The Psychological Assessment of Patients with Diabetes

©1999 by Daniel Bruns

All Rights Reserved.

Last update 2/1/99

Any serious medical condition is likely to give rise to a significant psychological reaction. This is especially true of enduring, chronic conditions, that require the person with this condition to make long term adjustments. The long term stress of an illness and treatment can erode the adaptive capacities of the individual, and precipitate a depressive or anxious reaction, activate underlying conflicts over dependency issues and so on.

During the course of the BHI development, I worked in two clinical settings. One of these of settings was at the Benchmark Physical Rehabilitation Program in Greeley, Colorado, where I saw persons with a variety of orthopedic conditions, pain disorders and related conditions. The other setting I was involved in was the Diabetes team at the North Colorado Medical Center, also in Greeley. During the course of the BHI development, I was involved in the evaluation of perhaps six to seven hundred diabetics, and an equal number of injured patients. Despite the diversity of their medical conditions, I was struck the number of parallel difficulties that both sets of patients faced.

Both pain patients and diabetic patients struggled with the lifestyle changes that were forced upon them. They suffered from anxiety, depression, and feelings of anger. The conditions gave rise to changes in the family system, and some became somatically preoccupied.

Although what follows is based on our clinical experience of the assessment of persons with diabetes, but it also may be useful for a variety of chronic medical conditions. The caveat here is that this is not based on systematic research, but rather on our clinical experience:

1. As an overall rule of thumb, I hope to see normal scores, in the midrange, which are between the two lines on the BHI profile. While those scores are sometimes indicative of a strength or something good, they can also be indicative of problems.

Persons commonly react emotionally to the diagnosis of Diabetes. This response varies across persons. Some persons become depressed, others fearful, or others become angry. Some combination of these feelings is also possible. The average normal patient responds with some emotional distress, and this is generally healthy. In particular, a certain amount of sadness or grieving over the loss of health is normal and healthy, as is a certain amount of anxious concern over the possibility of not doing the right thing. Again, a little bit of anxiety is a source of healthy motivation. Some people react more strongly, becoming very depressed, occasionally even suicidal, paralyzed by anxiety, or become angry at God or life over the perceived injustice. A high score on one or more of the affective subscales in reaction to a diagnosis of Diabetes suggests that we have a distressed patient. This is indicative of a substantial emotional difficulty with adjusting to the condition, and this emotional reaction could likely benefit from some sort of intervention. Such an intervention might include antidepressant medication, a support group, or reassurance from a physician or other health care providers.

In other cases, persons are observed to have unusually low scores on depression, anxiety or hostility following a diagnosis of Diabetes. Low scores here may indicate unusually well adjusted persons. At the same time, if a person has very low scores on these scales, suggesting a total of absence of any kind of emotional distress whatsoever, then I really wonder about the possibility of emotional denial. For example, a T score of 30 on any BHI scale indicates that the person is below the second percentile rank with regard to that particular trait. Thus, when I see a person who has been diagnosed with Diabetes, and scores that low, I seriously wonder if they could be dealing with it all so well that there was in fact a complete absence of any kind of emotional dysphoria. It seems too good to be true, and typically, it isn't true. The person is simply putting on a happy face, and concealing their underlying distress. In such cases, encouraging the patient to acknowledge in the process their distress can be very beneficial.

2. Patients who score high on the Borderline scale are some of the most difficult ones to work with. Such patients lead erratic, dysfunctional lives, and tend to behave in very self-destructive manners. For example, one patient was suffering from adult onset insulin-dependent Diabetes. She was also borderline personality, and when she became depressed, she would behave very dysfunctionally. For example, on one occasion, when she was feeling down, she baked a large pan of brownies, and ate the entire pan in one sitting. This is her way of trying to rage against life, showing that nothing could control her, and that she could still do whatever she wanted. On another level, it was also her way of punishing herself, as she had frequently been suicidal. Following this binge, she ended up in the emergency room with a blood sugar level of around 800 or so. Unfortunately, this became a monthly event. Due to her severe mismanagement of herself, this patient had to have both of her feet amputated. Through psychotherapy, she has gained a better handle on her dysfunctional behavior, and it now appears that she will be able to save her vision.

