Diabetes: Unmasking Its Hidden Toll
March 2006 Issue
For many people with diabetes, the effect of diabetes on the mind and emotions is its most devastating aspect. Psychological help is seldom the first line of defense, but rather a last resort, which in turn allows bearers to become so deeply entrenched in depression and anger that they become completely unable to control the disease.
There are about 798,000 new cases of diabetes diagnosed each year. Diabetes can cause or exacerbate other major health problems, such as cardiovascular disease, stroke, neuropathy, amputations, peripheral vascular disease, kidney disease, and retinopathy. However, to treat the "whole person" and enable better successful clinical management of diabetes, the health professional should be aware of psycho-social aspects faced by persons with diabetes.
Psycho-Social Complications of Diabetes
Many persons with diabetes are troubled more by the emotional factors associated with diabetes than by its biomedical aspect. However, it is in this area that they are least likely to receive support and guidance. Good diabetes management cannot be achieved without careful and constant monitoring by patients themselves. Therefore, it is essential that they be in good emotional health to provide that self-care.
Persons with diabetes may think that if it weren't for this rotten disease, their lives would be so much better. Most run through the entire gamut of diabetes-induced emotions of denial, fear, anxiety, anger, guilt, hostility, depression, and frustration.
There are no vacations from diabetes. It is a 24-hour-a-day, 365-days-a-year job.
If you are a person with diabetes, the condition affects every aspect of your life. It may force you to stick yourself with a needle multiple times a day and deprive yourself of foods you crave. If you succeed in keeping your blood glucose levels close to normal, your risk of going too low goes up, and often, so does your weight. To top it all off, you must live with the idea that there are no guarantees when it comes to diabetes. You may do everything right and still get a blood glucose reading you can't explain.
Diabetes-related psychological problems fall into two broad categories: 1) coping difficulties and 2) diagnosable psychological disorders. Coping difficulties are the more common problems, and diagnosable psychological disorders are the more grave.
Psychological problems to watch out for are depression, anxiety disorder, denial, anger, fear, and stress. These disorders tend to last longer, feel worse, and recur more often--and having psychological disorders makes controlling diabetes much more difficult.
Depression is probably the leading psychological disorder among people with diabetes. Depression causes sadness and a feeling of being emotionally drained. These feelings may come and go in a couple of hours or a couple of days. Clinical depression is far more debilitating. The signs of clinical depression are feeling sad and empty most of the day nearly every day, trouble sleeping or sleeping too much, feeling agitated or physically sluggish nearly every day, fatigue or loss of energy, diminished interest in many or all activities, feeling worthless, diminished ability to think or concentrate, and the list goes on.
Depression wreaks havoc with sleep. If you are dealing with depression, the less sleep you get, the more depressed you become. The more depressed you become, the worse your blood sugar level gets. The worse your blood sugar level gets, the more neuropathy can bother you. The worse the neuropathy gets, the worse the depression becomes. The deeper the depression, the angrier you become for not handling the depression better, making you even more depressed.
Research shows that persons with diabetes are four to eight times more likely to be clinically depressed than the general population. Chronic hyperglycemia is more common among persons with diabetes who are depressed. Depression is a concern not only because of its mental health implications, but also because of its negative impact on self-management, glucose control, and complications in both adults and children. Even with all these known facts about diabetes and depression, it is still under-diagnosed by many physicians.
Immediately after diagnosis, people are often in a state of shock. They may begin to experience intense feelings of disorganization, anxiety, fear, and other emotions. Eventually this crisis phase will end, and they must begin to develop a sense of how diabetes will affect the rest of their lives.
Researchers have found that people suffering from acute and chronic illnesses develop theories about how they contracted their illnesses. Where people place the blame for their illness is highly significant. Do they blame themselves, another person, the environment, or a quirk of fate?
Self-blame for diabetes is widespread. In some cases, these perceptions are, to a certain extent, correct. Poor health habits such as smoking, improper diet, or lack of exercise can cause illnesses such as diabetes. But what are the consequences to self-blame? Some say that it can lead to guilt, self-recrimination, or depression.
Persons in denial often will not be compliant and will not do all the things needed to keep themselves healthy. It is also unlikely they will be able to empower themselves--that is, to take charge of their diabetes and assume responsibility for their own care.
Reasons for Denial, Consequences
Some people hesitate to tell others about their diabetes because they feel ashamed and isolated. Some view diabetes as a weakness, especially when they're having trouble controlling it. This weakness also is a feeling of being a burden to others. Others have been taught to be secretive about it. This tends to be the case for those who developed diabetes as a child, since many years ago health issues were not discussed as openly as they are today.
