Depressive Symptoms Mediate the Relationship between Emotional Cutoff and Type 2 Diabetes Mellitus

Abstract

Background

Differentiation of self is a family systems construct defined as the ability to balance intimacy and autonomy and to separate instinctually driven emotional reactions and thoughtfully considered goal-directed functioning. In theory, low differentiation of self is reflected by four components: a low tendency to take an I-position in relationships (i.e., to own one’s thoughts and feelings); emotional cutoff from others; a greater tendency to fuse with others; and a tendency towards emotional reactivity. Low differentiation of self is associated with anxiety and depression, which are risk factors for type 2 diabetes mellitus. The current study examines the relationship between differentiation of self and type 2 diabetes mellitus.

Method

Individuals with type 2 diabetes mellitus (N = 107) and healthy individuals (N = 145) completed the Differentiation of Self Inventory-Revised (DSI-R), the State-Trait Anxiety Inventory (STAI), and the Beck Depression Inventory (BDI-II).

Results

Compared with healthy individuals, participants with type 2 diabetes had more severe depressive symptoms, higher levels of emotional cutoff, and a lower tendency to take an I-position, but had similar levels of trait anxiety, emotional reactivity, and fusion with others (factor analysis revealed these factors were not separable in the current sample and thus were merged into a single construct). Importantly, the severity of depressive symptoms mediated the relationship between emotional cutoff and being in the type 2 diabetes study group rather than the healthy group.

Conclusion

These findings suggest a new perspective on the role of psychological patterns in type 2 diabetes mellitus development and progression.

This is a preview of subscription content, log in to check access.

Fig. 1
Fig. 2

References

  1. 1.

    National Institute of Diabetes and Digestive and Kidney Diseases. Causes of diabetes. https://www.niddk.nih.gov/health-information/diabetes/overview/symptoms-causes. Accessed 15 July 2018.

  2. 2.

    Cohen JN, Byers ES. Minority stress, protective factors, and sexual functioning of women in a same-sex relationship. Psychol Sex Orientat Gend Divers. 2015;2(4):391–403.

    Article  Google Scholar 

  3. 3.

    Bellou V, Belbasis L, Tzoulaki I, Evangelou E. Risk factors for type 2 diabetes mellitus: an exposure-wide umbrella review of meta-analyses. PLoS One. 2018;13(3):e0194127.

    PubMed  PubMed Central  Article  CAS  Google Scholar 

  4. 4.

    Boudarene M, Legros JJ, Timsit-Berthier M. Study of stress response: role of anxiety, cortisol DHEAs. Encephale. 2002;28(2):139–46.

    CAS  PubMed  Google Scholar 

  5. 5.

    Walker S, O’Connor DB, Schaefer A, Talbot D, Hendrickx H. The cortisol awakening response: associations with trait anxiety and stress reactivity. Personal Individ Differ. 2011;51(2):123–7.

    Article  Google Scholar 

  6. 6.

    Tsenkova VK, Karlamangla A. Depression amplifies the influence of central obesity on 10-year incidence of diabetes: findings from MIDUS. PLoS One. 2016;11(10):e0164802.

    PubMed  PubMed Central  Article  CAS  Google Scholar 

  7. 7.

    Bowen M. Family therapy in clinical practice. New York: Jason Aronson; 1978.

    Google Scholar 

  8. 8.

    Hooper LM, Doehler K. The mediating and moderating effects of differentiation of self on body mass index and depressive symptomatology among an American college sample. Couns Psychol Q. 2011;24(1):71–82.

    Article  Google Scholar 

  9. 9.

    Kim-Appel D, Appel J, Newman I, Parr P. Testing the effectiveness of Bowen’s concept of differentiation in predicting psychological distress in individuals age 62 years or older. Fam J. 2007;15(3):224–33.

    Article  Google Scholar 

  10. 10.

    Peleg O, Tzischinsky O. Assessing satisfaction with differentiation of self through circle drawing: validation of a revised self-report instrument (SFI-R). J Psychol Psychother. 2016;5:1–10.

    Google Scholar 

  11. 11.

    Skowron EA, Schmitt TA. Assessing interpersonal fusion: reliability and validity of a new fusion with others subscale. J Marital Fam Ther. 2003;29(2):209–22.