The interpretation of unusually scores on the Borderline scale is less clear. It may well indicate something positive, that as a person who is unusually stable. As above though, extremely low scores here suggest a degree of stability which seems unrealistic, and which may not be genuine.

3. Persons high in Symptom Dependency use their physical condition to manipulate others. Such persons can find that their disease now in a way gives them some emotional power over others. Persons with high scores on this scale may be more likely to make such statements as "I'm feeling kind of shaky, you'll need to do the work around the house tonight. Why don't you bring me some juice? I'm feeling a sinking spell coming on." Another classic statement I heard by a person high in this trait was "You kids better stop fighting or I'll get sick."

Again, unusually low scores in this scale may suggest an independent person, although it also may be indicative of denied dependency. Such persons may be more inclined to reject the help of others, and this may make the course of adjustment more difficult for them. For example, a person with a really low score here may rather read information out of a book, as opposed to having to ask a doctor or a nurse for help with something. Again, such a tendency to reject the support of others may complicate the course of recovery.

4. Elevations on the Chronic Maladjustment scale indicated that the person is reporting a long- term history of dysfunctional behavior. Such persons have been unsuccessful in accomplishing a variety of ordinary life tasks. For example, they have been unsuccessful in school, in marriage, at work, have checkered legal histories, and instead tend to turn to substances for gratification. Given the general life pattern of being unable to achieve successful in these life tasks, their prognosis for success in recovery and rehabilitation is clouded by this. Persons who failed in school are unlikely to learn about their diabetic conditions. As they are unable to commit themselves to a job or a marriage, they are likewise often unable to commit themselves to a treatment regimen. As such persons are unable to be successful at such achievements, they are more inclined to turn to more immediate gratification, and this does not bode well for them.

In contrast, persons who have unusually low scores on chronic maladjustment are reporting that they have had unusually stable lives, and have generally been successful in achieving these common life goals. As applied to Diabetes, this is generally a good sign. However, if this is accompanied by a pervasive pattern of very low scores, this is more likely to be indicative that the person simply isn't being honest, and that they are in fact exaggerating their life accomplishments.

5. Persons high in substance abuse also present a challenge. Characterologically, persons who abuse substances typically have difficulty with self-soothing, and with delaying gratification. They use substances, even when they know it is self-destructive. For such persons, sugar becomes simply another substance. At some level they may realize that it hurts them, but they generally prefer not to think about this. Instead, they focus on the immediate gratification they get from using sugar, and simply learn to tolerate the elevated glucose "hangover" afterwards.

There are no psychological risk factors entailed in a person who abstains from abusing substances. However, as with chronic maladjustment, if a low score here is accompanied by unusually low scores on all the psychological factors scales, it is more suggestive of a situation where the person is simply not being honest. Under such circumstances, one might want to question the person's denial that no such substances are being used.

6. The Perseverance scale measures a critically important trait in patients who are adjusting to Diabetes and other chronic conditions. Obviously, it takes a good deal of determination to successfully make this adjustment. The Perseverance scale measures both the cognitive ability to plan and be determined, as well as the emotional resilience it takes to remain emotionally upbeat and positive through the course of the adjustment process. Persons with moderately high scores will find this to be an asset. Persons with extremely high scores here may find that this is more of a liability though. Persons who are extremely persevering tend to be stubborn and rigid. Such persons could become obsessive, refusing to consume a gram of sugar, and this rigidity may be more harmful than good. On the other hand, persons with lows scores of perseverance are essentially emotionally capitulating. They may be voicing a cognitive difficulty, saying "I don't understand, I can't figure this out, I can't figure out what to do." On the other hand, there may also be a lack of available emotional resources to invest in recovery. The person might say, "This is just too hard, I just can't stand it." If the perseverance scores are very low, it is quite likely that both cognitive and affective deficits are in operation.

7. Family dysfunction is an important scale as applied to Diabetes. Often, when a family member becomes diabetic, the whole family must take this into consideration, and it may well have an impact on the family's diet. In a very dysfunctional family, hostile family members may purposefully eat tempting, high sugar foods in front of the patient, simply to torture them or extract some measure of emotional revenge.

On the other hand, if the patient is a generally well adjusted person, a low score here is indicative of a highly supportive family, and this is a good thing. However, if a patient is very dysfunctional, then a highly supportive family can be enabling.

