Saturday, July 08, 2006

Psychological aspects of diabetes

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This coming week is National Diabetes Week in Australia and so it seemed appropriate to discuss some of the psychological issues related to diabetes.

Diabetes is one of the most common chronic health problems and it's prevalence is increasing. While rates of Type 1 diabetes are on the rise, Type 2 diabetes is appearing in children and adolescents and reaching epidemic proportions in the adult population. It is estimated that worldwide by 2010, 150 million to 220 million people will have developed Type 2 diabetes (Zimmet, Alberti, & Shaw, 2001).

Are you at risk of diabetes?

As a chronic condition, diabetes requires lifetime management. This involves a complex daily regimen involving diet, exercise, medication and self-monitoring of blood glucose. It can place considerable psychological and behavioural demands on the individual.

Depression & Anxiety

With that in mind, it's hardly surprising that depression and anxiety are reported to be at least twice as likely in individuals with diabetes. However, both conditions often go unrecognised, which is disappointing when treatment of these conditions could significantly improve quality of life.

Why does this happen?

This may be because some of the physical symptoms of high blood sugar levels (hyperglycaemia), such as tiredness, weight change and loss of libido, overlap with symptoms of depression. Similarly, symptoms of low blood sugar, such as faintness and sweating, coincide with symptoms of anxiety. Moreover, emotional reactions, such as crying, are often dismissed as a normal reaction to illness, which, of course, they may well be.

What is important is to determine what might represent a more serious problem. The symptoms of depression can be reviewed here and the symptoms of anxiety here. A key question to ask if whether the feelings experienced are interfering with self-management of diabetes. Are they impacting on adherence to treatment, affecting activity levels or eating habits?

If so, it could be a good idea to discuss these feelings with a member of the managing medical team, either a Diabetes Educator or a primary physician, who may then make a referral to a mental health professional if it is considered necessary.

People with a chronic illness may often reluctant to discuss their feelings because of a concern their physical health issues will be taken less seriously or because of concern of the stigma surrounding mental illness. However, it can often be extremely helpful to talk to someone who understands the emotional and physical impact of diabetes.

Diabetes and Stress

Stress has been shown to influence blood sugar control in two ways. Firstly, it can cause the release of stress hormones, which have been associated with hyperglycaemia. Secondly, the experience of stress can interfere with self-care activities, including treatment, dietary and exercise adherence.

Everyone experiences stress. A certain level of stress in life is inevitable and can sometimes be beneficial. It is not possible to totally eliminate stress but what is important is the way stress is managed, in order to control its effects on physical and mental health.

Important tools to help minimise the impact of stress can include good sleep habits, regular exercise, a nutritious diet and relaxation techniques.

Diabetes Burnout

Diabetes burnout is a major psychological complication of diabetes and is a very common experience. Burnout happens when individuals feel overburdened by diabetes and the associated self-care regimen. Typical warning signs of burnout can include:

A sense of feeling alone with or overwhelmed by diabetes.

Anger at the condition or frustration with the self-care regimen.

Thoughts that life is controlled by diabetes.

Worries about not taking good care of diabetes, yet feeling unmotivated to change.

Thoughts that diabetes management is not important, that complications cannot happen and yet feeling a sense of impending doom.

Stopping diabetes care and thinking about diabetes as little as possible.

Avoiding diabetes-related tasks that might provide feedback about the consequences of poor self-care.

Ways of dealing with burnout

Set realistic expectations. Even with strict adherence to all the management tasks associated with diabetes, it can be difficult to maintain blood glucose in the target range all the time.

If repeatedly experiencing difficulties with control, try to work out why. When, where and why might problems occur? Doing this might indicate possible changes in behaviors or the environment that might make it easier to cope with the problem or avoid it altogether.

Focus on the benefits of good care as opposed to the consequences of failure.

