Medically Unexplained Physical Symptoms: What They Are and Why Counseling Psychologists Should Care about Them

Medically unexplained symptoms and syndromes (MUS) affect the health of 20%-30% of patients seen in primary care. Optimally, treatment for these patients requires an interdisciplinary team consisting of both primary care and mental health providers. By developing an expertise in MUS, counseling psychologists can improve the care of patients with MUS who are already in their practice, expand the number of patients they help, and enhance the integration of counseling psychology into the broader medical community. Additionally, counseling psychologists' expertise in culture, attunement to therapeutic processes, and our focus on prioritizing patients' perspectives and quality of life can fill the gap in research on MUS and bringing increased attention to counseling psychologists' unique contributions to health service delivery.

Cultural incongruity predicts adjustment to college for student veterans

Little is known about what predicts student service members' and veterans' (SSM/V) adjustment to college. In qualitative research, SSM/V report feeling they do not belong and are misunderstood by college communities, a phenomenon that counseling psychologists call cultural incongruity. The goal of the current study was to quantitatively examine the relationship between cultural incongruity and adjustment to college. We surveyed 814 SSM/V about their adjustment to college using the Student Adaptation to College Questionnaire. Cultural incongruity was operationalized in two ways: feelings of not belonging were measured via direct report and the association with adjustment to college assessed with regression. Feelings of being misunderstood about academic barriers were assessed by comparing SSM/V's perceptions of academic barriers and SSM/V's perceptions of how others view the SSM/V's academic barriers and the association with adjustment was assessed using polynomial regression and response surface analysis. Cultural incongruity predicted adjustment to college. After controlling for other known predictors, feelings of not belonging accounted for 18% of the variance in adjustment to college. Polynomial regression showed that feeling understood about academic barriers protected against the negative impact of the barrier on adjustment to college. Cultural incongruity predicts adjustment to college for SSM/V. Helping SSM/V feel their unique barriers to college adjustment are understood may blunt the impact of these barriers. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Mutual maintenance of PTSD and physical symptoms for Veterans returning from deployment

Background: The mutual maintenance model proposes that post-traumatic stress disorder (PTSD) symptoms and chronic physical symptoms have a bi-directional temporal relationship. Despite widespread support for this model, there are relatively few empirical tests of the model and these have primarily examined patients with a traumatic physical injury. Objective: To extend the assessment of this model, we examined the temporal relationship between PTSD and physical symptoms for military personnel deployed to combat (i.e., facing the risk of death) who were not evacuated for traumatic injury. Methods: The current study used a prospective, longitudinal design to understand the cross-lagged relationships between PTSD and physical symptoms before, immediately after, 3 months after, and 1 year after combat deployment. Results: The cross-lagged results showed physical symptoms at every time point were consistently related to greater PTSD symptoms at the subsequent time point. PTSD symptoms were related to subsequent physical symptoms, but only at one time-point with immediate post-deployment PTSD symptoms related to physical symptoms at three months after deployment. Conclusion: The findings extend prior work by providing evidence that PTSD and physical symptoms may be mutually maintaining even when there is not a severe traumatic physical injury.

Helpful ways providers can communicate about persistent medically unexplained physical symptoms

BACKGROUND

Communication between patients and providers about persistent "medically unexplained" physical symptoms (MUS) is characterized by discordance. While the difficulties are well documented, few studies have examined effective communication. We sought to determine what veterans with Gulf War Illness (GWI) perceive as the most helpful communication from their providers. Veterans with GWI, a type of MUS, have historically had complex relationships with medical providers. Determining effective communication for patients with particularly complex relationships may help identify the most critical communication elements for all patients with MUS.

METHODS

Two hundred and-ten veterans with GWI were asked, in a written questionnaire, what was the most useful thing a medical provider had told them about their GWI. Responses were coded into three categories with 10 codes.

