Psychology of Stress and Coping

Stress, Coping, and Health Behavior

• Primary appraisal is a person's judgment about the significance of an event as stressful, positive, controllable, challenging, benign, or irrelevant.
• Health problems are usually evaluated initially as threatening or as negative stressors.
• Two basic primary appraisals are perceptions of susceptibility to the threat and perceptions of severity of the threat.
• Appraisals of personal risk and threat severity prompt efforts to cope with the stressor.

Secondary Appraisal

• Secondary appraisal is an assessment of a person's coping resources and options.
• It addresses what one can do about the situation.
• Key aspects are: perceived ability to change the situation, perceived ability to manage one's emotional reactions to the threat, and expectations about the effectiveness of one's coping resources.

The Theory of Planned Behavior (TPB)

• The TPB states that behavioral achievement depends on both motivation (intention) and ability (behavioral control).
• It distinguishes between three types of beliefs - behavioral, normative, and control.
• Attitudes: refers to the degree to which a person has a favorable or unfavorable evaluation of the behavior of interest.
• Behavioral intention: it refers to the motivational factors that influence a given behavior where the stronger the intention to perform the behavior.
• Subjective norms: it refers to the belief about whether most people approve or disapprove of the behavior.
• Social norms: it refers to the customary codes of behavior in a group or people or larger cultural context.
• Perceived power: it refers to the perceived presence of a behavior.
• Perceived behavioral control: it refers to a person's perception of the ease or difficulty of performing the behavior of interest.

Factors Controlling Patient Behavior

• Determinants of health behavior include social, social-cognitive, political, environmental, personal, and economic factors.

Lifestyle Counseling

• Helps patient to gain insight into own behavior, reasons, barriers, and solutions.
• Counsellor guides patients toward self-chosen lifestyle change.
• Patient-centered approach.
• Relation between patient and counsellor.
• Guiding and goal-directed way of communication.

Steps in Lifestyle Counseling

• Introduction: establish work relationship.
• Awareness: assess and improve awareness.
• Motivation: assess and improve motivation.
• Action: prepare for action and start to make changes.
• Relapse prevention: make plans for difficult situations.
• Continuation: help client to keep going.

Classification of Diabetes

• Type I diabetes: results from b-cell destruction, leading to absolute insulin deficiency
• Type II diabetes: results from a progressive insulin secretory defect on the background of insulin resistance, impaired insulin secretion, and excessive hepatic glucose production
• Gestational diabetes mellitus (GDM): diabetes diagnosed during pregnancy
• Secondary diabetes: genetic, exocrine pancreatic diseases, drugs, infections

Pathogenesis of Type I DM

• Results from pancreatic islet β cell destruction, most commonly by autoimmune process
• Typically presents in the first two decades of life
• Catabolic disorder in which circulating insulin is virtually absent and the pancreatic β cells fail to respond to all known insulinogenic stimuli
• Unable to utilize glucose in peripheral muscle and adipose tissues
• Require insulin replacement

Pathogenesis of Type II DM

• Caused by relative insulin deficiency (mismatch between insulin production and insulin requirements)
• Clinically, patients with type 2 diabetes can range from those with severe insulin resistance and minimal insulin secretory defects to those with a primary defect in insulin secretion
• More common than Type I DM, commonly present as adults with some degree of obesity
• At onset, most patients with type 2 diabetes do not require insulin to survive, but over time their insulin secretory capacity tends to deteriorate, and many eventually need insulin treatment to achieve optimal glucose control

Diagnosis of Diabetes

• Fasting plasma glucose (FPG) ≥ 126 mg/dL
• 2-h plasma glucose (2-h PG) ≥ 200 mg/dL
• Hemoglobin A1c (A1C) ≥ 6.5%

Categories of Increased Risk for Diabetes

• Fasting plasma glucose (FPG) 100-125 mg/dL
• A1C 5.6-6.4%
• 2-h PG in the 75-g oral glucose tolerance test (OGTT) 140-199 mg/dL

Comprehensive Medical Evaluation

• Confirm the diagnosis and classify diabetes
• Evaluate for diabetes complications and potential comorbid conditions
• Review previous treatment and risk factor control
• Begin patient engagement in the formulation of a care management plan
• Develop a plan for continuing care

Comprehensive Diabetes Evaluation

• Age and onset of DM
• History of DM-related complications
• Physical activity, habits, and nutritional status
• Current treatment of DM, including medications
• Psychosocial problems
• Hypoglycemic episodes

Laboratory Evaluation

• If results not available within past 2-3 months: A1c
• If not performed/available within past year: LDL, HDL cholesterol, and triglycerides, liver function tests, serum creatinine, and calculated GFR, test for urinary albumin/creatinine ratio in a urine spot, TSH in type 1 diabetes

Management Plan

• Evaluate for diabetes complications and potential comorbid conditions
• Review previous treatment and risk factor control
• Begin patient engagement in the formulation of a care management plan
• Develop a plan for continuing care

Pathophysiology of Diabetic Complications

• Glucose-induced cell injury
• Increased production of reactive oxygen species (ROS) and advanced glycation end products (AGEs)
• Accelerated polyol and hexosamine pathways and protein kinase C activation
• Non-enzymatic glycosylation of proteins, including haemoglobin, collagen, LDL, and tubulin
• AGEs accumulate in various tissues, including kidneys and blood vessels, and bind to a receptor for AGE (RAGE)

Microvascular Complications

• Retinopathy
• Nephropathy
• Neuropathy (peripheral and autonomic)

Retinopathy

• Caused by chronic hyperglycemia
• Retinal ischemia leads to proliferative retinopathy
• Treat with pan retinal laser photocoagulation
• Stages: preretinopathy, non-proliferative diabetic retinopathy (NPDR), preproliferative diabetic retinopathy, proliferative diabetic retinopathy (PDR)

Nephropathy

• Caused by chronic hyperglycemia
• Earliest functional abnormality is renal hypertrophy associated with a raised glomerular filtration rate
• Afferent arteriolar vasodilation with an increase in the intraglomerular filtration pressure
• Later on, mesangial cell hypertrophy and increased secretion of extracellular mesangial matrix material and glomerular sclerosis at the end

Obesity and Diabetes

• Severe obesity is defined as a BMI >40 kg/m2 (or ≥35 kg/m2 in the presence of comorbidities)
• Obesity affects psychosocial function as obese individuals are often exposed to public disapproval
• Treating obesity and obesity-related conditions represents an enormous economic burden

Exercise and Nutrition

• Adults with diabetes should perform at least 150 min/week of moderate-intensity aerobic physical activity
• Resistance training at least twice per week
• Weight loss (7% body weight) is recommended for all overweight or obese individuals who have or are at risk for diabetes