lead to poor attention to glucose and/or urine testing, as well as altered eating behaviors, decreased exercise, etc., all of which can have a negative effect on blood glucose levels. All can impair short-term and, if these event(s) continue unresolved, longterm control. Of additional importance is the finding that a decrease in social support predicted worsening of control, as measured by an increase in Hgb A-1C at time 2. Support from others is something that is always evolving; it is not static. The same is true for the Hgb A-1C control measure, which demonstrates blood glucose control over the preceding 3 month period. FBS is a measure of control at only one point in time. It would not be as likely to be affected by perceived support as is Hgb A-lC, and in this study, FBS was not so affected. As persons develop and/or more effectively utilize support networks to deal with stress, a positive cumulative effect might be expected to exert control on diabetes. Support from important others can help with the stress of coping with chronic illnesses like diabetes as well as stressors associated with life in general. Our support system findings substantiate the findings of the previous pilot study [83] and those of other studies which have demonstrated the importance of social support on the control of diabetes [49,62-66,71-731. Previous investigations have not been consistently able to demonstrate a relationship between locus of control and the control of diabetes. Results have been varied, some connecting improved control to an external locus [Bl] and some to an internal locus [78,82]. Poorer control has also been linked both to an external [BO] and an internal [75-771 locus of control. The present study is unique in finding that for persons with an external locus of control, there was predicted a worsening of control of the diabetes over time. These people see things and/or persons outside themselves as responsible for what happens to them. Persons with an external locus can be influenced positively or negatively by external events or persons, and therefore, they would be more subject to high life stress and/or decreases in social support. The latter could then contribute to poorer diabetes control. That external locus of control was positively associated with
Biopsychosocial Management of Diabetes
higher FBS is also consistent with this hypothesis. This type of person would be more adversely affected by distressing events occurring during the short period before the FBS is measured. On the other hand, persons with a more internal locus of control might be expected to find resources within themselves to deal with the variables that affect diabetes control. Why such inconsistency between these and previous results? We postulate that the answer may lie in the role of the health care professional in helping the patient use his or her own coping style to deal with the diabetes. Early life conflicts over control, as far back as the toddler stage, when the child begins to establish a sense of autonomy over his or her body, have been implicated in problems with diabetes control [87]. The latter can emerge in conflicts with the physician as well. In addition to studying how external or internal is a patient’s locus of control, it is important to consider the match between the patient’s locus of control and the care-giver’s style. The individual with an internal locus is unlikely to derive much support from a physician who dictates the treatment, rather than involving the patient, who in this case wants to be responsible for what happens to him or her. Likewise, an individual who looks to others for direction might find it stressful to work with a physician who expects the patient to make his or her own adjustments in diabetes management. In either case, control of the diabetes will be more difficult. Studying the patient alone, without examining the match between patient and caregiver, might be the basis for previous inconsistencies in locus of control findings. We acknowledge some inconsistencies in these findings as well. First, there was no association found between social support or locus of control and Hgb A-1C. However, both a decrease (i.e., change) in social support and an external locus of control predicted a worsening of control over time. The regression model for change in Hgb A-IC was significant. As social support is not static over time and persons more affected by external events might be more affected by decrease in support, it may be that the significant findings here are reflected best in changes over time. In addition, although high life events were significantly associated with poorer long-term control at time 1 (p < O.Ol), the same association reached only trend significance at time 2 (p < 0.06). External locus of control was significantly positively associated with poor FBS at time 1, but not at time 2. Obviously these findings
are not unambiguously positive. Acknowledged are the potential confounding effects of variables like changes in diet, exercise, and outside factors like infection. Nevertheless, such variables are a part of the life of a person with diabetes and should not diminish the importance of the psychosocial variables studied here. In addition, these findings are limited to an allmale sample. Two previous studies of non-insulindependent patients found satisfaction with supportive relationships to correlate positively with control for women but negatively for men [88,89]. Findings from those studies suggested that social support may operate differently for men than for women who have diabetes. Our study demonstrates for men a significant relationship between decreased social support and poorer diabetes control over time. Unlike the previous studies [88,89], the present one (1) included insulin-dependent as well as non-insulin-dependent patients and (2) examined change in control over time. It is not possible to know which of these differences (or perhaps others) accounted for the difference in findings. However, if social support does work differently for men, then a more sensitive way to examine the relationship between support and control is needed. In this study, by measuring support in relationship to glucose control at two points in time, and, hence, to change in control over time, we feel we have provided one.
Implications
for Diabetes Health Care
Most people with diabetes are not strangers to the fact that stress and lack of support affect their lives and their diabetes. But they can benefit from acknowledgment by their physician and/or nurse that those things have valid effects on their control. Both physicians and nurses, who treat diabetic persons over an extended period of time, can help create an environment in which the patient feels comfortable discussing events perceived as psychological in nature. The health care provider can let the patient know that stress can disturb control and that wanting to discuss the stressor is not cause for concern. Time may be used to help the patients discuss their reactions to stressful life events, along with options for coping. A physician treating a diabetic patient over months to years can be a powerful force in providing helpful support and reassurance, especially during times of increased stress. Supportive treatment requires a provider who is perceived as em23
L. S. Schwartz et al.
pathic and available for what might be weekly visits. Diabetes can make the patient feel isolated, as he or she reacts to the need for a special diet, insulin injections, oral medication, and/or daily finger sticks for glucose monitoring, by feeling “different.” With the help of the American Diabetes Association, referral to a support group can help patients to know that their problems are not necessarily unique and to see how others cope with those problems. Likewise, helping someone else with a similar problem may actually help the patient to feel more in control of his or her own diabetes. If the patient is not receiving support at home, this too needs to be examined. Family units are easily disrupted by the guilt of a parent or sibling of the family member with diabetes. Guilt can result both in overindulgence of the family member with diabetes and/or distancing of that person from the rest of the family. Fear of developing diabetes is possible in family members and can make the family avoid even the mention of a diabetic treatment routine like injections, thus diminishing support that the diabetic person needs. If a family was dysfunctional even before the diabetes appeared, without intervention, stress might be further heightened. Sometimes the health care provider will need the help of a mental health professional. Selfimposed isolation, brought about by a person who does things to keep other people away, if due to a chronic personality disorder, will result in poor available support to deal with the diabetes. Usually for such individuals, there is evidence of interpersonal difficulties that preceded the diabetes. Good control is also harder to achieve for the diabetic person who has chronic difficulty dealing with stress, or who continually creates situations that add stress to his or her life. For all of these problems, psychotherapy can be helpful in altering such self-destructive tendencies. Likewise, underlying anxiety or depressive disorders can alter control by negatively affecting the patient’s usual means of coping. In summary, these findings suggest potential psychosocial contributions to the control of diabetes, a chronic medical condition. In discussing these findings, we postulate a way to improve control as well as impart optimism in the patient coping with the chronicity of the disease. The authors wish to express appreciation to Dr. Dean Rosset, M.D., whose assistance in recruitment and testing of subjects made this study
24
possible, and to Mary Pittman, M.S.W., for her help with data compilation and analysis. Dr. Schwartz’s work was supported by the Medical Research Service of the United States Department of Veterans Affairs.
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Management
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