Review
sychological Aspects of Diabetes Mellitus: A Critical Review STUART T. HAUSER AND DANIEL POLLETS
I
n recent years, there have been an increasing number of studies concerning psychological aspects of diabetes mellitus. Four important topics are raised in these varied studies: (1) the role of psychological factors in the onset of diabetes; (2) the influence of the immediate environment upon the course of the disease; (3) the immediate response and long-term psychological adjustment of the diabetic individual after the onset; and (4) the family: the reaction of the family to the illness and the impact of diabetes upon the family structure. Since this is so complex and broad an area, we will review each of these topics by looking at the specific studies. In this review, we will focus on specific issues that concern research designs and conflicting findings. Our own interests have been in the impact of diabetes upon both individual development and the family. We have uncovered some interesting developmental patterns from our pilot studies.1 We will also indicate our own approach, and some of these initial findings.
PSYCHOLOGICAL PREC1PITANTS OF DIABETES
Most of the early studies that reported evidence connecting emotional factors to the onset of diabetes have been clinical case studies in which the clinicians observed precipitation of the disease following sudden stressful environmental occurrences,2 or varying patterns of association between diabetes and psychiatric illness.3'4 In two related papers, Menninger5'6 concluded that, ". . . diabetes may be the direct result of psychological disturbances."5 Reviewing 22 cases of psychiatric illness associated with diabetes, Menninger found four patients in whom a psychosis either preceded or developed simultaneously with the onset of diabetes. 5 More recently, Slawson and co-workers7 evaluated 25 newly diagnosed adult diabetic patients psychiatrically and found that 14 of the patients gave a history of recent object loss; in addition, many of the patients presented pat-
terns of unresolved grief and emotional deprivation. They suggest that adult-onset diabetic patients may be particularly prone to specific stress. Two empirical studies by Stein and Charles 8 ' 9 also focus on the role psychological factors may play in the etiology of diabetes. They conceptualize diabetes as a disease of disordered physiologic and psychological adaptation. They then raise the question of whether a preexisting state of physiologic disturbance might be present in the patient before the symptomology became manifest due to physiologic change and/or psychologic stress. In their first study, Stein and Charles8 compared 38 diabetic patients with 38 matched, nondiabetic subjects in terms of separations, divorce, and family disturbance. The control group consisted of patients suffering other chronic diseases (sickle cell anemia, other blood diseases). The authors found that the diabetic patients as predicted, had a significantly higher incidence of parental loss and severe family disturbance than the control group. Tietz and Vidmar10 also described patterns of disturbance in diabetic families. The conclusions of these studies are problematic given their research design. The sample sizes were small, and the data relied upon consisted only of clinical observations. On the whole, then, the results of a number of studies have not clearly shown that psychic stress, or psychopathology, are etiologic factors in the onset of diabetes. In addition, large scale epidemiologic surveys have failed to find significant correlations between onset and emotional stress.11 Besides the dearth of empirical support, there are conceptual difficulties in this area as well. At this point, we do not have a developed theoretical model that formulates the relationships between psychological processes and the appearance of diabetes. The general concept of a "prediabetic state" 12 which is transformed to diabetes by environmental stress situations8 does not detail the specific mechanisms that might link stressful events and the onset of the diabetic syndrome.
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PSYCHOSOCIAL ENVIRONMENT AND THE COURSE OF DIABETES
A number of studies have investigated relationships between psychological stress and fluctuations in the course of diabetes. The findings suggest that events generating anxiety, specific intrapsychic conflicts, emotional deprivations, conscious and unconscious threats to security, and actual unpleasant psychologic experience might upset diabetic control.13 Hinkle and Wolf14 present evidence supporting the notion that stressful life situations, either consciously or unconsciously interpreted by the diabetic patient as having relevance to his security, produce fluctuations in the level of ketone bodies and glucose in the venous blood as well as in the amount of urine excreted. In the 50 diabetic patients studied, they found that, in nearly all cases, the onset of the biochemical shifts occurred after a period of environmental and interpersonal stress characterized by a loss of significant persons, objects, relationships, or cultural values regarded by the patient as indispensable to his security. In general, these earlier studies are difficult to compare, since many are clinical case reports15'16 and were conducted at a time when there were no reliable techniques for assessing the impact of life experience on individuals. A recent approach to this complex problem has been through Holmes and Rahe's "Schedule of Life Events."17 Their instrument weighs recent life events in terms of their relative impact on the individual's life, and the amounts of readjustment needed to respond to such events.17 Such an instrument allows comparisons to be made across patients rather than being restricted, as in the earlier studies, to the unique conflicts of each case. Using life-stress assessment, Grant and colleagues13 recently reported empirical evidence of a relationship between undesirable life events and changes in diabetic condition. In this study, 37 private clinic patients were interviewed on five different office visits over a period of 8-18 months. At each visit, the patients were given a physical examination and a global physical condition rating. Patients also filled out the "schedule of life events." The findings revealed a positive correlation between undesirable life events and the course of the diabetes. Holmes and Masuda,18 working with the schedule of life events, emphasize that it is not simply a specific traumatic event that can affect the disease course or lead to its onset. More likely, it may be the cumulative "life crisis units" that will be associated with clinical deterioration. Kimball,11 in his review of this material, describes a situation in which the individual is repeatedly forced to deal with stressful events, eventually diminishing his ability for readjustment, adaptation, and homeostasis. Such an impaired adaptive capacity may in turn lead to feelings of helplessness or depression, which have physiologic concomitants. The lifestress research is a promising approach and may open up the possibility of studying stress events in larger samples that 228
vary by age, social class, and control of diabetes. Another possible direction to pursue in this research would be to investigate diabetic patients' individual differences in susceptability to stress and determine how these individual differences might influence shifts in the course of diabetes. Despite the fact that such systematic stress research is in its earliest stages, the preliminary results begin to systematically document the frequent anecdotal observation that the patient's psychological states may be closely linked with the course of his diabetes. In summary, the published empirical research in this area certainly supports the view that psychological factors, and the surrounding social-emotional context, need to be considered in understanding fluctuations that occur in diabetic control. Specifics such as which are key aspects of the environment, and what are the relevant personality dimensions remain unclear. Such important questions will likely be resolved through further empirical and conceptual work in stress research.19 RESPONSE AND PSYCHOLOGICAL ADJUSTMENT OF THE INDIVIDUAL
T