For example, I think of a young man who is very high in symptom dependency, who is diabetic, and quite manipulative. His Family Dysfunction score was very low, indicating that his parents were perceived by him as being very gratifying. Given his symptom dependency, this suggested to me that they were meeting his dysfunctional dependent needs. For example, for his birthday, his mother made a great variety of high sugar treats. She could have chosen to provide other things that were healthier, but she chose not to. Instead, her excessively supportive style enabled his dependency. She said to me, "I can't do that! It's his birthday!!" Her catering to his dysfunctional needs was physically damaging to him. I pointed out to her how this was physically harming her son, and she shrugged her shoulders and said, "I guess I shouldn't, but I love him so much I just can't say no." Thus, again, if a patient is dysfunctional, an unusually supportive family can indicate that there is some emotional enabling present.

8.A high score on Doctor Dissatisfaction indicates that the patient doesn't trust his doctor, and perhaps even blames them for many difficulties or side effects they may be suffering. A high score here suggests that there is a major rift in the doctor-patient relationship, and this can greatly disrupt the flow of information between doctor and patient. The patient likely simply does not trust the physician, or may feel that the physician is incompetent or unempathic. This strongly suggests that something must be done to repair this relationship.

On the other hand, an unusually low score on Doctor Dissatisfaction suggests that the physician may be perceived as being empathic and a strong source of support. Again, this is generally a good thing. However, as with family dysfunction, if a patient is highly dysfunctional, then an unusually low score here can indicate that the physician is enabling this condition. For example, in a case mentioned previously, one patient cyclically binged on brownies and other high sugar foods, which on multiple occasions led to medical crises. Her family physician was very supportive, telling her in essence, "You poor thing, I'm sure you are feeling horrible. Well, just don't worry about it, I'm sure you'll do better next time." The patient was a dysfunctional symptom dependent borderline, and she perceived her physician as being very caring and supportive. Unfortunately, his excessive support was simply enabling her dysfunctional behavior. A better approach may have been less empathic, something along the lines of getting in her face and saying, "What the hell do you think you are doing?" In such a case, he may well have been perceived as less empathic in the patient's eyes, but in the long run, this may have led to a better outcome.

9. The Job Dissatisfaction scale is probably less important as applied to Diabetes. Overall, low scores suggest that there is a supportive work place environment, and having a generally supportive environment is a good thing when adjusting to a chronic condition. It may be necessary to make some work place accommodations for a diabetic condition, and a supportive work place can facilitate this change.

10. Somatic complaints in the most important of the physical factors scale for Diabetes. Persons high in somatic complaints are prone to somatization, and to be excessively preoccupied with their physical functioning. If a such a person develops a chronic condition such as Diabetes, it becomes grist for their mill. Now they truly have something to be obsessively preoccupied with.

It is more difficult to diagnose persons high in somatic complaints, as they are prone to being hypochondriacal. Some of the symptoms they are reporting are probably true objective symptoms secondary to their Diabetes. However, at the same time, they are probably prone to magnifying their perceptions of such symptoms, and also may be simultaneously reporting a number of psychogenic symptoms. This can make the process of diagnosis more difficult for the physician.

11. To a lesser extent, the Pain Complaints scale is also important in the assessment of diabetics. Persons high on this scale are also obsessively preoccupied with symptomatology, although in this case it is more pain and discomfort symptoms than it is physical illness symptoms. It is worth noting that the individual's pain reports on this scale may be important, as high scores in legs and feet or hands and arms areas could potentially be indicative of the development of peripheral neuropathies, while chest pain reports could be indicative of coronary complications.

12. The Muscular Bracing scale may be the BHI scale which has the least applicability to the diabetic condition. Persons high in muscular bracing are prone to responding to stress in a psychophysiological manner, with increased levels of muscle tension. Persons who are high in this trait may respond to a diagnosis such as Diabetes with increased stress and muscle tension. Following being diagnosed with this condition, muscular bracers may respond with the onset of a condition such as tension headaches or bruxism. It should also be noted that muscular bracing tends to be a response to a threat. Consequently, the presence of muscular bracing may be indicative of underlying anxiety or hostility, which expresses itself through increased levels of muscle tension. If muscular bracing is present, it may be indicative of the intensity of these underlying feelings.

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