This study investigated whether the link between stress and metabolic control in adolescents with insulin-dependent diabetes mellitus (IDDM) is direct or indirect and whether this association is mediated by either social competence or parental support. Subjects included 104 adolescents with IDDM and their mothers. Measures of adherence, life stress, social competence, and parental support were obtained during the assessment session, and metabolic control was determined by averaging the adolescent's glycosylated hemoglobin levels during the previous year. Multiple regression analysis revealed that stress was directly associated with metabolic control, independent of the link between adherence and metabolic control. Multiple regression analysis also showed that social competence buffered the negative association between stress and metabolic control. Moreover, parental support was directly linked with adherence, and adolescent age was indirectly linked with adherence through its association with parental support. These findings are consistent with the developmental transitions that accompany adolescence.

Social competence and parental support as mediators of the link between stress and metabolic control in adolescents with insulin-dependent diabetes mellitus.

Diabetes mellitus is a very prevalent illness that produces a variety of stresses for the individual patient, but the role of psychosocial factors in this illness is frequently minimized in the teaching ofphysicians and the care of patients. The authors review a framework f or evaluating the role of psychosocial issues in illness in general and examine the evidence that demonstrates the importance of these issues in diabetes. (AmJ Psychiatry 1990; 147:1275-1282)

Evidence of the role of psychosocial factors in diabetes mellitus: a review.

Psychosomatic research findings correlating psychologic stress with diabetic control fail as yet to provide valid conclusions. Investigators have presented many contradictory findings. The two major pathways by which stress could affect control, a) changes in compliance behavior, and b) a neurohumoral axis, have not been clearly distinguished from each other. The study of adolescent cohorts is associated with the problem of heterogeneity, limiting the application of results to other diabetic populations. Methods of determining diabetic control have been incomplete and the definition and measurement of stress have major inadequacies for the analysis of such a complex psychosomatic problem. Existing evidence is comprehensively reviewed and evaluated. The authors use a modified definition of stress to construct a stress scale specific to pregnant diabetics.

Stress and metabolic control in diabetes: psychosomatic evidence and evaluation of methods.

Although the role of emotional and psychosocial factors in diabetes is generally appreciated, most health care professionals, diabetic patients, and families of patients have no clear model that clarifies the nature of psychosocial variables and provides defined principles for effective treatment and preventative interventions. A multivariate clinical model for coping with predictable crises of diabetes is presented. The model is based on the constructs of crisis, coping, and social support as well as a developmental and life course perspective. The psychosocial tasks to be addressed in coping with crises, in general, as well as strategies of coping are defined and discussed. The specific predictable crises of diabetes are described with reference to the demands and sources of stress inherent in the critical situations and the associated strategies for coping with them. Special attention is given to coping with the initial diagnosis and onset of the disease, the role of health care professionals, and developmental issues in coping with diabetes.

Coping with predictable crises of diabetes.

Objective To determine what psychological and behavioral factors were most predictive of diabetic control. Method Seventy-nine youths with diabetes were assessed cross-sectionally, using youths' reports of self-esteem, anxiety, and attitudes about diabetes, and parents' reports of competence and psychopathology (from the Child Behavior Checklist) and diabetic adherence as independent variables. Glycosylated hemoglobin A 1c was the dependent variable, reflecting diabetic control. After the effects of several background variables were partialed out, a principal-components analysis grouped the substantive variables into three larger components. Results Among the background variables, duration of illness and family size significantly predicted diabetic control. Among substantive components, Competence/Adherence (including Total Competence, dietary compliance, and frequency of blood glucose checks) was highly predictive of diabetic control, primarily due to the effect of Total Competence. Adjustment (including self-esteem, anxiety levels, and attitudes about diabetes) and Psychopathology were less predictive. A model was constructed showing the relationships between these predictive components and diabetic control. Conclusions In this generally well-adjusted sample, that Total Competence, more than other measures, predicted diabetic control suggests it could be used by clinicians to anticipate diabetic youths at risk.

Predicting diabetic control from competence, adherence, adjustment, and psychopathology.

Diabetes Mellitus is the most common endocrine disease found in children, and its reported incidence is increasing. Most investigators now agree that improved diabetic control is effective in decreasing both long and short term complications. The delineation of factors which affect control are, therefore, of importance. Classically, the physician has emphasized insulin dose, presence of infection, diet, and exercise. Emotional factors have long been thought to play a role in diabetes mellitus. The exact nature of this role, however, has been rather elusive and controversial. The authors review this literature, summarize the major viewpoints, and conclude that psychological factors can influence the physiology of the disease.The focus of this paper is the synthesis of recent advances in basic metabolic, endocrinologic, and stress research, relevant to juvenile diabetes, into a psychophysiologic model. The authors discuss future research directions necessary for clarification of the model, as well as its ps...

Seth W. Silverman

Papers

The Psychophysiologic Aspects of Stress in Juvenile Diabetes Mellitus