he largest number of studies by far have approached the topic of "psychological aspects of diabetes" from this perspective. Two themes are especially salient in this literature: (1) the question of whether there is "more" or unique psychopathology associated with diabetes mellitus; and (2) the concern with how those diabetic patients who are in "good control" differ from those whose control is labile or "poor." Both themes are often intertwined in the discussions. Benedek,16 in an early paper, observed the traumatic effect of the diagnosis of diabetes on patients, an effect which she viewed as deeper than Jthe anxiety induced by other chronic diseases. The diabetic patient may develop a habit of dealing with every external and internal situation in terms of food and his diabetes. Benedek speculated that the processes secondary to the diabetes may become a part of the personality so that we can speak of a "superstructure" of the diabetic individual. Individual differences in adaptation to diabetes may then depend upon the nature of this superstructure as well as premorbid personality structures. In our research interviews with diabetic adolescents,1 we have often been struck by their preoccupation with, or pervasive awareness, of their diabetes, accompanied by a general sadness. This is a clinical picture reminiscent of the diabetic patients Mirsky20 described. He noted their hurt pride and their intensified fears and feelings of inadequacy. Still another pertinent point about the individual diabetic patient has to do with his or her uniqueness. Palmer21 emphasized the disturbing specialness, noting that the diabetic patient is "faced with interminable diet restriction, which virtually eliminates many highly gratifying foods." In addi-
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tion, there is no other disease that requires daily selfadministration of medication with a hypodermic syringe with the threat of disaster if this practice is not observed. Daily urine testing may further emphasize the nearness of disaster, as the patient faces evidence of deviations from strict control. Finally, patients are usually aware of the later complications: blindness, and heart and kidney disease. These facets of the impact of diabetes on the individual have been touched on many times in our own interviews and clinical observations. We would expect that these unique and powerful features of insulin-dependent diabetes would influence the psychological development and adaptation of diabetic children and adults. Therefore, it is especially curious that studies in this realm have generated conflicting and unclear findings. There are a number of studies that indicate significant psychic disturbance in diabetic patients. Swift and coworkers22 followed 50 juvenile diabetic patients and 50 individually matched nondiabetic controls together with their families. Their data included a basic diagnostic test battery and a clinical interview that was later coded for specific psychiatric problems. The diabetic patients were also rated for "level of diabetic control." Results were consistent with an earlier study and showed the diabetic child to exhibit more psychopathology than the nondiabetic controls. The diabetic children were described as more dependent, having less adequate self-images, greater levels of anxiety (manifest and latent), more pathologic sexual identifications, greater constriction, more pathologic hostility, and greater oral preoccupation. Level of pathology was compared to duration of diabetes and the quality of diabetic control. They found that duration of diabetes was most strongly associated with control: the longer the duration, the worse the control. The psychiatric classification and self-perception were also associated with control. Control was more disturbed in the more abnormal patients. Swift and colleagues attribute these results to the effects of chronic illness, which strain the "emotional and self-evaluative characteristics" of the diabetic adolescent.22 At odds with the picture of various degrees of diabetic psychopathology portrayed in the clinical and empirical studies are the findings presented in several recent papers.23"26 These authors report essentially no difference between diagnosis or individual symptoms. Simonds,24 for example, compared 40 diabetic youths in good control, 40 diabetic youths in poor control, and a matched, nondiabetic control group selected from a family practice clinic. Information regarding psychiatric difficulties was collected through interviews in patient's homes. The interviewer was blind to the level of control of the diabetic patients but knew who were the diabetic patients and who were the normal controls. These interviews were then rated for "psychiatric diagnosis," "interpersonal conflict," and "no interpersonal conflict." The results revealed that there were no differences between the
diabetic patients and the normal controls. This negative finding was repeated in the evaluation of the parents. Still another surprising pattern was that the "well controlled" diabetic group seemed to be in better mental health than the nondiabetic group. The "poor controlled" group, however, had significantly more dependency conflicts and more anxiety and depression than the control group. This trend was interpreted by Simonds as being caused by the worsening of the control. A second study that found no differences in psychiatric symptomology between diabetic children and normal controls was carried out by Olatawara,26 who compared 50 diabetic children and 50 matched controls. Olatawara used a semistructured behavior inventory, which was administered in the home of the subject. The diabetic and nondiabetic children could be distinguished from each other on only two items: sleep disturbance and stealing—the control group being more disturbed than the diabetic group. In order to grasp these contradictory findings, it is important to first realize that there are major differences between Swift's22"27 methods and those of Simonds24 and Olatawara.26 In the work of Swift and colleagues, the data was based on psychiatric interviews and psychological tests. Simonds and Olatawara, in contrast, draw their data from behavioral inventories and individual classifications made by the authors. Given these differences, it is no surprise that the results are conflicting. Besides the methodological problems (i.e. lack of inter-rater reliability, experimenter bias) there is a major conceptual one: it is likely that gross psychiatric categories (i.e. "problem with anxiety," "interpersonal conflict"24) are not sensitive enough to distinguish the subtle ways diabetes may influence specific aspects of psychological functioning and development. There are, however, a number of recent empirical studies that follow more discrete psychological processes such as mood, interpersonal orientations, attitudes, perceptual style, and ego development. Murawski and colleagues28 administered the Minnesota Multiphasic Personality Inventory (MMPI) to 112 adult patients who had had diabetes for 25-48 yr. The items that make up this test were selected empirically because of their ability to differentiate a normal population from clinically diagnosed psychopathologic groups. His sample was subdivided into one group made up of patients who had been free of vascular complications. The patients were given the MMPI while awaiting physical examination. Analyses of the test data revealed a high depression score for the entire sample. Clinically, these patients were not withdrawn from social contact; they continued to seek out and enjoy people. However, they expressed pervasive feelings of pessimism, hopelessness, and depression in their test responses. A second finding was a significant sex difference. The men who developed vascular complications had higher psychopathology scores on all but one scale when compared with the male complication-
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free group; and in general, their scores were more pathologic than the female complication-free patients. Murawski interprets this pattern as one that indicates that men without complications "tended to acknowledge less vitality and less impulsiveness" than the men with clear complications and "were perhaps more accepting of their physical •disability." This sex difference—of more psychic difficulty for men—also appears in our findings.1
A