RESULTS

The most prevalent helpful communication reported by patients was when the provider offered acknowledgement and validation (N = 70). Specific recommendations for managing GWI or its symptoms (N = 48) were also commonly reported to be helpful. In contrast, about a third of the responses indicated that nothing about the communication was helpful (N = 63). There were not differences in severity of symptoms, disability or healthcare utilization between patients who found acknowledgement and validation, specific recommendations or nothing helpful.

CONCLUSIONS

Previous research has documented the discord between patients and providers regarding MUS. This study suggests that most patients are able to identify something helpful a provider has said, particularly acknowledgement and validation and specific treatment recommendations. The findings also highlight missed communication opportunities with a third of patients not finding anything helpful.

Using the common-sense model to understand health outcomes for medically unexplained symptoms: a meta-analysis

Consistent with the common-sense model of self-regulation, illness representations are considered the key to improving health outcomes for medically unexplained symptoms and illnesses (MUS). Which illness representations are related to outcomes and how they are related is not well understood. In response, we conducted a meta-analysis of the relationship between illness representations, self-management/coping, and health outcomes (perceived disease state, psychological distress, and quality of life) for patients with MUS. We reviewed 23 studies and found that threat-related illness representations and emotional representations were related to worse health outcomes and more negative coping (moderate to large effect). Generally, increases in negative coping mediated (with a moderate to large effect) the relationship of threat/emotional illness representations and health outcomes. Protective illness representations were related to better health outcomes, less use of negative coping and greater use of positive coping (small to moderate effect). The relationship of protective illness representations to better health outcomes was mediated by decreases in negative coping (moderate to large effect) and increases in positive coping (moderate effect). Perceiving a psychological cause to the MUS was related to more negative health outcomes (moderate to large effect) and more negative emotional coping (small effect). The relationship of perceiving a psychological cause and more negative health outcomes was mediated by increases in negative emotional coping. Improving our understanding of how illness representations impact health outcomes can inform efforts to improve treatments for MUS. Our results suggest behavioural treatments should focus on reducing threat-related illness representations and negative coping.

Longitudinal relationship between onset of physical symptoms and functional impairment

Patients with chronic physical symptoms (e.g., chronic pain) often have significant functional impairment (i.e., disability). The fear avoidance model is the dominant theoretical model of how the relationship between chronic physical symptoms and functional impairment develops and proposes a cyclical/bidirectional relationship. There has never been a definitive test of the proposed bi-directional relationship. The current study followed 767 Operation Enduring Freedom/Operation Iraqi Freedom soldiers from pre-deployment, when they were relatively healthy, to 1 year after deployment, when it was anticipated that symptoms would increase or develop. Over the four assessment time points, physical symptom severity consistently predicted worse functional impairment at the subsequent time point. Functional impairment did not show a consistent relationship with worsening of physical symptom severity. These findings suggest that changes to functional impairment do not have a short-term impact on physical symptom severity.

Telephone-Based versus In-Person Delivery of Cognitive Behavioral Treatment for Veterans with Chronic Multisymptom Illness: A Controlled, Randomized Trial

BACKGROUND

The goal of this randomized clinical trial was to examine the efficacy of a cognitive behavioral stress reduction treatment for reducing disability among veterans with chronic multisymptom illness (CMI).

METHOD

Veterans (N=128) who endorsed symptoms of CMI were randomized to: usual care (n=43), in-person (n=42) or telephone-delivered cognitive behavioral stress management (n=43). Assessments were conducted at baseline, three months, and twelve months. The primary outcome was limitation in roles at work and home (i.e., 'role physical'). Reductions in catastrophizing cognitions were evaluated as a mechanism of action.

