**3. Inadequate coping attitudes in type 1 diabetic patients**

People suffering from any type of chronic disease, need to make minor or major lifestyle adjustments. Diabetes, in particular, can eventually take its toll on the emotional, psychological, and physical well being of any person. These adjustments can lead to either successful adherence to medical regimens and control of the disease, or among other things, ineffective or maladaptive coping. The literature reveals that successfully adjusting to a

occur independently without being a consequence of diabetes. It has been shown that individuals with diabetes have a disproportionately higher rate of psychiatric disorders (Bogner et al, 2007; Llorente & Urrutia, 2006), with affective and anxiety disorders being more commonly diagnosed than in the general population (De Mont-Marin et al, 1995). This is evidenced by research showing high rates of psychiatric disorders, particularly depression and anxiety, for example, Fettahoglu et al., (Fettahoglu et al, 2007) found over 40% increased risk in having any type of psychiatric disorder in patients with diabetes, and Gülseren et al. (Gülseren et al, 2001) found that depression and anxiety account for 45% of psychiatric disorders in patients with diabetes. These results show the negative impact that diabetes can have on an individual's psychosocial adjustment, and the need for research to determine the

Other psychological problems of these patients are Eating Disorders (ED). The classical ED are anorexia nervosa (AN) and bulimia nervosa (BN), but recently another entity was recognized, the so called eating disorders not otherwise specified (EDNOS), which are incomplete forms of classical ED that are diagnosed when patients did not fulfill the classical ED diagnostic criteria. Type 1 diabetic patients have a high risk of suffering from ED due to these patients have to select the food they eat carefully in an early period of their development and because both entities, type 1 diabetes and ED, often affect adolescents and young adults. Furthermore, type 1 diabetic patients suffer from other eating behavior anomalies, which mainly appear in girls, that consist in spliting insulin doses or restricting food intake in order to reduce their body weight, but with the high price of the metabolic disturbance and subsequent chronic vascular complications if such

In this chapter we will review these psychological anomalies suffered by type 1 diabetic patients, especially problems with coping attitudes, disordered eating behaviors (DEB) and eating disorders (ED), and also discuss some aspects of their forms of presentation,

We identified relevant studies published in English by searching MEDLINE from January 1990 to December 2010. We included randomised and quasi-randomised controlled studies, clinical series, reviews and systematic reviews on type 1 diabetic patients with inadequate coping attitudes, disordered eating behaviors and eating disorders, in which children, adolescents and young adults with type 1 diabetes were properly defined. As study strategy, relevant questions about type 1 diabetes and eating disorders were previously determined: coping with diabetes, epidemiology, clinical forms of eating disorders and specific behavioral anomalies in type 1 diabetic patients, metabolic consequences and

People suffering from any type of chronic disease, need to make minor or major lifestyle adjustments. Diabetes, in particular, can eventually take its toll on the emotional, psychological, and physical well being of any person. These adjustments can lead to either successful adherence to medical regimens and control of the disease, or among other things, ineffective or maladaptive coping. The literature reveals that successfully adjusting to a

**2. Search strategy for identification and selection of studies** 

vascular complications, management and prevention.

**3. Inadequate coping attitudes in type 1 diabetic patients** 

most appropriate and common coping strategies to deal with the stress of illness.

behavior persists over time.

management and prevention.

chronic illness yields the following outcomes: successful performance of adaptive tests, absence of psychological disorders, low experience of negative affect, improved functional status, and appraisals of well-being in varying life domains (Stanton et al, 2001).

Coping can generally be defined as cognitive and/or behavioral attempts to manage and tolerate situations that are appraised as stressful to an individual. No single coping strategy or dimension can be considered maladaptive. The quality of the coping strategy and process is evaluated according to its impact on the outcome of interest. From the previous conceptual definition, Folkman and Lazarus (Folkman & Lazaruz, 1980; Folkman & Lazaruz, 1985; Folkman & Lazaruz, 1988) distinguished two primary dimensions of coping (or categories): emotion-focused (composed of individual coping strategies such as seeking emotional support) and problem-focused (composed of individual coping strategies such as making a plan of action). These coping categories described efforts to either alleviate the personal emotional stress induced by the stressor or alter the source of stress in the environment. Use of problem-focused coping has been found to be associated with better metabolic control, emotional status, and better adjustment overall in patients with diabetes (Lundman & Norberg, 1993); use of emotion-focused coping has been found to be associated with poor adjustment and adherence to health regimens in chronically ill samples (Bombardier et al, 1990).

