• Husband died two years ago.

• No money to attend clinics.

• Have to work from 8 am to 10 pm.

• Daughter divorced recently.

• Two daughters not married/ not working.

• Wife does not care.

• Daughter in law having an affair.

• Son migrated does not communicate.

• Injections too painful.

• I just cannot control my diabetes—what can I do?

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Some diabetic patients’ issues

Stress & Diabetes Mellitus

Prepared by Dr Rajeshwar Sharma Suva Diabetic Hub, Fiji

Stress: definition • We need to be very active at certain times—during

urgent situations, for instance.

• Our nerves and hormones get us activated for such times.

• Increased activation leads to overload .

• The activation has to be fine tuned for us to get the job done without getting too overloaded.

• Up to a certain level this is beneficial: (eustress)

• If uncontrolled, stress builds up and leads to harmful effects.

• compare iron for ironing clothes—too hot and the clothes will get burnt.

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uncontrolled stress • manifested as intense negative thoughts, emotions,

impulses, and leads to unwanted behavior.

• can lead to psychological disorders.

• can lead to psychosomatic ails—gastritis/ asthma/ NCD/ other.

• affects all aspects of being: physical, psychological, spiritual, and social.

• May not be felt, but does it damage.

• Stress worsens diseases; diseases worsen stress: form problem complex that worsen the suffering.

• Delay healing and recovery.

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Stress and diabetes 1. Stress has direct and indirect effects—

through behavior—on diabetes. Stress hormones lead to elevated glucose.

Person does not take care of self.

2. DM = serious chronic disorder requiring hands on approach/ lots of limitations and threat of impending complications.

3. Can lead to vicious cycle

• Diabetic distress = pts overwhelmed

• Depression around 30% in diabetics

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Diabetic distress • a condition where patients are

overwhelmed with the management of their diseases,

• getting the support they need,

• managing the emotional burden of diabetes,

• getting access to needed care,

• distinct from depression.

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Stress and illness: problem complex

Generic problem =

DM (other)

Reflex stress

Past traumas

Ongoing issues

Deficiencies a. Client’s b. Provider’s c. System’s

Note a small issue can lead to so much suffering when the stress responses are added in the memory processes and clients are unequipped to manage their situations appropriately .

Stress responses

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Case example: problem complex

• 49 year old diabetic: Poor control • Emotional responses: stress/ depression/fear/

despair/ worries of future/ frustration • Past traumas: husband died 2 years previously • Ongoing issues: little financial support/ family:

teenage daughter/ lifetime ailment • Deficiencies

a. Client: poor compliance/ lacks effective stress management strategy/ difficulty in selecting meals/ not motivated/ cannot exercise

b. Provider: too busy with more serious cases c. System: does not provide monitoring strips/

clients too busy/ check ups too infrequent. availability/ cost of health services

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Stress management: strategy

Generic problem

DM

Reflex stress

Past traumas

Ongoing issues

Deficiencies a. Client’s b. Provider’s c. System’s

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SNAP medications

Manage negative thoughts feelings and impulses

Manage past traumas

Explore and deal with theses

Client skills Provider issues System upgrade

Caution: feeling stress • Stress may not be felt easily (or denied)

• The worst stress is the one where the person is not aware that he or she is stressed.

• But stress is a fact of life.

• Consider stress in ALL patients (as well as their close relatives).

• Consider yourself stressed as well.

• Better to deal with it rather than denying it.

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Stress management • Make SM part of management for all diabetics. • Use the above model for holistic care. • Explore stressors—feelings/ major trauma/

ongoing issues/ coping status. • Emotional support: empathic understanding • Allow ventilation by clients’ expression of

thoughts and feelings. • Teach simple relaxation skills. • Teach to be proactive and positive. • Engage social support. • Medications—for e.g depression. • Refer when necessary.

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Excess energy

• Central to stress reaction is the excess energy.

• The extra energy is also stored in memory and builds up.

• Harmful if not used appropriately— for example, anger and its consequences.

• Goal is to use the excess energy appropriately.

• Or release it (if above not possible).

• We should not be built up the excess energy.

• To deal with this excess energy we can use the 4R technique.

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4R technique

Cognitive behavior model

1. Redirect towards beneficial actions.

2. Release the extra energy

3. Review past traumatic events and present actions.

4. Refer if things do not work out.

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Redirection • Stressed clients tend to be engaged

in inappropriate (self/ others harmful) behaviors.

• Need to redirected towards helpful/ problem solving actions.

• Energy from fear and anxiety can be used for improved compliance--.

• Excess energy from negative thoughts can be redirected to learning more about diabetes.

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Release

• There are times when ideal solutions are not available.

• We can use the technique of releasing the excess energy.

• This will mean that the energy will not be stored in the memory and will not be harmful in future.

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Release of excess energy

• Physical exercise

• Hobby

• Prayerfulness

• Rituals

• Breathing exercises

• Hot and cold shower

• Mental surfing

• Naps

• Take a walk

• Look at some scenes • Take care of self—

grooming • Talk to someone • Social groups • Friends • Movie • Visit a family • Help someone in need • Listen to /dance to music • massage

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Release by listening

• Vocalizing allows release of patients pent up negatives (= ventilation).

• encourage the clients to express their feelings.

• Listen empathetically (= trying to understand them in their contexts).

• be non-judgmental.