RESULTS

Intent-to-treat analyses showed no statistically significant main effect (F(2, 164)=.58, p=.56) or interaction effect (F(4,164)=.94, p=.45) for role physical. Over time, veterans improved in their physical function (F(2,170)=5.34, p<.01; ὴ² _partial=.06), PTSD symptoms (F(2,170)=9.39, p<.01; ὴ² _partial=.10), depressive symptoms (F(2,170)=10.81, p<.01, ὴ² _partial=.11), and physical symptoms (F(2, 172)=12.65, p<.01; ὴ² _partial=.13), but these improvements did not differ across study arms over time. Completer analyses yielded similar results. There were no differences in catastrophizing between arms.

CONCLUSION

Findings suggest stress reduction may not be the right target for improving disability among veterans with CMI. Veterans with CMI may need intervention that directly impacts medical self-management to improve disability.

Less Engagement in Pleasure Activities is associated with poorer quality of life for Veterans with Comorbid Post-Deployment Conditions

Objective

The presence of multiple comorbid conditions is common after combat deployment and complicates treatment. A potential treatment approach is to target shared mechanisms across conditions that maintain poorer health-related quality of life (HRQOL). One such mechanism may be decrements in pleasurable activities. Impairment in pleasurable activities frequently occurs after deployment and may be associated with poorer HRQOL.

Method

In this brief report, we surveyed 126 Veterans who had previously sought an assessment at a Veterans Affairs post-deployment health clinic and assessed pleasurable activities, HRQOL, and post-deployment health symptoms.

Results

Forty-three percent of Veterans met our criteria for all three post-deployment conditions (PTSD, depression and chronic wide-spread physical symptoms). Greater engagement in pleasurable activities was associated with better HRQOL for all Veterans regardless of type or level of post-deployment health symptoms.

Conclusion

Future research should study if interventions that encourage Veterans with post-deployment health conditions to engage in pleasurable activities are effective rehabilitation strategies.

The Common Sense of Counseling Psychology: Introducing the Common-Sense Model of Self-Regulation

The goal of therapy is typically to improve clients' self-management of their problems, not only during the course of therapy but also after therapy ends. Although it seems obvious that therapists are interested in improving client's self-management, the psychotherapy literature has little to say on the topic. This article introduces Leventhal's Common-Sense Model of Self-Regulation, a theoretical model of the self-management of health, and applies the model to the therapeutic process. The Common-Sense Model proposes that people develop illness representations of health threats and these illness representations guide self-management. The model has primarily been used to understand how people self-manage physical health problems, we propose it may also be useful to understand self-management of mental health problems. The Common-Sense Model's strengths-based perspective is a natural fit for the work of counseling psychologists. In particular, the model has important practical implications for addressing how clients understand mental health problems over the course of treatment and self-manage these problems during and after treatment.

High healthcare utilization near the onset of medically unexplained symptoms

OBJECTIVE

Patients with medically unexplained syndromes (MUS) often do not receive appropriate healthcare. A critical time for effective healthcare is the inception of MUS. The current study examined data from a prospective longitudinal study of Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) soldiers to understand the relationship of increasing physical symptom burden to healthcare utilization.

METHODS

Data was examined from a prospective study of OEF/OIF soldiers assessed before and one year after deployment (n=336). Physical symptom burden was measured with the Patient Health Questionnaire (PHQ-15). Analyses were conducted with polynomial regression and response surface analysis (RSA).

RESULTS

Increases in physical symptom burden predicted greater healthcare utilization one year after deployment: primary care practitioner (slope=-0.26, F=4.07, p=0.04), specialist (slope=-0.43, F=8.67, p=0.003), allied health therapy (e.g., physical therapy) (slope=-0.41, F=5.71, p=0.02) and mental health (slope=-0.32, F=4.04, p=0.05). There were no significant difference in utilization between those with consistently high levels and those with increases in physical symptom burden.

CONCLUSION

This is the first prospective study to examine, and show, a relationship between onset of clinically significant physical symptoms and greater healthcare utilization. Our data suggest that patients with increasing physical symptom burden have the same level of healthcare as patients with chronic physical symptom burden. Needed next steps are to better understand the quality of care at inception and determine how to intervene so that recommended approaches to care are provided from the onset.