second personality study used a perceptual measure, that of field dependence-independence.29 Using Witkin's field dependence test, Karp found significantly more field dependence in a group of 80 male and female diabetic adults than in a matched control group. Evidence from a number of other studies indicates that individuals high in field dependence also tend to be more socially dependent and have less distinct body boundaries.30 Additional findings were that women had higher field dependent scores than men, and diabetic clinic patients had higher field dependent scores than private patients. This latter finding, that patients attending a diabetes clinic were significantly more field dependent than their counterparts who were seeing a private physician, is of clinical relevance. Since there were no social class differences between the groups, there is the implication here that psychologically different patients may attend clinics as opposed to private practice offices. Karp suggests that the clinic milieu may provide greater support for a patient who is socially dependent and who requires external sources to gain such support.29 Sullivan31 followed self-esteem and depression in diabetic adolescents using previously constructed assessment techniques. Her results parallel Murawski's observation of depression in diabetic patients.28 In addition to higher depression scores, she observed that the diabetic group had significantly lower self-esteem levels than a nondiabetic comparison group. In our own studies,1 we followed what appear to be two important personality dimensions: ego development and selfesteem. A number of reports and clinical observations have noted the disruption in individual development that frequently accompanies the onset of diabetes.11 Besides interrupting maturation, the course of the diabetes may be importantly influenced by the level of development that the patient has reached at the time of diagnosis. We also followed the dimension of self-esteem. Here again, clinical observers have described the low self-esteem of many diabetic patients,11'22 a pattern that also appears in the empirical studies by Murawski et al.28'and Sullivan.31 Using two systematic instruments, Coopersmith's selfesteem inventory32 and Loevinger's ego development test,33 we followed the ego development and self-esteem of 164 diabetic adolescents, drawn primarily from diabetes summer camps. The adolescents were between 11 and 19 yr of age,
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with an average age of 13. We also conducted clinical interviews with 10 of the patients after they had taken the self-esteem and ego development tests. Since this was a pilot study, we did not employ control groups. However, we located comparison samples of nondiabetic adolescents34"36 and a control group from other current pilot studies. When contrasted with the comparison groups, the diabetic adolescents were at lower levels of ego development, and, in addition, showed a narrower range of stages present. This distribution of stages was not associated with duration of diabetes. There were no significant correlations between duration and ego development level. A second ego development result was unexpected. Among the diabetic subjects we found significant sex differences in ego development levels. Girls were at higher ego development stages than boys at all ages, regardless of duration of diabetes. This is an important result, since it is at variance with the absence of sex differences in ego development studies of many hundreds of nondiabetic subjects of all ages.33 The finding is reminiscent of Murawski's28 observation of greater psychiatric impairment for male diabetic patients. As a group, we found that the diabetic patients showed slightly higher levels of self-esteem than comparable, sameaged subjects. However, when we looked more closely within the group of diabetic patients, we found that self-esteem was significantly associated with.duration. The longer the duration of the diabetes, the more likely it was for a patient to have lower self-esteem. The diabetic adolescents, then, were clearly at lower stages of ego development than other comparable adolescents. This pattern, suggestive of an arrest in ego development, was more dramatic in the male subjects. We also found self-esteem to be more impaired in diabetic adolescents who were at lower levels of ego development and/or had a longer duration of diabetes. The test protocols revealed that these patients at the lower levels of ego development were more preoccupied with separation and loss than those patients at higher ego development levels. Our study was originally planned to be a pilot project for a much larger, more comprehensive project. It generated, however, much more data and findings than we had anticipated and suggests at least two future research directions. One possibility involves longitudinal investigations. Since ours was a cross-sectional study, we do not know if the low ego development levels were the result of a transient interruption in development or of a more sustained arrest or fixation in maturation. In order to resolve this question, and the related question concerning the stability of the low self-esteem, we need to follow such patients over several years of development. In addition, we do not know what impact these patients have had upon their families and how families have influenced individual development. Several of the patients gave intriguing, elabo-
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rate descriptions of their interactions with their families, often around aspects of diabetes. There are a number of studies that suggest that the family represents an important developmental environment of the adolescent patient.37
these were families in which there was an inability or unwillingness to resolve conflicts. Even the brief excursion
into the recent family research of Minuchin makes it clear how different the data about families is when it is collected and analyzed through such direct observations and interaction analyses.
DIABETES AND THE FAMILY
This brings us to the fourth psychological aspect of diabetes: the family. This is the sparest of the four literatures. While pediatricians and internists have long been aware of the importance of family influence, there have been few systematic studies of families with diabetic members. Several investigations of diabetic patients have also included interviews with family members. Koski38 interviewed the parents of 60 diabetic children. She described their initial reaction to the illness of their child as characterized by bewilderment, anxiety, fears, and depressive feelings. The parents of children in poor diabetic control were characterized as showing "nonconstructive external coping processes," mainly helplessness and poor cooperation in the daily care of the diabetic child. These parents handled their feelings of anxiety and depression through chronic underlying pathologic forms such as omnipotent thinking, denial, and phobias. In contrast, Koski found the parents of the children who were in good control to be adequately working through their feelings of anxiety, loss, and depression. Five years after the original research, Koski began a follow-up study of the same 60 diabetic children.39 Using data from the psychiatric interviews with the children, she categorized the families in terms of their overall functioning. Eighteen of the 23 families where the child's control was good or fair belonged to the healthy, well functioning family type. The families of the children in poor control were categorized as chaotic, with internal cliques and severe conflicts. Unfortunately, there was no discussion of how parental coping mechanisms correlated with constancy or change in the quality of diabetic control. Other family studies also rely on clinical impressions usually gathered from individual interviews with patients and occasionally other family members, including parents.10'40 The only group to use the approach of direct family observation is that of Minuchen.41'42 Using a series of family tasks, they compared the interactions of families of labile juvenile diabetic patients (multiple recurrent bouts of ketoacidosis) with two other groups of diabetic families—one made up of children showing behavior disorders, the other with no psychological difficulties. A number of unique elements were found in the families of the "brittle" diabetics. The children appeared to be intensely enmeshed in their families' current conflicts; family members demonstrated a high degree of overprotectiveness and concern for each other's welfare; and the family itself was marked by extreme rigidity, committed to maintaining the family status quo. Consistent with these other features,
DISCUSSION
I
n this critical review we have included all systematic empirical studies, and a number of clinical approaches, to psychological facets of diabetes mellitus. Our emphases have been twofold: (1) to review methodological dimensions, which are important influences upon the findings and clinical implications of these studies; and (2) to explore clinical implications and relevance of findings where possible. Our most salient conclusion concerns the need for more carefully designed, conceptually based, systematic empirical research in all four of the psychological aspects of diabetes mellitus. More specifically, the areas of development and family functioning appear to be particularly interesting and potentially fruitful ones for future research efforts. The recent emergence of new measurement techniques and the interest in family interaction studies are encouraging signs, which may signal the beginnings of clinical research into this complex and important interface between diabetes and psychosocial processes.