Persons with diabetes also may assign the blame to others. They say, "I can't follow my diet because my wife cooks too much food, and I can't resist eating it if it's there," or, "I can't follow my diet because the family doesn't like the things I'm supposed to eat, and I don't have the time and energy to cook two different meals." Bosses are blamed for creating stressful situations that cause blood sugar to skyrocket. Health professionals are blamed for not spending enough time explaining how to manage diabetes. Children complain that if their parents would only get off their backs, they could handle their diabetes much better.
Denial is especially risky in the case of diabetes. People who deny that the problem exists will not take steps to treat the condition. Poorly controlled diabetes can lead to further short-term and long-term complications. Denial may interfere with the ability to monitor conditions, to take the initiative in seeking treatment, or to follow through with specified medical care.
There can be a huge amount of marital discord and tension when the person with diabetes is in denial and the other spouse is frantic over the situation. It's most often the wives who experience this kind of frustration when their husbands refuse to take care of their diabetes, ignoring it as if it doesn't exist. They complain that nothing they do makes any difference and may feel like giving up completely.
Diabetes brings on plenty of reasons for anger, which can be destructive. A surge of anger can spike blood sugar in seconds. Anger triggers a fight-or-flight response that releases considerable adrenaline and other stress hormones, which in turn plays havoc with blood sugar and leaves patients emotionally drained. Diabetes also can induce a physiological anger when blood sugar drops too low; then a normally happy person with diabetes can quickly turn into a frantic, irritated individual.
Persons with diabetes may be angry because they can no longer eat what they want, or they feel that the diabetes has imposed certain limitations on their life, or their family is not understanding enough, or they become frustrated when they cannot keep their blood sugar under control, no matter how hard they try. Thoughtless comments from uneducated individuals can produce plenty of anger.
Often people become angry about things they are really afraid of. Diabetes can give rise to many fears: "How will I deal with hypoglycemia?" "Will I be able to have children?" "Will I end up having an amputation?" And, the biggest question: "Why did this happen to me?"
When people are diagnosed with diabetes, many feel a grief similar to that experienced when a loved one dies. They also understand the unfortunate idea that they are not invulnerable and immortal. Grief needs to be understood, accepted, and dealt with, or later on it can become stronger and harder to cope with.
Food deprivations are probably the single most common source of grief. Food can become an emotional comfort for persons with diabetes, just as it can with other individuals; it's a way of giving and receiving love. It's no wonder that food restrictions make a person with diabetes feel so deprived.
Grieving over complications such as loss of sight, kidney dialysis, or loss of a limb creates another new form of grief where they feel guilt, denial, shock, anger, and depression all over again.
Many persons with diabetes have a fear of dying, since death becomes not just a sobering possibility but a reality that needs to be faced emotionally. Many persons with diabetes also fear that they will become disabled because of complications related to the diabetes.
Frustration is a constant companion. Besides other causes, they can be frustrated by the relatively slow progress of medical science in developing a preventive or cure. Mostly they are frustrated by the unpredictable nature of their own bodies and the inability to always control their blood sugar levels. Unrealistic expectations from healthcare professionals cause frustration. Even when a person with diabetes does everything right, blood sugar levels may not achieve expectations. A simple cold, flu, or infection can send blood sugar levels sky-high.
When persons with diabetes become guilt-ridden, they believe that they are bad, weak, self-destructive persons incapable of doing anything right, especially when it comes to their diabetes. They begin having negative thoughts such as, "I'll never be able to stop smoking," or, "I have no will power when it comes to food," or, "I'm incapable of losing weight." These feelings of guilt involve negative judgments about themselves which tend to focus on the past, paralyzing them from making needed changes.
They may feel guilty if they need to impose some of their regimen requirements on family and friends, so that others have to adjust to their new lifestyle.
Anxious patients tend to report poor glucose levels and increased symptoms soon after being diagnosed with diabetes. While anxiety attributed to the illness may decrease over time, anxiety about possible complications, the disease's implications for the future, and its impact on work and social activities may increase.
Stress is known to cause or exacerbate almost any medical problem, and diabetes is no exception. Stress is particularly dangerous for people with diabetes. The hormones that the body releases as part of the fight or flight response are meant to prepare the body for quick action. These hormones break down stored glycogen into blood glucose, which the body should be able to use for energy. But people with diabetes cannot effectively use this extra glucose for energy, so the result is an extremely rapid rise in blood sugar.
Just as in physiological symptoms, each person with diabetes may experience different psychological reactions. They need to be able to accept the changes in their lives caused by the illness in order to better manage the physiological symptoms. Persons with diabetes should seek treatment when faced with depression, anxiety disorder, frustration, guilt or stress; the physical and emotional burden of being a person with diabetes can become too great to handle alone.