Resilience during war: Better unit cohesion and reductions in avoidant coping are associated with better mental health function after combat deployment

OBJECTIVE

The majority of individuals who endure traumatic events are resilient; however, we do not yet understand why some individuals are more resilient than others. We used data from a prospective longitudinal study Army National Guard and Reserve personnel to examine how unit cohesion (military-specific social support) and avoidant coping relate to resilience over the first year after return from deployment.

METHOD

Soldiers (N = 767) were assessed at 4 phases: predeployment (P1), immediately postdeployment (P2), 3 months' postdeployment (P3), and 1-year postdeployment (P4).

RESULTS

After controlling for predeployment avoidant coping and overall social support, higher unit cohesion was associated with a reduction in avoidant coping (from P1 to P3). This reduction in avoidant coping (from P1 to P3) mediated the relationship between unit cohesion (P2) and improvement in mental health function (from P1 to P3).

CONCLUSIONS

The results are consistent with the hypothesis that higher unit cohesion may mitigate increases in avoidant coping in military personnel after a combat deployment and in turn may improve mental health function. (PsycINFO Database Record

Fibromyalgia syndrome care of Iraq- and Afghanistan-deployed Veterans in Veterans Health Administration

Little is known regarding fibromyalgia syndrome (FMS) care among Operation Iraqi Freedom/Operation Enduring Freedom/Operation New Dawn (OIF/OEF/OND) Veterans. Current recommendations include interdisciplinary, team-based combined care approaches and limited opioid use. In this study of OIF/OEF/OND Veterans who accessed Veterans Health Administration services between 2002 and 2012, we hypothesized that combined care (defined as at least 4 primary care visits/yr with visits to mental health and/or rheumatology) versus <4 primary care visits/yr only would be associated with lower risk of at least 2 opioid prescriptions 12 mo following an FMS diagnosis. Using generalized linear models with a log-link, the Poisson family, and robust standard errors, we estimated risk ratios (RRs) and 95% confidence intervals (CIs). We found that 1% of Veterans had at least 2 FMS diagnoses (International Classification of Diseases-9th Revision-Clinical Modification code 729.1) or at least 1 FMS diagnosis by rheumatology. Veterans with (vs without) FMS were more likely to be female, older, Hispanic, and never/currently married. Combined primary, mental health, and rheumatology care was associated with at least 2 opioid prescriptions (RR [95% CI] for males 2.2 [1.1-4.4] and females 2.8 [0.4-18.6]). Also, combined care was associated with at least 2 nonopioid pain-related prescriptions, a practice supported by evidence-based clinical practice guidelines. In tandem, these results provide mixed evidence of benefit of combined care for FMS. Future studies of healthcare encounter characteristics, care coordination, and benefits for Veterans with FMS are needed.

Iraq and Afghanistan Veterans report symptoms consistent with chronic multisymptom illness one year after deployment

Many Veterans returning from service in Operation Iraqi Freedom/Operation Enduring Freedom (OIF/OEF) experience chronic pain. What is not known is whether for some OIF/OEF Veterans this pain is part of a larger condition of diffuse multisystem symptoms consistent with chronic multisymptom illness (CMI). We use data from a prospective longitudinal study of OIF/OEF Veterans to determine the frequency of CMI. We found that 1 yr after deployment, 49.5% of OIF/OEF Veterans met criteria for mild to moderate CMI and 10.8% met criteria for severe CMI. Over 90% of Veterans with chronic pain met criteria for CMI. CMI was not completely accounted for either by posttraumatic stress disorder or by predeployment levels of physical symptoms. Veterans with symptoms consistent with CMI reported significantly worse physical health function than Veterans who did not report symptoms consistent with CMI. This study suggests that the presence of CMI should be considered in the evaluation of OIF/OEF Veterans. Further, it suggests the pain management for these Veterans may need to be tailored to take CMI into consideration.