ACKNOWLEDGMENTS: Important assistance in completing this review was provided by Mr. Kirk Daffner and Ms. Barbara Turner. This review was supported in part by NIMH Research Scientist Development Award 5-KO2-MH-7O178 to S. T. Hauser. REFERENCES 1 Hauser, S. T., Pollets, D., and Turner, B.: Ego development and self-esteem in diabetic adolescents. Submitted for publication. 2 Daniels, G. E.: Present trends in the evaluation of psychic factors in diabetes mellitus. Psychosom. Med. I: 527-552, 1939. 3 Pike, H. V.: Significance of diabetes mellitus in mental disorder. J.A.M.A. 76: 1571-1572, 1921. 4 Neilson, C. H.: Emotional and psychic factors in disease. J.A.M.A. 89: 1020-1023, 1927. 5 Menninger, W. C.: Psychological factors in the etiology of diabetes. J. Nervous Mental Disease 81: 1-13, 1935. b Menninger, W. C : The interrelationships of mental disorders and diabetes mellitus. J. Mental Sci. 81: 332-357, 1935. 7 Slawson, F. P., Flynn, W. R., and Kollar, E. J.: Psychological factors associated with the onset of diabetes mellitus. J.A.M.A. 185: 166-170, 1963. 8 Stein, S. P., and Charles, E. S.: Emotional factors in juvenile diabetes mellitus: a study of early life experience of adolescent diabetes. Am. J. Psychol. 128: 700-704, 1971. 9 Stein, S. P., and Charles, E. S.: Emotional factors in
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juvenile diabetes mellitus: a study of early life experience of eight diabetic children. Psychosom. Med. 37: 237-244, 1975. 10 Tietz, W., and Vidmar, J. T.: The impact of coping styles on the control of juvenile diabetes. Psychiatr. Med. 3: 67-74, 1972. 11 Kimball, C. P.: Emotional and psychosocial aspects of diabetes mellitus. Med. Clin. N. Am. 55: 1007-1018, 1971. 12 Conn, J. W., and Fajans, S. S.: The pre-diabetic state. A concept of dynamic resistance to a genetic diabetogenic influence. Am. J. Med. 31: 839-850, 1961. 13 Grant, I., Kyle, G. C., Teichman, A., and Mendels, J.: Recent life events and diabetes in adults. Psychosom. Med. 36: 121-128, 1974. 14 Hinkle, L. E., Jr., and Wolf, S.: Importance of life stress in course and management of diabetes mellitus. J. A. M. A. 148: 513-520, 1952. 15 Rosen, H., and Lidz, T.: Emotional factors in the precipitation of recurrent diabetic acidosis. Psychosom. Med. 11: 211-222, 1949. 16 Benedek, T.: An approach to the study of the diabetic. Psychosom. Med. 10: 284-287, 1948. 17 Holmes, T. H., and Rahe, R. H.: The social readjustment rating scale. J. Psychosom. Res. 11: 213-218, 1967. 18 Holmes, T. H., and Masuda, M.: Life Change and Illness Susceptibility. In Dohrenwend, B. S., and Dohrenwend, B. P., Eds. Stressful Life Events. New York, John Wiley &. Sons, 1974, pp. 45-72. 19 Dohrenwend, B. S., and Dohrenwend, B. P. (Eds.): Stressful Life Events. New York, John Wiley & Sons, 1974. 20 Mirsky, I. A . : Emotional factors in t h e patient with diabetes mellitus. Bull. Menninger Clin. 12: 1 8 7 - 1 9 4 , 1948. 21 Palmer, R. W . : T h e diabetic personality. J. Indiana State Med. Assoc. 51: 1 3 9 9 - 1 4 0 0 , 1958. 22 Swift, C. R., Seidman, F. L., and Stein, H . : Adjustment problems in juvenile diabetes. Psychosom. Med. 29: 5 5 5 - 5 7 1 , 1967. 23 Sterky, G . : Family background and t h e state of mental health in a group of diabetic schoolchildren. Acta Pediatr. 52: 277— 390, 1963. 24 Simonds, J. F.: Psychiatric status of diabetic youth matched with a control group. Diabetes 26: 9 2 1 - 9 2 5 , 1977. 25 Simonds, J. F.: Psychiatric status of diabetic youth in good and poor control. Int. J. Psych. Med. 7: 1 3 3 - 1 5 1 , 1 9 7 6 - 7 7 .
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26
Olatawara, M. O.: The psychiatric complications of diabetes mellitus in children. Afr. J. Med. Sci. 3: 231-240, 1972. 27 Swift, C. R., and Seidman, F. L.: Adjustment problems of juvenile diabetes. J. Acad. Child Psychiatr. 3: 500-515, 1964. 28 Murawski, B. J., C h a z a n , B. I., Balodimos, M . C , a n d Ryan, J. R.: Personality patterns in patients with diabetes mellitus of long duration. Diabetes 19: 259-263, 1970. 29 Karp, S. A., Winters, S., and Pollack, I. W.: Field dependence among diabetics. Arch. Gen. Psychiatr. 21: 72-76, 1969. 30 Witkin, H. A., Dyk, R. B., Faterson, H. F., Goodenough, D. R., and Karp, S. A.: Psychological Differentiation, New York, John Wiley & Sons, 1962. 31 Sullivan, B.: Self-esteem and depression in adolescent diabetic girls. Diabetes Care I: 18-22, 1978. 32 Coopersmith, S.: A n t e c e d e n t s of Self-esteem. S a n Francisco, W . H . Freeman, 1967. 33 Loevinger, J., a n d Wessler, R . : Measuring Ego D e v e l o p m e n t , Vol. 1. S a n Francisco, Jossey-Bass, 1970. 34 Hoppe, C : Ego Development and Conformity Behavior. Doctoral dissertation, Washington University, St. Louis, 1972. 35 Redmore, C , and Waldman, K.: Reliability of a sentence completion measure of ego development. J. Pers. Assessment 39: 236-243, 1975. 36 Sullivan, E. V . , McCullough, G . , and Stager, M. C : A developmental study of the relationship between conceptual, ego, and moral development. Child Dev. 41: 3 9 9 - 4 1 1 , 1970. 37 Stierlin, H . : Separating parents and adolescents. New York, Quadrangle, 1974. 38 Koski, M. L.: T h e coping processes in childhood diabetes. Acta Pediatr. Scand. Suppl. 19: 1 - 5 6 , 1969. 39 Koski, M. L., Ahlas, A . , and Kumento, A . : A psychosomatic follow-up of childhood diabetics. Acta Paedopsychiatr. 42: 1 2 - 2 6 , 1976. 40 Wishner, W. J., and O'Brien, M. D.: Diabetes and the family. Med. Clin. N . Am. 62: 8 4 9 - 8 5 6 , 1978. 41 Minuchin, D., Baker, L., Rosman, B., Liebman, R., Milman, L., and Todd, T.: A conceptual model of psychosomatic illness in children: family organization and family therapy. Arch. Gen. Psychiatr. 32: 1031-1038, 1975. 42
Segal, J.: Psychosomatic Diabetic Children and Their Families. Mental Health Studies and Reports Branch, N I M H , 1977.
