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'Dismissing' style predicts poor diabetes control. (Attachment Style Linked to Noncompliance).

WASHINGTON -- Diabetes patients with a "dismissing" attachment style have much poorer glucose control than do those with the other three adult attachment styles, Dr. Paul Ciechanowski reported at an international conference sponsored by the National Institute of Mental Health.

These patients appear to be disengaged from their physicians and the treatment those physicians recommend. They don't adhere well to their medication regimens or to glucose monitoring procedures, said Dr. Ciechanowski of the department of psychiatry and behavioral sciences at the University of Washington, Seattle.

Adult attachment theory holds that the quality of early caregiving influences how people perceive and engage in interpersonal relationships throughout their lives.

People with a dismissing attachment style--about 25% of the general population--develop a pervasive need for independence and self-sufficiency because of unresponsive or even neglectful caregiving in childhood. They become compulsively self-reliant, are uncomfortable being close to or trusting others, and appear unaware that everyone needs other people.

Noting that this behavior would obstruct the collaborative working relationship crucial between people with chronic illness and their physicians, Dr. Ciechanowski and his associates hypothesized that diabetes patients with a dismissive attachment style would have poorer control of their disease than those with the other three categories of attachment in adults: secure attachment, which accounts for about half of the general population; and preoccupied attachment and fearful attachment, which together account for the remaining 25%.

It is likely that a similar proportion of people with other chronic diseases are also affected by a dismissing attachment style. Their defensive self-reliance could likewise obstruct collaborative relationships with their physicians and thus interfere with treatment adherence, he noted in an interview at the meeting.

The researchers studied 276 subjects with type 1 diabetes who received their medical care at two HMO clinics staffed by family physicians. The subjects completed two questionnaires that determined their attachment style, another on their perception of the quality of communication with their physician, one that checked for depression and other psychiatric symptoms, one that measured the severity of their diabetes, and two that assessed their knowledge about and their self-management of the disease.

A medical database provided information on the subjects' hemoglobin [A.sub.1c] ([HbA.sub.1c]) levels and their use of oral hypoglycemic agents.

As in the general population, 25% of these subjects were found to have a dismissing attachment style. They had significantly higher [HbA.sub.1c] levels, poorer adherence to glucose monitoring, and more interruptions in oral hypoglycemic therapy than the other subjects.

A total of 62% of the subjects with dismissing attachment had [HbA.sub.1c] levels of 8% or higher, compared with only one-third of those with secure attachment. Even a 1% difference in this hemoglobin level translates into a nearly 60% increase in the development of diabetic retinopathy over a 10-year period, the investigator noted.

Once clinicians understand the source of such patients' noncompliance with diabetes management, they can feel more empathic toward them and less frustrated in providing their care. Clinicians can diminish the interpersonal threat of intimate clinical settings "by taking on a 'businesslike' but patient-centered interactive style, or by having a small number of providers, rather than a single clinician, alternately providing coordinated care," he suggested.

Since patients with the dismissing attachment style also tend to put off, cancel, or skip appointments, they would benefit from regular telephone contact "to ensure continuity in the clinical relationship while maintaining a less interpersonally threatening clinical context," he said.
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Author:Moon, Mary Ann
Publication:Clinical Psychiatry News
Geographic Code:1USA
Date:Jun 1, 2002
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