Comparison of the functional health limitations of Iraq or Afghanistan Veterans to Desert Shield/Storm Veterans with chronic fatigue syndrome

Initial evidence suggests some Operation Enduring/Iraqi Freedom (OEF/OIF) veterans suffer from significant physical symptoms. It is not known if other medical conditions may explain these symptoms or if they are causing functional limitations. We compared OEF/OIF veterans with CFS to Desert Shield/Storm veterans with CFS seen at a post-deployment VA clinic soon after their respective deployments. We found 17.6% of OEF/OIF veterans met criteria for CFS. Compared to Desert Shield/Storm veterans with CFS, the OEF/OIF veterans with CFS demonstrated worse mental health function and similar physical health function.

Using the common sense model of self-regulation to understand the relationship between symptom reporting and trait negative affect

BACKGROUND/PURPOSE

Based on the Common Sense Model of Self-Regulation, we examined if the relationship of trait NA to physical symptom reporting was moderated by life events and illness representations.

METHODS

This relationship was examined using a cross-sectional dataset of 554 elderly adults.

RESULTS

A significant three-way interaction demonstrated that individuals who reported the greatest severity of physical symptoms were higher in trait NA, and reported more life events and a chronic illness history.

CONCLUSIONS

The results of this study are consistent with the hypothesis that individual high on trait NA who have a history of a chronic illness have illness representations with both disease specific physical symptoms and symptoms from other causes, such as emotional distress. This may complicate the care of medical conditions for these patients.

Chronic multisymptom illness among female Veterans deployed to Iraq and Afghanistan

BACKGROUND

Chronic multisymptom illness (CMI) may be more prevalent among female Operation Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn (OEF/OIF/OND) deployed Veterans due to deployment-related experiences.

OBJECTIVES

To investigate CMI-related diagnoses among female OEF/OIF/OND Veterans.

RESEARCH DESIGN

We estimated the prevalence of the International Classification of Disease-9th edition-Clinical Modification coded CMI-related diagnoses of chronic fatigue syndrome, fibromyalgia (FM), and irritable bowel syndrome (IBS) among female OEF/OIF/OND Veterans with Veterans Health Administration (VHA) visits, FY2002-2012 (n=78,435). We described the characteristics of female Veterans with and without CMI-related diagnoses and VHA settings of first CMI-related diagnoses.

RESULTS

The prevalence of CMI-related diagnoses among female OEF/OIF/OND Veterans was 6397 (8.2%), over twice as high as the prevalence 95,424 (3.9%) among the totality of female Veterans currently accessing VHA (P<0.01). There were statistically significant differences in age, education, marital status, military component, service branch, and proportions of those with depression and/or post-traumatic stress disorder diagnoses across females with and without CMI-related diagnoses. Diagnoses were mainly from primary care, women's health, and physical medicine and rehabilitation clinics.

CONCLUSIONS

CMI-related diagnoses were more prevalent among female OEF/OIF/OND Veterans compared with all female Veterans who currently access VHA. Future studies of the role of mental health diagnoses as confounders or mediators of the association of OEF/OIF/OND deployment and CMI are warranted. These and other factors associated with CMI may provide a basis for enhanced screening to facilitate recognition of these conditions. Further work should evaluate models of care and healthcare utilization related to CMI in female Veterans.

Challenges to healthy eating for people with diabetes in a low-income, minority neighborhood

OBJECTIVE

This study used qualitative interviews with black and Latino participants with diabetes to further understanding about types of foods eaten, food preparation, sources of foods and meals, communication with providers, and effects of race and ethnicity on eating in this population.

RESEARCH DESIGN AND METHODS

Researchers recruited black and Latino adults from East Harlem, New York, to participate in four English and Spanish focus groups. Discussions were transcribed, coded, and analyzed to uncover prevalent themes, which were interpreted with the Common Sense Model of Self-Regulation.