DIABETES CARE. VOL. 2 NO. 2, MARCH-APRIL 1979
sychological Aspects of Diabetes Mellitus: A Critical Review STUART T. HAUSER AND DANIEL POLLETS
I
n recent years, there have been an increasing number of studies concerning psychological aspects of diabetes mellitus. Four important topics are raised in these varied studies: (1) the role of psychological factors in the onset of diabetes; (2) the influence of the immediate environment upon the course of the disease; (3) the immediate response and long-term psychological adjustment of the diabetic individual after the onset; and (4) the family: the reaction of the family to the illness and the impact of diabetes upon the family structure. Since this is so complex and broad an area, we will review each of these topics by looking at the specific studies. In this review, we will focus on specific issues that concern research designs and conflicting findings. Our own interests have been in the impact of diabetes upon both individual development and the family. We have uncovered some interesting developmental patterns from our pilot studies.1 We will also indicate our own approach, and some of these initial findings.
PSYCHOLOGICAL PREC1PITANTS OF DIABETES
Most of the early studies that reported evidence connecting emotional factors to the onset of diabetes have been clinical case studies in which the clinicians observed precipitation of the disease following sudden stressful environmental occurrences,2 or varying patterns of association between diabetes and psychiatric illness.3'4 In two related papers, Menninger5'6 concluded that, ". . . diabetes may be the direct result of psychological disturbances."5 Reviewing 22 cases of psychiatric illness associated with diabetes, Menninger found four patients in whom a psychosis either preceded or developed simultaneously with the onset of diabetes. 5 More recently, Slawson and co-workers7 evaluated 25 newly diagnosed adult diabetic patients psychiatrically and found that 14 of the patients gave a history of recent object loss; in addition, many of the patients presented pat-
terns of unresolved grief and emotional deprivation. They suggest that adult-onset diabetic patients may be particularly prone to specific stress. Two empirical studies by Stein and Charles 8 ' 9 also focus on the role psychological factors may play in the etiology of diabetes. They conceptualize diabetes as a disease of disordered physiologic and psychological adaptation. They then raise the question of whether a preexisting state of physiologic disturbance might be present in the patient before the symptomology became manifest due to physiologic change and/or psychologic stress. In their first study, Stein and Charles8 compared 38 diabetic patients with 38 matched, nondiabetic subjects in terms of separations, divorce, and family disturbance. The control group consisted of patients suffering other chronic diseases (sickle cell anemia, other blood diseases). The authors found that the diabetic patients as predicted, had a significantly higher incidence of parental loss and severe family disturbance than the control group. Tietz and Vidmar10 also described patterns of disturbance in diabetic families. The conclusions of these studies are problematic given their research design. The sample sizes were small, and the data relied upon consisted only of clinical observations. On the whole, then, the results of a number of studies have not clearly shown that psychic stress, or psychopathology, are etiologic factors in the onset of diabetes. In addition, large scale epidemiologic surveys have failed to find significant correlations between onset and emotional stress.11 Besides the dearth of empirical support, there are conceptual difficulties in this area as well. At this point, we do not have a developed theoretical model that formulates the relationships between psychological processes and the appearance of diabetes. The general concept of a "prediabetic state" 12 which is transformed to diabetes by environmental stress situations8 does not detail the specific mechanisms that might link stressful events and the onset of the diabetic syndrome.
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PSYCHOSOCIAL ENVIRONMENT AND THE COURSE OF DIABETES
A number of studies have investigated relationships between psychological stress and fluctuations in the course of diabetes. The findings suggest that events generating anxiety, specific intrapsychic conflicts, emotional deprivations, conscious and unconscious threats to security, and actual unpleasant psychologic experience might upset diabetic control.13 Hinkle and Wolf14 present evidence supporting the notion that stressful life situations, either consciously or unconsciously interpreted by the diabetic patient as having relevance to his security, produce fluctuations in the level of ketone bodies and glucose in the venous blood as well as in the amount of urine excreted. In the 50 diabetic patients studied, they found that, in nearly all cases, the onset of the biochemical shifts occurred after a period of environmental and interpersonal stress characterized by a loss of significant persons, objects, relationships, or cultural values regarded by the patient as indispensable to his security. In general, these earlier studies are difficult to compare, since many are clinical case reports15'16 and were conducted at a time when there were no reliable techniques for assessing the impact of life experience on individuals. A recent approach to this complex problem has been through Holmes and Rahe's "Schedule of Life Events."17 Their instrument weighs recent life events in terms of their relative impact on the individual's life, and the amounts of readjustment needed to respond to such events.17 Such an instrument allows comparisons to be made across patients rather than being restricted, as in the earlier studies, to the unique conflicts of each case. Using life-stress assessment, Grant and colleagues13 recently reported empirical evidence of a relationship between undesirable life events and changes in diabetic condition. In this study, 37 private clinic patients were interviewed on five different office visits over a period of 8-18 months. At each visit, the patients were given a physical examination and a global physical condition rating. Patients also filled out the "schedule of life events." The findings revealed a positive correlation between undesirable life events and the course of the diabetes. Holmes and Masuda,18 working with the schedule of life events, emphasize that it is not simply a specific traumatic event that can affect the disease course or lead to its onset. More likely, it may be the cumulative "life crisis units" that will be associated with clinical deterioration. Kimball,11 in his review of this material, describes a situation in which the individual is repeatedly forced to deal with stressful events, eventually diminishing his ability for readjustment, adaptation, and homeostasis. Such an impaired adaptive capacity may in turn lead to feelings of helplessness or depression, which have physiologic concomitants. The lifestress research is a promising approach and may open up the possibility of studying stress events in larger samples that 228
vary by age, social class, and control of diabetes. Another possible direction to pursue in this research would be to investigate diabetic patients' individual differences in susceptability to stress and determine how these individual differences might influence shifts in the course of diabetes. Despite the fact that such systematic stress research is in its earliest stages, the preliminary results begin to systematically document the frequent anecdotal observation that the patient's psychological states may be closely linked with the course of his diabetes. In summary, the published empirical research in this area certainly supports the view that psychological factors, and the surrounding social-emotional context, need to be considered in understanding fluctuations that occur in diabetic control. Specifics such as which are key aspects of the environment, and what are the relevant personality dimensions remain unclear. Such important questions will likely be resolved through further empirical and conceptual work in stress research.19 RESPONSE AND PSYCHOLOGICAL ADJUSTMENT OF THE INDIVIDUAL