    PubMed  Article  Google Scholar 

  12. 12.

    Skowron EA, Stanley KL, Shapiro MD. A longitudinal perspective on differentiation of self, interpersonal and psychological well-being in young adulthood. Contemp Fam Ther. 2008;31(1):3–18.

    Article  Google Scholar 

  13. 13.

    Bowen M. Theory in the practice of psychotherapy. In: Guerin PJ, editor. Family therapy. New York: Gardner; 1976.

    Google Scholar 

  14. 14.

    Kerr M, Bowen M. Family evaluation: an approach based on Bowen theory. New York: Norton; 1988.

    Google Scholar 

  15. 15.

    Tuason MT, Friedlander ML. Do parents’ differentiation levels predict those of their adult children? And other tests of Bowen theory in a Philippine sample. J Couns Psychol. 2000;47(1):27–35.

    Article  Google Scholar 

  16. 16.

    Titelman P. Triangles: Bowen family systems theory perspectives. Philadelphia: Haworth Press; 2008.

    Google Scholar 

  17. 17.

    Choi S, Murdock NL. Differentiation of self, interpersonal conflict, and depression: the mediating role of anger expression. Contemp Fam Ther. 2016;39(1):21–30.

    Article  Google Scholar 

  18. 18.

    Skowron EA, Friedlander M. The differentiation of self inventory: development and initial validation. J Couns Psychol. 1998;28:235–46.

    Article  Google Scholar 

  19. 19.

    Peleg-Popko O. Bowen theory: a study of differentiation of self, social anxiety, and physiological symptoms. Contemp Fam Ther. 2002;24:355–69.

    Article  Google Scholar 

  20. 20.

    Murray TL, Daniels MH, Murray CE. Differentiation of self, perceived stress, and symptom severity among patients with fibromyalgia syndrome. Fam Syst Health. 2006;24(2):147–59.

    Article  Google Scholar 

  21. 21.

    Peleg O. The relation between differentiation of self and marital satisfaction: what can be learned from married people over the course of life? Am J Fam Ther. 2008;36(5):388–401.

    Article  Google Scholar 

  22. 22.

    Demmer RT, Gelb S, Suglia SF, et al. Sex differences in the association between depression, anxiety, and type 2 diabetes mellitus. Psychosom Med. 2015;7(4):467–77.

    Article  CAS  Google Scholar 

  23. 23.

    Spielberger CD. State-trait anxiety inventory for children. Palo Alto: Consulting Psychologist Press; 1973.

    Google Scholar 

  24. 24.

    Teichman Y. Manual for the Hebrew State-Trait Anxiety Inventory. Tel Aviv: Tel Aviv University Press; 1978. [Hebrew]

    Google Scholar 

  25. 25.

    Beck AT, Steer RA, Brown G. Beck Depression Inventory–II. PsycTESTS Dataset; 1996.

  26. 26.

    Solomon-Ziner L. Stressful life events of suicidal adolescents (Master’s thesis), Bar-Ilan University, Israel; 2001.

  27. 27.

    Hayes AF. Introduction to mediation, moderation, and conditional process analysis: a regression-based approach. New York: Guilford Press; 2013.

    Google Scholar 

  28. 28.

    Deschênes SS, Burns RJ, Graham E, Schmitz N. Prediabetes, depressive and anxiety symptoms, and risk of type 2 diabetes: a community-based cohort study. J Psychosom Res. 2016;89:85–90.

    PubMed  Article  Google Scholar 

  29. 29.

    Bryson SE, Pilon DJ. Sex differences in depression and the method of administering the Beck Depression Inventory. J Clin Psychol. 1984;40(2):529–34.

    CAS  PubMed  Article  Google Scholar 

  30. 30.

    Page S. Two studies of gender and reporting differences with the Beck Depression Inventory. CRISP. 1999;4:146–59.

    Google Scholar 

  31. 31.

    Thombs BD. Routine depression screening for patients with diabetes. JAMA. 2014;312(22):2412–3.

    PubMed  Article  Google Scholar 

  32. 32.

    Anderson RJ, Freedland KE, Clouse RE, Lustman PJ. The prevalence of comorbid depression in adults with diabetes: a meta-analysis. Diabetes Care. 2001;24(6):1069–78.