RESULTS

Thirty-seven adults with diabetes participated in four focus groups. The following four major themes emerged from the analyses: 1) The food environment limited participants' access to healthy foods; 2) understanding of diabetes and communication with clinicians about healthy eating was limited and abstract; 3) the short-term, negative consequences of healthy eating outweighed the benefits; and 4) stress, in large part from poverty and discrimination, was seen as a causal factor for both poor eating and diabetes.

CONCLUSIONS

Participants' responses indicated that using healthy eating to control diabetes does not provide immediate, tangible results. Thus, these participants followed their own common sense to guide their diabetes management and improve their health. Clinicians may be better able to help patients eat healthfully if they consider these factors during medical visits.

Using the Common Sense Model of Self-Regulation to Review the Effects of Self-Monitoring of Blood Glucose on Glycemic Control for Non–Insulin-Treated Adults With Type 2 Diabetes

Purpose

This systematic review examined the relationship between self-monitoring of blood glucose (SMBG) and glycemic control in patients with type 2 diabetes. The Common Sense Model of Self-Regulation (CSM) served as a theoretical framework for examining how, when (mediators), and for whom (moderators) SMBG improved glycemic control.

Data Sources

Five databases were searched: Medline, PsychInfo, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, and Cumulative Index to Nursing & Allied Health Literature.

Study Selection

Included studies had cross-sectional, longitudinal, or randomized controlled trial designs; were published between 2007 and 2011; and included patients with type 2 diabetes at least some of whom were not taking insulin; 1318 studies were screened, 119 were reviewed in detail, and 26 were included.

Data Extraction

Data were collected on the relationship between SMBG and glycemic control, study design, mediators, moderators, participant characteristics, the CSM, and limitations.

Data Synthesis

Twenty-six studies met criteria for inclusion: 11 cross-sectional, 4 longitudinal, and 11 randomized controlled trials. The results of the cross-sectional studies were inconclusive. Results from the longitudinal studies and randomized control trials suggested that SMBG may improve glycemic control. The few studies investigating mediators or moderators reported mixed results. Few studies effectively measured the CSM.

Conclusion

Data suggested that SMBG may help improve glycemic control. Future trials must be designed to test hypotheses and improve our understanding of when, how, and for whom SMBG can enhance glycemic control. Rigorously controlled repetitions of current 2-arm trials will yield little new knowledge of theoretical or practical value.

What pre-deployment and early post-deployment factors predict health function after combat deployment?: a prospective longitudinal study of Operation Enduring Freedom (OEF)/Operation Iraqi Freedom (OIF) soldiers

Background

Physical and mental function are strong indicators of disability and mortality. OEF/OIF Veterans returning from deployment have been found to have poorer function than soldiers who have not deployed; however the reasons for this are unknown.

Methods

A prospective cohort of 790 soldiers was assessed both pre- and immediately after deployment to determine predictors of physical and mental function after war.

Results

On average, OEF/OIF Veterans showed significant declines in both physical (t=6.65, p<.0001) and mental function (t=7.11, p<.0001). After controlling for pre-deployment function, poorer physical function after deployment was associated with older age, more physical symptoms, blunted systolic blood pressure reactivity and being injured. After controlling for pre-deployment function, poorer mental function after deployment was associated with younger age, lower social desirability, lower social support, greater physical symptoms and greater PTSD symptoms.

Conclusions

Combat deployment was associated with an immediate decline in both mental and physical function. The relationship of combat deployment to function is complex and influenced by demographic, psychosocial, physiological and experiential factors. Social support and physical symptoms emerged as potentially modifiable factors.

A retrospective cohort study of U.S. service members returning from Afghanistan and Iraq: is physical health worsening over time?

Background

High rates of mental health disorders have been reported in veterans returning from deployment to Afghanistan (Operation Enduring Freedom: OEF) and Iraq (Operation Iraqi Freedom: OIF); however, less is known about physical health functioning and its temporal course post-deployment. Therefore, our goal is to study physical health functioning in OEF/OIF veterans after deployment.