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he largest number of studies by far have approached the topic of "psychological aspects of diabetes" from this perspective. Two themes are especially salient in this literature: (1) the question of whether there is "more" or unique psychopathology associated with diabetes mellitus; and (2) the concern with how those diabetic patients who are in "good control" differ from those whose control is labile or "poor." Both themes are often intertwined in the discussions. Benedek,16 in an early paper, observed the traumatic effect of the diagnosis of diabetes on patients, an effect which she viewed as deeper than Jthe anxiety induced by other chronic diseases. The diabetic patient may develop a habit of dealing with every external and internal situation in terms of food and his diabetes. Benedek speculated that the processes secondary to the diabetes may become a part of the personality so that we can speak of a "superstructure" of the diabetic individual. Individual differences in adaptation to diabetes may then depend upon the nature of this superstructure as well as premorbid personality structures. In our research interviews with diabetic adolescents,1 we have often been struck by their preoccupation with, or pervasive awareness, of their diabetes, accompanied by a general sadness. This is a clinical picture reminiscent of the diabetic patients Mirsky20 described. He noted their hurt pride and their intensified fears and feelings of inadequacy. Still another pertinent point about the individual diabetic patient has to do with his or her uniqueness. Palmer21 emphasized the disturbing specialness, noting that the diabetic patient is "faced with interminable diet restriction, which virtually eliminates many highly gratifying foods." In addi-
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tion, there is no other disease that requires daily selfadministration of medication with a hypodermic syringe with the threat of disaster if this practice is not observed. Daily urine testing may further emphasize the nearness of disaster, as the patient faces evidence of deviations from strict control. Finally, patients are usually aware of the later complications: blindness, and heart and kidney disease. These facets of the impact of diabetes on the individual have been touched on many times in our own interviews and clinical observations. We would expect that these unique and powerful features of insulin-dependent diabetes would influence the psychological development and adaptation of diabetic children and adults. Therefore, it is especially curious that studies in this realm have generated conflicting and unclear findings. There are a number of studies that indicate significant psychic disturbance in diabetic patients. Swift and coworkers22 followed 50 juvenile diabetic patients and 50 individually matched nondiabetic controls together with their families. Their data included a basic diagnostic test battery and a clinical interview that was later coded for specific psychiatric problems. The diabetic patients were also rated for "level of diabetic control." Results were consistent with an earlier study and showed the diabetic child to exhibit more psychopathology than the nondiabetic controls. The diabetic children were described as more dependent, having less adequate self-images, greater levels of anxiety (manifest and latent), more pathologic sexual identifications, greater constriction, more pathologic hostility, and greater oral preoccupation. Level of pathology was compared to duration of diabetes and the quality of diabetic control. They found that duration of diabetes was most strongly associated with control: the longer the duration, the worse the control. The psychiatric classification and self-perception were also associated with control. Control was more disturbed in the more abnormal patients. Swift and colleagues attribute these results to the effects of chronic illness, which strain the "emotional and self-evaluative characteristics" of the diabetic adolescent.22 At odds with the picture of various degrees of diabetic psychopathology portrayed in the clinical and empirical studies are the findings presented in several recent papers.23"26 These authors report essentially no difference between diagnosis or individual symptoms. Simonds,24 for example, compared 40 diabetic youths in good control, 40 diabetic youths in poor control, and a matched, nondiabetic control group selected from a family practice clinic. Information regarding psychiatric difficulties was collected through interviews in patient's homes. The interviewer was blind to the level of control of the diabetic patients but knew who were the diabetic patients and who were the normal controls. These interviews were then rated for "psychiatric diagnosis," "interpersonal conflict," and "no interpersonal conflict." The results revealed that there were no differences between the
diabetic patients and the normal controls. This negative finding was repeated in the evaluation of the parents. Still another surprising pattern was that the "well controlled" diabetic group seemed to be in better mental health than the nondiabetic group. The "poor controlled" group, however, had significantly more dependency conflicts and more anxiety and depression than the control group. This trend was interpreted by Simonds as being caused by the worsening of the control. A second study that found no differences in psychiatric symptomology between diabetic children and normal controls was carried out by Olatawara,26 who compared 50 diabetic children and 50 matched controls. Olatawara used a semistructured behavior inventory, which was administered in the home of the subject. The diabetic and nondiabetic children could be distinguished from each other on only two items: sleep disturbance and stealing—the control group being more disturbed than the diabetic group. In order to grasp these contradictory findings, it is important to first realize that there are major differences between Swift's22"27 methods and those of Simonds24 and Olatawara.26 In the work of Swift and colleagues, the data was based on psychiatric interviews and psychological tests. Simonds and Olatawara, in contrast, draw their data from behavioral inventories and individual classifications made by the authors. Given these differences, it is no surprise that the results are conflicting. Besides the methodological problems (i.e. lack of inter-rater reliability, experimenter bias) there is a major conceptual one: it is likely that gross psychiatric categories (i.e. "problem with anxiety," "interpersonal conflict"24) are not sensitive enough to distinguish the subtle ways diabetes may influence specific aspects of psychological functioning and development. There are, however, a number of recent empirical studies that follow more discrete psychological processes such as mood, interpersonal orientations, attitudes, perceptual style, and ego development. Murawski and colleagues28 administered the Minnesota Multiphasic Personality Inventory (MMPI) to 112 adult patients who had had diabetes for 25-48 yr. The items that make up this test were selected empirically because of their ability to differentiate a normal population from clinically diagnosed psychopathologic groups. His sample was subdivided into one group made up of patients who had been free of vascular complications. The patients were given the MMPI while awaiting physical examination. Analyses of the test data revealed a high depression score for the entire sample. Clinically, these patients were not withdrawn from social contact; they continued to seek out and enjoy people. However, they expressed pervasive feelings of pessimism, hopelessness, and depression in their test responses. A second finding was a significant sex difference. The men who developed vascular complications had higher psychopathology scores on all but one scale when compared with the male complication-
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free group; and in general, their scores were more pathologic than the female complication-free patients. Murawski interprets this pattern as one that indicates that men without complications "tended to acknowledge less vitality and less impulsiveness" than the men with clear complications and "were perhaps more accepting of their physical •disability." This sex difference—of more psychic difficulty for men—also appears in our findings.1
A