Don't think of blood sugar levels as 'good' or 'bad', rather as 'high' or 'low'. Don't think about monitoring levels as a 'test', rather as a 'check.' Getting an unsatisfactory result on a 'test' can lead to a sense of failure. Rather than getting upset at results, use the information to help plan what to do next. Ask a member of the diabetes management team for help if unsure.

Make use of available sources of support, including family and friends. Bear in mind that it can be hard for people to know exactly how to help, needing to find a balance between being supportive and the acting as the diabetes police. It is important to decide on the kind of support needed and ask accordingly.

In closing...

While 95% of the day to day care of diabetes is handled by the individual, management remains a team effort. If experiencing emotional problems coping with the demands of diabetes or experiencing symptoms of burnout, talking to a member of the diabetes team may make a difference.


Depression in the medically ill

Anderson, B. J., & Rubin, R. R. (2003). Practical Psychology for Diabetes Clinicians.

Polonsky, W. H. (1999). Diabetes Burnout: What to do when you can't take it anymore.

Rubin, R. R., Bierman, J., & Toohey, B. (1999). Psyching out diabetes: A positive approach to your negative emotions.

Zimmet, P., Alberti, K. G. M. M., & Shaw, J. (2001). Global and societal implications of the diabetes epidemic. Nature, 414, 782-787.


Anonymous said...

This is a great post. Diabetes is tough especially for kids I think. It's hard to get your head around the importance of strict management because you "don't look sick." Any chronic illness would be difficult, but what you wrote about the symptoms of diabetes overlapping depression and anxiety is thought provoking. I went to a talk about diabetes given by an experienced advanced practice nurse. She new her stuff, but I don't remember hearing much about the psychological aspects. Thanks for this.

Alison said...

I can relate to a lot of what you say as I suffered with gestational diabetes in my second pregnancy. It was a huge shock to be diagnosed. Your links here are excellent - I love the relaxation and sleep suggestions in particular. Great stuff and an all round valuable post.

healthpsych said...

Hi Tiesha,
Thanks. Of course, these aren't all the psychological aspects of diabetes - there's more specific aspects such as needle phobia, hypogycaemia related anxiety etc and there are more specific issues related to children and adolescents which I haven't covered here eg. trying to adjust to diabetes in the middle of all the other developmental challenges of that time.

Hi Alison,
Snap! Me too. I had to take very large doses of insulin and it was certainly a wake up call for me. I can quite empathise with hypoglycaemic anxiety!

Dr. A said...

Good post. Sometimes, I have to remind myself of the psychological aspects of diabetes. It's more than blood tests and blood sugars and the physical aspects of the disease.

Fallen Angels said...

I had a period of diabetic burnout, the no testing, not taking meds, no watching carb intake type. It lasted about 10 months and I am now "back on the wagon". Fortunately, my A1C only went up to 6.6. I suffered from depression and anxiety both before being diagnosed. The anxiety has increased in some areas...especially hypoglycemia anxiety. I am a student taking core sciences for nursing school and someimtes it's very hard to stop mid chem lab to check sugar and eat if needed...the reaction won't wait for me! That would be the chem reaction, not the physical one ...blah...that won't wait for me either!

healthpsych said...

Hi Dr. A,
Thanks for dropping by. These are only some of the issues, of course.

Hi Fallen Angels,
Thanks for visiting. As someone who also experiences hypoglycaemia fairly regularly, I can understand
your anxiety. But chemical or physical reaction, that's some dilemma!

Dr. Deborah Serani said...

This is a fabulous post!

healthpsych said...

Hi Deborah,
Thanks for dropping by!

Mekon said...

I'd love to hear more about any experiences of helping people through diabetic burnout. We're currently working on a trial of a nurse-led intervention that attempts to automatise adherence to metformin, but we've included a motivational component that seeks to enhance believes associated with adherence and address negative beliefs. It doesn't address burnout at all.

healthpsych said...

Hi Mekon,
Thanks for dropping by. Tried to contact you via your blog but it doesn't seem to be working. Can you email me at health-psych at and I can help you further. :)

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