Methods

We analyzed self-reported physical health functioning as physical component summary (PCS) scores on the Veterans version of the Short Form 36 health survey in 679 OEF/OIF veterans clinically evaluated at a post-deployment health clinic. Veterans were stratified into four groups based on time post-deployment: (1Yr) 0 – 365 days; (2Yr) 366 – 730 days; (3Yr) 731 – 1095 days; and (4Yr+) > 1095 days. To assess the possibility that our effect was specific to a treatment-seeking sample, we also analyzed PCS scores from a separate military community sample of 768 OEF/OIF veterans evaluated pre-deployment and up to one-year post-deployment.

Results

In veterans evaluated at our clinic, we observed significantly lower PCS scores as time post-deployment increased (p = 0.018) after adjusting for probable post-traumatic stress disorder (PTSD). We similarly observed in our community sample that PCS scores were lower both immediately after and one year after return from deployment (p < 0.001) relative to pre-deployment PCS. Further, PCS scores obtained 1-year post-deployment were significantly lower than scores obtained immediately post-deployment (p = 0.02).

Conclusion

In our clinical sample, the longer the duration between return from deployment and their visit to our clinic, the worse the Veteran’s physical health even after adjusting for PTSD. Additionally, a decline is also present in a military community sample of OEF/OIF veterans. These data suggest that, as time since deployment length increases, physical health may deteriorate for some veterans.

Rumination moderates the associations between PTSD and depressive symptoms and risky behaviors in U. S. veterans

Risky behaviors, including unsafe sex, aggression, rule breaking, self-injury, and dangerous substance use have become a growing issue for U.S. veterans returning from combat deployments. Evidence in nonveteran samples suggests that risky behaviors reflect efforts to cope with and alleviate depressive and/or anxious symptoms, particularly for individuals with poor emotion-regulation skills. These associations have not been studied in veterans. Rumination, or repeated thoughts about negative feelings and past events, is a coping strategy that is associated with several psychopathologies common in veterans. In this cross-sectional study, 91 recently returned veterans completed measures of trait rumination, self-reported risky behaviors, and symptoms of posttraumatic stress disorder (PTSD) and depression. Analyses revealed that veterans with more depressive and PTSD symptoms reported more risky behaviors. Moreover, rumination significantly interacted with PTSD symptoms and depressive symptoms (both β = .21, p < .05), such that psychiatric symptoms were associated with risky behaviors only for veterans with moderate to high levels of rumination. Although cross-sectional, these findings support theory that individuals with poor coping skills may be particularly likely to respond to negative mood states by engaging in risky behaviors. Implications include using rumination-focused interventions with veterans in order to prevent engagement in risky behaviors.

The impact of self-monitoring of blood glucose on a behavioral weight loss intervention for patients with type 2 diabetes

PURPOSE

The purpose of the study was to examine the association of self-monitoring of blood glucose (SMBG) to weight loss and A1C among participants in a behavioral weight loss intervention.

METHODS

Multivariate analyses were employed to evaluate the relationship between SMBG and changes in patient weight and A1C levels. Bootstrapping was used to determine whether there was an indirect effect of SMBG on weight loss through diet adherence and an indirect effect of SMBG on A1C through weight loss.

RESULTS

The relationship between increased SMBG and greater weight loss was mediated by better adherence to diet. The relationship of increased SMBG and greater reductions in A1C were mediated by greater weight loss.

CONCLUSIONS

Results of the study were consistent with the hypothesis that SMBG leads to an increased adherence to dietary recommendations. For patients who are taught to use their diet to lose weight, increased adherence to dietary recommendations is associated with increased weight loss and subsequently better glucose control. SMBG may be of value as an adjunctive intervention in behavioral programs for type 2 diabetes.