Instructions

Special Considerations: Trauma Response

Not all diabetes populations are the same. One of these special groups within the diabetes community are patients who are working through a trauma response. It’s important to recognize the difference between a phobia and a trauma response.

Phobia – prexisting irrational fear not linked to life event

Example – hypophobia- newly diagnosed PWD purposely leaves their blood sugar above 200 fearful that they will go low, lose consciousness and crash their car. No history of severe hypo, but does get jittery if BG drops below 110.

Trauma response – maladaptive response to life event (or events) resulting in ongoing fears, anxieties or fixations on situations perceived by the observer as irrational in situation or scale.

Example- Patient with diabetes does not tolerate blood sugar below 150, 2 years following severe hypoglycemia with loss of consciousness and administration of glucagon.

Very often in the diabetes world anyone exhibiting an intense fear or anxiety is labeled as a phobia patient. They’ll be labeled as being hydrophobic, needle phobic, or something else. But that can be really demeaning and also can cut the patient off from the appropriate care and treatment they need because a phobia can be a pre-existing, rational fear not linked to a life event (for example someone with a hypophobia might be someone who’s newly diagnosed and purposely leaves their blood sugar above 200 because they’re afraid they’ll go low, lose consciousness, and crash their car. They don’t actually have a history of severe hypos, but they may have been told about that they were going to lose consciousness at some point. This kind of phobia can react well to education and to exposure therapy, gradually increasing their comfort level. On the other hand we have a trauma response that is a maladaptive response to a life event that results in them having ongoing fears, anxieties or fixations on situations that are perceived by others as irrational in situation or scale. An example is a patient with diabetes who won’t allow their blood sugar below 150 because two years ago they had a severe hypoglycemia event with a loss of consciousness and were administered glucagon. You can see this person doesn’t have an irrational fear--it’s a very real fear—it’s an event that actually happened. So they’re going to need a different form of therapy from the previous example. They will benefit from a different sort of cognitive behavioral approach that is going to allow them to work through that trigger and thought process. Calling what they’re experiencing a phobia is demeaning because they know phobias are irrational fears of something that’s not really going to harm (the example that comes to mind is someone who fears sharks and so avoids swimming pools). In a trauma response they have experienced a real, near life-threatening event and their reaction, though irrational in nature, is an adaptive mechanism to a very real, potential threat to life and safety. This actually has an impact on Maslow’s hierarchy of needs and so we have to identify that differently and get those patients a different level of support. It’s also important to let the patient know that what they’re dealing with is a trauma response. Giving them that validation can help empower them to seek appropriate treatment and move forward through recovery.

Special Considerations: Disordered Eating

Diabetes, by definition, requires some level of disordered eating. To eat effectively with diabetes requires the ongoing quantification and qualification of foods. It also encourages the active avoidance of some types of foods. People with diabetes learn that some foods are “good” for their blood sugar while others are “bad”.

Definitive Disordered eating:

Addition of specific food related behaviors out of feelings of shame, control, guilt, or fixation.

Definitive eating for diabetes management:

-quantifying and qualifying all food intake

-feeling a need to control what foods and how much one eats

-concern that deviating from that plan will result in physical harm

Labeling of foods as “good” or “bad” based on content or blood sugar impact

These messages are then echoed by “food policing” supports and caregivers who restrict food options or add guilt and shame to the food relationship. This is the key piece that converts the “distorted eating” of diabetes into the disordered eating that can post a mental and physical health risk. When these practices of restriction, avoidance, fasting, or binging are combined with shame, guilt, or thoughts of self loathing or self harm, they cross over into the realm of disordered eating and eating disorders.

These are particularly hard to spot in diabetes because from the outside they can look like dieting.

We must avoid promoting food restrictive diets in diabetes populations, labeling foods as good or bad, and avoiding all judgmental language regarding food (such as talking about good or bad foods, junk foods, overeating, or gorging).

We should also avoid rewarding and complimenting weight loss or carb restriction that results in blood sugar goals being met. Any weight loss or goal reaching should be done at a steady, healthy, and sustainable pace long-term. And forward movement toward goals should be met with discussions about the resultant stress levels, whether they feel deprived or are avoiding any foods, situations or events to accomplish their goals, and how they feel about their progress and how they would feel if their progress stopped today.

Disguised as “dieting”

Do not “reward” weight loss, carb restriction etc.

Always ask open ended questions about food

and eating.

Never use “judgement words” (good, bad,

junk, over-eat, gorge) about food.

These kinds of open discussions can then be followed with encouragement and reward for the openness of expression and their willingness to entertain new ideas.