second personality study used a perceptual measure, that of field dependence-independence.29 Using Witkin's field dependence test, Karp found significantly more field dependence in a group of 80 male and female diabetic adults than in a matched control group. Evidence from a number of other studies indicates that individuals high in field dependence also tend to be more socially dependent and have less distinct body boundaries.30 Additional findings were that women had higher field dependent scores than men, and diabetic clinic patients had higher field dependent scores than private patients. This latter finding, that patients attending a diabetes clinic were significantly more field dependent than their counterparts who were seeing a private physician, is of clinical relevance. Since there were no social class differences between the groups, there is the implication here that psychologically different patients may attend clinics as opposed to private practice offices. Karp suggests that the clinic milieu may provide greater support for a patient who is socially dependent and who requires external sources to gain such support.29 Sullivan31 followed self-esteem and depression in diabetic adolescents using previously constructed assessment techniques. Her results parallel Murawski's observation of depression in diabetic patients.28 In addition to higher depression scores, she observed that the diabetic group had significantly lower self-esteem levels than a nondiabetic comparison group. In our own studies,1 we followed what appear to be two important personality dimensions: ego development and selfesteem. A number of reports and clinical observations have noted the disruption in individual development that frequently accompanies the onset of diabetes.11 Besides interrupting maturation, the course of the diabetes may be importantly influenced by the level of development that the patient has reached at the time of diagnosis. We also followed the dimension of self-esteem. Here again, clinical observers have described the low self-esteem of many diabetic patients,11'22 a pattern that also appears in the empirical studies by Murawski et al.28'and Sullivan.31 Using two systematic instruments, Coopersmith's selfesteem inventory32 and Loevinger's ego development test,33 we followed the ego development and self-esteem of 164 diabetic adolescents, drawn primarily from diabetes summer camps. The adolescents were between 11 and 19 yr of age,
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with an average age of 13. We also conducted clinical interviews with 10 of the patients after they had taken the self-esteem and ego development tests. Since this was a pilot study, we did not employ control groups. However, we located comparison samples of nondiabetic adolescents34"36 and a control group from other current pilot studies. When contrasted with the comparison groups, the diabetic adolescents were at lower levels of ego development, and, in addition, showed a narrower range of stages present. This distribution of stages was not associated with duration of diabetes. There were no significant correlations between duration and ego development level. A second ego development result was unexpected. Among the diabetic subjects we found significant sex differences in ego development levels. Girls were at higher ego development stages than boys at all ages, regardless of duration of diabetes. This is an important result, since it is at variance with the absence of sex differences in ego development studies of many hundreds of nondiabetic subjects of all ages.33 The finding is reminiscent of Murawski's28 observation of greater psychiatric impairment for male diabetic patients. As a group, we found that the diabetic patients showed slightly higher levels of self-esteem than comparable, sameaged subjects. However, when we looked more closely within the group of diabetic patients, we found that self-esteem was significantly associated with.duration. The longer the duration of the diabetes, the more likely it was for a patient to have lower self-esteem. The diabetic adolescents, then, were clearly at lower stages of ego development than other comparable adolescents. This pattern, suggestive of an arrest in ego development, was more dramatic in the male subjects. We also found self-esteem to be more impaired in diabetic adolescents who were at lower levels of ego development and/or had a longer duration of diabetes. The test protocols revealed that these patients at the lower levels of ego development were more preoccupied with separation and loss than those patients at higher ego development levels. Our study was originally planned to be a pilot project for a much larger, more comprehensive project. It generated, however, much more data and findings than we had anticipated and suggests at least two future research directions. One possibility involves longitudinal investigations. Since ours was a cross-sectional study, we do not know if the low ego development levels were the result of a transient interruption in development or of a more sustained arrest or fixation in maturation. In order to resolve this question, and the related question concerning the stability of the low self-esteem, we need to follow such patients over several years of development. In addition, we do not know what impact these patients have had upon their families and how families have influenced individual development. Several of the patients gave intriguing, elabo-
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rate descriptions of their interactions with their families, often around aspects of diabetes. There are a number of studies that suggest that the family represents an important developmental environment of the adolescent patient.37
these were families in which there was an inability or unwillingness to resolve conflicts. Even the brief excursion
into the recent family research of Minuchin makes it clear how different the data about families is when it is collected and analyzed through such direct observations and interaction analyses.
DIABETES AND THE FAMILY
This brings us to the fourth psychological aspect of diabetes: the family. This is the sparest of the four literatures. While pediatricians and internists have long been aware of the importance of family influence, there have been few systematic studies of families with diabetic members. Several investigations of diabetic patients have also included interviews with family members. Koski38 interviewed the parents of 60 diabetic children. She described their initial reaction to the illness of their child as characterized by bewilderment, anxiety, fears, and depressive feelings. The parents of children in poor diabetic control were characterized as showing "nonconstructive external coping processes," mainly helplessness and poor cooperation in the daily care of the diabetic child. These parents handled their feelings of anxiety and depression through chronic underlying pathologic forms such as omnipotent thinking, denial, and phobias. In contrast, Koski found the parents of the children who were in good control to be adequately working through their feelings of anxiety, loss, and depression. Five years after the original research, Koski began a follow-up study of the same 60 diabetic children.39 Using data from the psychiatric interviews with the children, she categorized the families in terms of their overall functioning. Eighteen of the 23 families where the child's control was good or fair belonged to the healthy, well functioning family type. The families of the children in poor control were categorized as chaotic, with internal cliques and severe conflicts. Unfortunately, there was no discussion of how parental coping mechanisms correlated with constancy or change in the quality of diabetic control. Other family studies also rely on clinical impressions usually gathered from individual interviews with patients and occasionally other family members, including parents.10'40 The only group to use the approach of direct family observation is that of Minuchen.41'42 Using a series of family tasks, they compared the interactions of families of labile juvenile diabetic patients (multiple recurrent bouts of ketoacidosis) with two other groups of diabetic families—one made up of children showing behavior disorders, the other with no psychological difficulties. A number of unique elements were found in the families of the "brittle" diabetics. The children appeared to be intensely enmeshed in their families' current conflicts; family members demonstrated a high degree of overprotectiveness and concern for each other's welfare; and the family itself was marked by extreme rigidity, committed to maintaining the family status quo. Consistent with these other features,
DISCUSSION
I
n this critical review we have included all systematic empirical studies, and a number of clinical approaches, to psychological facets of diabetes mellitus. Our emphases have been twofold: (1) to review methodological dimensions, which are important influences upon the findings and clinical implications of these studies; and (2) to explore clinical implications and relevance of findings where possible. Our most salient conclusion concerns the need for more carefully designed, conceptually based, systematic empirical research in all four of the psychological aspects of diabetes mellitus. More specifically, the areas of development and family functioning appear to be particularly interesting and potentially fruitful ones for future research efforts. The recent emergence of new measurement techniques and the interest in family interaction studies are encouraging signs, which may signal the beginnings of clinical research into this complex and important interface between diabetes and psychosocial processes.