Diabetic patients initially experience high levels of depression and anxiety (Lustman et al, 1997; Tuncay, 2008). Anderson et al. (Anderson et al, 2001) found that adults with diabetes have twice the odds of comorbid depression. It was also found that this prevalence was much higher in women than in men. Within their sample, one in every three individuals had a level of depression that impaired their ability to function on a daily basis which in turn affected quality of life, regimen adherence, and blood glucose control. Regarding to coping strategies, it has been shown that problem-focused coping was positively associated with glycaemia control and negatively associated with anxiety and depression (Maes et al, 1996). Smari and Valtysdottir (Smari & Valtysdottir, 1997) also found that problem-focused coping was associated with lower blood glucose levels—indicative of better adjustment. On the contrary, individuals who engaged in more emotion-focused types of coping experienced more anxiety, depression, and higher levels of glycaemia. It is obvious that any deviation from a normal routine or health status serves as a continual source of stress that leads to the individuals' inability to care for themselves (White et al, 1992). Therefore, management of this stress via coping strategies is crucial for psychological and physical health.

An author found that treating depression through therapy is effective for individuals with diabetes so they may regain confidence and abilities to control the disease, leading to improved quality of life and social and physiological functioning (Eisenberg, 1992). The treatment includes the development of coping skills through training programs (Grey & Berry, 2004) as well as patient empowerment (Anderson et al, 1995). DeRidder and Schreurs (DeRidder & Schreurs, 2001) observed that diabetic patients in particular are inclined to use coping strategies that are aimed at reducing the negative emotions surrounding the disease and its maintenance. If this suggestion was found to be empirically true across diabetes studies and patients, it may portend a particularly problematic issue since these strategies were generally viewed as less adaptive. It is apparent that stress permeates the management of diabetes and thus use of effective coping skills is imperative not only in illness management but general stress management as well. At present, there is no systematic quantitative review of the stress and coping literature in diabetes that links coping strategies to indices of adjustment. Thus, a summary statement of the adaptive versus maladaptive strategies identified for these coping-adjustment relations cannot be made with any degree of confidence.

Inadequate Coping Attitudes, Disordered Eating

levels than among the general population.

diabetic women than in the general population.

BN (American Psychiatric Association, 1994).

specified and seven had a subthreshold ED.

(Rodin et al, 2002).

**5. Clinical forms of eating disorders in type 1 diabetics** 

Behaviours and Eating Disorders in Type 1 Diabetic Patients 99

interview, showed that 14.9%, at baseline, and 26%, at the end of the follow-up period, had evidence of bingeing or purging while insulin misuse for weight control was reported by 35.6% of the patients (Peveler et al, 2005). A recent study from France (Ryan et al, 2008) concluded that abnormal eating behavior is present in French diabetic patients at higher

Thus, nowadays, there is clear evidence that EB and DEB are more prevalent in type 1

The three diagnostic forms of ED are AN, BN and EDNOS. Common to all three is a core problem in which the self-evaluation is unduly influenced by body weight or shape. This can be characterized by an extreme pursuit of thinness, in the case of AN, or recurrent episodes of binge eating and compensatory caloric purging behaviors, in the case of BN. EDNOS encompasses those ED that are clinically significant enough to compromise the patient health and the quality of life, but do not meet formal diagnostic criteria for AN or

Eating disorders that meet Diagnostic and Statistical Manual of Mental Disorders four edition (DSM-IV) diagnostic criteria, mostly bulimia nervosa and EDNOS, are more than twice as common in girls with diabetes compared to their non-diabetic peers, furthermore, subthreshold eating disorders were also almost twice as common in girls with diabetes compared to controls (American Psychiatric Association, 1994). In line with these studies, it was found that the ED associated with bingeing and purging are the most common types of ED among girls with diabetes as they are in girls in the general population (American Psychiatric Association, 1994; Fairburn & Beglin, 1990; Jones et al, 2001). Restricting ED are much less common conditions (Jones et al, 2000), thus a specific association between anorexia nervosa and type 1 diabetes has not been demonstrated

In a longitudinal study by Colton et al, (Colton et al, 2007), at 5 years, 49% of a cohort of girls with type 1 diabetes reported current disordered eating behavior (DEB), 43.9% active dietary restraint, 6.1% binge-eating episodes, 3.1% self-induced vomiting, 3.1% insulin omission and 25.5% excessive exercise for weight control. Furthermore, 13.3% met criteria for an ED: three girls had bulimia nervosa, three had an eating disorder not otherwise

Using the DSM-III-R or the DSM-IV for interview-based diagnosis, the prevalence of AN varies between 0.0-1.8% for diabetic patients, whereas 0.0-0.6% for controls. The prevalence of BN was 0.0-5.8% and 0.0-2.0%, respectively (Engström et al, 1999; Fairburn et al, 1991; Jones et al, 2000; Mannucci et al, 1995; Peveler et al, 1992; Robertson et al, 1990; Striegel-Moore et al, 1992; Vila et al 1995). In a study that aimed to determine the prevalence of ED in young adolescents, 98 type 1 diabetic patients and 575 age-matched controls were studied. The authors found neither AN nor BN case among diabetics and controls. However, the prevalence of EDNOS was significantly higher in adolescent diabetics than in controls both in boys (1.7% vs. 0.9% respectively) and girls (5.3% vs. 1.6% respectively). In addition, subthreshold ED were more common in male diabetic adolescents than in non-diabetic peers (García-Reyna et al, 2004). In a meta-analysis by Mannucci et al (Mannucci et al, 2005),