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Review 1. Involves reviewing life events

• Traumatic events are re-viewed in a different light,

• To get positives • maybe lessons learnt • May re-view as a survivor with certain

strengths

2. Also involves regular reviews to see where one is • What works: continue same of these • What does not work: change

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The basic relaxation exercise 1 1. Lie down in a quiet place and close your

eyes. Read the entire exercise first. Breathe in gently and as naturally as you can. Above all, relax yourself. Do not rush through this exercise. Do it as slowly as possible.

2. Breath gently a few times. Focus on your face. – Say to yourself silently; “relax the whole face”.

Feel your face area relax. – Say to yourself silently “relax the whole face”. – And another time, “relax the whole face”.

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The basic relaxation exercise 2 3. Move on to focus on your head and neck.

Relax the whole head and neck area by sang silently three times, “relax the whole head and neck.”

4. Next, move on to the chest area. Relax the chest by silently repeating three times, “relax the whole chest area”.

5. Relax your tummy by repeating three times: relax the whole tummy.

6. Relax the whole back similarly.

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The basic relaxation exercise 3 7. Go on and relax both thighs.

8. Relax your legs and feet in the same manner.

9. Move to focus on both hands and relax them by saying silently three times, “relax both hands”.

10. Relax your shoulders by repeating three times. Relax both shoulders.

11. Now relax your whole body by repeating three times: relax the whole body, relax the whole body, and relax the whole body. Feel completely relaxed. You will feel like floating in the sea.

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The basic relaxation exercise 4 12. Feel each body part relaxed. 13. Simply open eyes to end the basic relation

exercise. • You may repeat the steps 3 to 12 as many times

as time allows. • Focus on each area and ensure that it is well

relaxed. • Relax those areas more if necessary. • At your own leisure, open your eyes to end the

relaxation exercise. • Feel entirely relaxed and greatly energized.

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The basic relaxation exercise: application

1. Learn: lie down with eyes closed in a quiet area

2. (May take a while to learn to relax)

3. Once learnt can be done anywhere with or without eyes closed

4. Do daily: form a habit (am pm)

5. Apply in real life situations; a. Waiting in line

b. Stressful situations

c. Even attending this session

d. Other situations

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Advanced relaxation • Involves forcing to relax during difficult

situations.

• Relax as basic relaxation and

a. Tighten fist (or any other body part) and force to relax. Relax all parts of your body.

b. Recall a traumatic memory and force yourself to relax. Relax all parts of your body.

c. Visualize impending event and force to relax.

Repeatedly doing above will eliminate the stress

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Event management 1 • Involves dealing with important happenings. • Perception of control is important • Need to change perspective that pt can

significantly alter response to events: adversities, illness, stress

• i.e. can control DM. • Overcome emotional overreaction/

helplessness. • Focus on problem solving. • Improve problem solving skills. • Think and act positively.

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Event management 2 From problem centeredness to discovery mode to

discover creative options.

• Gather information.

• Define the problem/ isolate facts and fiction/

• Isolate and deal with emotional aspects.

• Discover solutions.

• Make plans/ include contingency plans.

• Act to solve using problem complex modeling.

• Keep reviewing/ revising

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Rhythm rule of 5

• Best way of dealing with stress while at work.

• Divide activity into smaller parts.

• Do the first five with short rests in between.

• Take a longer rest after the fifth task.

• Continue to complete all the tasks while establishing a rhythm.

• This optimizes the activation of the stress responses.

• Can be easily applied to every task.

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Rhythm rule of 5

No. PHASE THOUGHTS AND FEELINGS

1 Just do it “Only a small task, let’s just do it”.

2 Creative “Let me do this in a clever way”. Feel

confident.

3 Power “Only two more to go”. Feel that

power.

4 Super-power “Only one to go”. Feel super-

powered.

5 Relax & enjoy “Last one”. Feel joyful and relaxed.

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Mindfulness • = being aware of the present time.

• what is happening right now, in the present moment.

• If you are remembering a past an event, that is memory.

• When you then become aware that you are remembering that event that is mindfulness.

• If you then conceptualize the process and say to yourself, “Oh, I am remembering,” that is thinking.

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Mindfulness: de-stressing 1

• Focus on the present.

• Ask yourself: "What is going on with me at the moment?"

• You simply allow yourself to observe whatever happens. Label any thoughts that you have and then leave them alone…. let them float away. Attend to your breathing or simply take in your surroundings instead.

• Besides thoughts, there may be sounds you hear, bodily sensations that you are aware of.

• If you find yourself constantly elaborating on thoughts, rather than labeling them and returning to the neutral, remember to observe your breathing.

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Mindfulness: de-stressing 2

• When emotions or memories of painful events occur, don’t allow yourself to become caught up by them.

• Give them short labels such as “that’s a sad feeling”, “that’s an angry feeling” and then just allow them to drift or float away. These memories and feelings will gradually decrease in intensity and frequency.

• identify yourself as an objective observer or witness rather than a person who is disturbed by these thoughts and feelings.

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Mindfulness de-stressing 3

• Stay with any distressing thoughts for a few moments, then as you let them float away, you gently redirect your full attention to your breathing.

• Pay attention to each breath in and out as they follow rhythmically one after the other. This will ground you in the present and help you to move into a state of awareness and stillness.

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Stress summary

• Activation of body.

• Helpful up to a point.

• Devastating if not controlled.

• Problem complex model for diseases.

• Worsened suffering.

• Consider stress management in ALL cases.

Stress managed

• 4R technique: redirect, release, review, refer.

• The relaxation exercise.

• Advanced relaxation.

• Event management techniques.

• Rhythm rule of five.

• Mindfulness.

• Personalized techniques.

• Refer if necessary.

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