ACKNOWLEDGMENTS: Important assistance in completing this review was provided by Mr. Kirk Daffner and Ms. Barbara Turner. This review was supported in part by NIMH Research Scientist Development Award 5-KO2-MH-7O178 to S. T. Hauser. REFERENCES 1 Hauser, S. T., Pollets, D., and Turner, B.: Ego development and self-esteem in diabetic adolescents. Submitted for publication. 2 Daniels, G. E.: Present trends in the evaluation of psychic factors in diabetes mellitus. Psychosom. Med. I: 527-552, 1939. 3 Pike, H. V.: Significance of diabetes mellitus in mental disorder. J.A.M.A. 76: 1571-1572, 1921. 4 Neilson, C. H.: Emotional and psychic factors in disease. J.A.M.A. 89: 1020-1023, 1927. 5 Menninger, W. C.: Psychological factors in the etiology of diabetes. J. Nervous Mental Disease 81: 1-13, 1935. b Menninger, W. C : The interrelationships of mental disorders and diabetes mellitus. J. Mental Sci. 81: 332-357, 1935. 7 Slawson, F. P., Flynn, W. R., and Kollar, E. J.: Psychological factors associated with the onset of diabetes mellitus. J.A.M.A. 185: 166-170, 1963. 8 Stein, S. P., and Charles, E. S.: Emotional factors in juvenile diabetes mellitus: a study of early life experience of adolescent diabetes. Am. J. Psychol. 128: 700-704, 1971. 9 Stein, S. P., and Charles, E. S.: Emotional factors in
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juvenile diabetes mellitus: a study of early life experience of eight diabetic children. Psychosom. Med. 37: 237-244, 1975. 10 Tietz, W., and Vidmar, J. T.: The impact of coping styles on the control of juvenile diabetes. Psychiatr. Med. 3: 67-74, 1972. 11 Kimball, C. P.: Emotional and psychosocial aspects of diabetes mellitus. Med. Clin. N. Am. 55: 1007-1018, 1971. 12 Conn, J. W., and Fajans, S. S.: The pre-diabetic state. A concept of dynamic resistance to a genetic diabetogenic influence. Am. J. Med. 31: 839-850, 1961. 13 Grant, I., Kyle, G. C., Teichman, A., and Mendels, J.: Recent life events and diabetes in adults. Psychosom. Med. 36: 121-128, 1974. 14 Hinkle, L. E., Jr., and Wolf, S.: Importance of life stress in course and management of diabetes mellitus. J. A. M. A. 148: 513-520, 1952. 15 Rosen, H., and Lidz, T.: Emotional factors in the precipitation of recurrent diabetic acidosis. Psychosom. Med. 11: 211-222, 1949. 16 Benedek, T.: An approach to the study of the diabetic. Psychosom. Med. 10: 284-287, 1948. 17 Holmes, T. H., and Rahe, R. H.: The social readjustment rating scale. J. Psychosom. Res. 11: 213-218, 1967. 18 Holmes, T. H., and Masuda, M.: Life Change and Illness Susceptibility. In Dohrenwend, B. S., and Dohrenwend, B. P., Eds. Stressful Life Events. New York, John Wiley &. Sons, 1974, pp. 45-72. 19 Dohrenwend, B. S., and Dohrenwend, B. P. (Eds.): Stressful Life Events. New York, John Wiley & Sons, 1974. 20 Mirsky, I. A . : Emotional factors in t h e patient with diabetes mellitus. Bull. Menninger Clin. 12: 1 8 7 - 1 9 4 , 1948. 21 Palmer, R. W . : T h e diabetic personality. J. Indiana State Med. Assoc. 51: 1 3 9 9 - 1 4 0 0 , 1958. 22 Swift, C. R., Seidman, F. L., and Stein, H . : Adjustment problems in juvenile diabetes. Psychosom. Med. 29: 5 5 5 - 5 7 1 , 1967. 23 Sterky, G . : Family background and t h e state of mental health in a group of diabetic schoolchildren. Acta Pediatr. 52: 277— 390, 1963. 24 Simonds, J. F.: Psychiatric status of diabetic youth matched with a control group. Diabetes 26: 9 2 1 - 9 2 5 , 1977. 25 Simonds, J. F.: Psychiatric status of diabetic youth in good and poor control. Int. J. Psych. Med. 7: 1 3 3 - 1 5 1 , 1 9 7 6 - 7 7 .
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Olatawara, M. O.: The psychiatric complications of diabetes mellitus in children. Afr. J. Med. Sci. 3: 231-240, 1972. 27 Swift, C. R., and Seidman, F. L.: Adjustment problems of juvenile diabetes. J. Acad. Child Psychiatr. 3: 500-515, 1964. 28 Murawski, B. J., C h a z a n , B. I., Balodimos, M . C , a n d Ryan, J. R.: Personality patterns in patients with diabetes mellitus of long duration. Diabetes 19: 259-263, 1970. 29 Karp, S. A., Winters, S., and Pollack, I. W.: Field dependence among diabetics. Arch. Gen. Psychiatr. 21: 72-76, 1969. 30 Witkin, H. A., Dyk, R. B., Faterson, H. F., Goodenough, D. R., and Karp, S. A.: Psychological Differentiation, New York, John Wiley & Sons, 1962. 31 Sullivan, B.: Self-esteem and depression in adolescent diabetic girls. Diabetes Care I: 18-22, 1978. 32 Coopersmith, S.: A n t e c e d e n t s of Self-esteem. S a n Francisco, W . H . Freeman, 1967. 33 Loevinger, J., a n d Wessler, R . : Measuring Ego D e v e l o p m e n t , Vol. 1. S a n Francisco, Jossey-Bass, 1970. 34 Hoppe, C : Ego Development and Conformity Behavior. Doctoral dissertation, Washington University, St. Louis, 1972. 35 Redmore, C , and Waldman, K.: Reliability of a sentence completion measure of ego development. J. Pers. Assessment 39: 236-243, 1975. 36 Sullivan, E. V . , McCullough, G . , and Stager, M. C : A developmental study of the relationship between conceptual, ego, and moral development. Child Dev. 41: 3 9 9 - 4 1 1 , 1970. 37 Stierlin, H . : Separating parents and adolescents. New York, Quadrangle, 1974. 38 Koski, M. L.: T h e coping processes in childhood diabetes. Acta Pediatr. Scand. Suppl. 19: 1 - 5 6 , 1969. 39 Koski, M. L., Ahlas, A . , and Kumento, A . : A psychosomatic follow-up of childhood diabetics. Acta Paedopsychiatr. 42: 1 2 - 2 6 , 1976. 40 Wishner, W. J., and O'Brien, M. D.: Diabetes and the family. Med. Clin. N . Am. 62: 8 4 9 - 8 5 6 , 1978. 41 Minuchin, D., Baker, L., Rosman, B., Liebman, R., Milman, L., and Todd, T.: A conceptual model of psychosomatic illness in children: family organization and family therapy. Arch. Gen. Psychiatr. 32: 1031-1038, 1975. 42
Segal, J.: Psychosomatic Diabetic Children and Their Families. Mental Health Studies and Reports Branch, N I M H , 1977.
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