    CAS  PubMed  Article  Google Scholar 

  33. 33.

    Frisard C, Gu X, Whitcomb B, Ma Y, Pekow P, Zorn M, et al. Marginal structural models for the estimation of the risk of diabetes mellitus in the presence of elevated depressive symptoms and antidepressant medication use in the Women’s Health Initiative observational and clinical trial cohorts. BMC Endocr Disord. 2015;15(1):56.

    PubMed  PubMed Central  Article  CAS  Google Scholar 

  34. 34.

    Gragnoli C. Depression and type 2 diabetes: cortisol pathway implication and investigational needs. J Cell Physiol. 2012;227(6):2318–22.

    CAS  PubMed  Article  Google Scholar 

  35. 35.

    Gold PW, Chrousos G, Kellner C, et al. Psychiatric implications of basic and clinical studies with corticotropin-releasing factor. Am J Psychiatry. 1984;41(5):619–27.

    Google Scholar 

  36. 36.

    Kunugi H, Ida I, Owashi T, Kimura M, Inoue Y, Nakagawa S, et al. Assessment of the dexamethasone/CRH test as a state-dependent marker for hypothalamic-pituitary-adrenal (HPA) axis abnormalities in major depressive episode: a multicenter study. Neuropsychopharmacology. 2006;31(1):212–20.

    CAS  PubMed  Article  Google Scholar 

  37. 37.

    Owashi T, Otsubo T, Oshima A, Nakagome K, Higuchi T, Kamijima K. Relationships of DEX/CRH and GHRH test results to the outcome of depression: preliminary results suggest the GHRH test may predict relapse after discharge. J Psychiatr Res. 2008;42(5):356–64.

    PubMed  Article  Google Scholar 

  38. 38.

    Garvey WT, Huecksteadt TP, Monzon R, Marshall S. Dexamethasone regulates the glucose transport system in primary cultured adipocytes: different mechanisms of insulin resistance after acute and chronic exposure. Endocrinology. 1989;124(5):2063–73.

    CAS  PubMed  Article  Google Scholar 

  39. 39.

    Coderre L, Vallega GA, Pilch PF, Chipkin SR. In vivo effects of dexamethasone and sucrose on glucose transport (GLUT-4) protein tissue distribution. Am J Phys. 1996;271(4).

  40. 40.

    Hackett RA, Kivimäki M, Kumari M, Steptoe A. Diurnal cortisol patterns, future diabetes, and impaired glucose metabolism in the Whitehall II cohort study. J Clin Endocrinol Metab. 2016;101(2):619–25.

    CAS  PubMed  Article  Google Scholar 

  41. 41.

    Schoorlemmer RM, Peeters GM, Schoor NM, Lips P. Relationships between cortisol level, mortality and chronic diseases in older persons. Clin Endocrinol. 2009;71(6):779–86.

    CAS  Article  Google Scholar 

  42. 42.

    Jankowski PJ, Hooper LM. Differentiation of self: a validation study of the Bowen theory construct. CFP. 2012;1(3):226–43.

    Google Scholar 

  43. 43.

    Glasgow RE, Toobert DJ. Social environment and regimen adherence among type II diabetic patients. Diabetes Care. 1988;11(5):377–86.

    CAS  PubMed  Article  Google Scholar 

Download references

Acknowledgments

The authors wish to thank Paula S. Herer, biostatistician, MSc, MPH, for her contribution to the statistical analyses.

Author information

Affiliations

Authors

Corresponding author

Correspondence to Ami Cohen.

Ethics declarations

Conflict of Interest

The authors declare that they have no conflict of interest.

Ethics Approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.

Informed Consent

Informed consent was obtained from all individual participants included in the study.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Electronic Supplementary Material

ESM 1

(DOCX 21 kb)

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Cohen, A., Peleg, O., Sarhana, A. et al. Depressive Symptoms Mediate the Relationship between Emotional Cutoff and Type 2 Diabetes Mellitus. Int.J. Behav. Med. 26, 591–599 (2019). https://doi.org/10.1007/s12529-019-09816-0

Download citation

Keywords

  • Type 2 diabetes
  • Differentiation of self
  • Emotional cutoff
  • I-position
  • Depression
  • Trait anxiety