stress affects all chronic disorders, esp Diabetes mellitus. reflex stress, past traumas, and ongoing issues are combined with the disease to form problem complex. Dealing with each component of the problem complex will enable holistic care in a structured manner.

1. • 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

2. Stress & Diabetes
Mellitus
Prepared by
Dr Rajeshwar Sharma
Suva Diabetic Hub, Fiji

3. 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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4. 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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5. 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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6. 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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7. 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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8. 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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9. 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
medicati
ons
Manage
negative
thoughts
feelings
and
impulses
Manage
past
traumas
Explore
and deal
with
theses
Client skills
Provider
issues
System
upgrade

10. 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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11. 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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12. 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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13. 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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14. 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. 14

15. 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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16. 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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17. 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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18. 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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19. 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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20. 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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21. 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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22. 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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23. 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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24. 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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25. 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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26. 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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27. 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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28. 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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29. 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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30. 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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31. 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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32. 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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33. 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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