The importance of emotional issues in diabetes mellitus has been recognized for centuries. In 1679, Thomas Willis, the British physician who was the first person to recognize the presence of glucose in the urine of people with diabetes, wrote, 'The cause of diabetes is an emotional state I will call extreme sorrow'. Until the past 20 years, those studying the role of psychosocial issues in diabetes concentrated, as Willis had, on psychological causes of diabetes. More recently, researchers and clinicians have turned their attention to psychological issues which affect diabetes self-management, and to the sequelae of living with diabetes. This chapter deals with counselling and psychotherapeutic inverventions intended to relieve psychological distress in people with diabetes. Psychological or emotional distress in people with diabetes takes two forms: coping difficulties, which arise as a consequence of the daily stress and hassles of living with the disease; and frank psychopathology1.
Psychology in Diabetes Care COPING PROBLEMS
WHY ARE COPING PROBLEMS SO COMMON?
Coping problems are common among people with diabetes largely because the demands of diabetes management are so substantial and unremitting. Specifically, the regimen is demanding and unpleasant, factors outside the patient's control often affect glycaemic control, and the avoidance of diabetes-related complications can not be guaranteed. Each of these points deserves elaboration. There are no vacations from diabetes. Diabetes management is a 24-hour-a-day, 365-day-a-year proposition. Thus, diabetes affects every aspect of a person's life, including job, social life, recreation and family life. My son, who has had diabetes for 20 years, recently told me that he has had to think about his diabetes at least once every 15 minutes every day for the past two decades. At least that often he stops to ponder how he feels, and what he must do to avoid high or low blood glucose levels. Another thing that makes the diabetes regimen so demanding is the fact that many of its requirements are unpleasant. Few people relish the prospect of sticking themselves with sharp objects four to eight or more times a day, as many people with diabetes must do. And almost everyone feels that diabetes-related dietary restrictions are a major burden.
In addition, my patients often remind me that even when they manage their diabetes by the book, their blood glucose levels are still sometimes unpredictable. Many of these individuals are stress-responsive, and the release of stress-induced counter-regulatory hormones can dramatically affect their glycaemic control. Finally, while the benefits of good glycaemic control are now beyond debate following the release of the results of several large-scale randomized clinical trials2-5, we can not assure our patients that good glycaemic control offers an absolute guarantee that they will not suffer from diabetes-related complications.
'DIABETES OVERWHELMUS' AND ITS CONSEQUENCES
What is common to all the demands of diabetes which I have just noted is the fact that they can leave a person feeling overwhelmed and unable to cope, a state inimical to an effective effort to manage diabetes and to the achievement of optimal glycemic control.
This sense of being overwhelmed, which I call 'diabetes overwhelmus', to parallel diabetes mellitus, the technical name for the disease which affects our patients, is one important factor leading to the low levels of diabetes self-care we see reported in the literature. Robiner and Keel6 reviewed studies of medication taking, self-monitoring of blood glucose (SMBG), diet, weight management and exercise among people with diabetes, and Ruggiero and colleagues7 described self-reported self-management patterns in a large sample of people with diabetes. Both studies reported a wide range of findings, with medication taking adherence highest and life-style behaviour adherence lowest. The difficulty most people with diabetes report in their efforts to manage their diabetes effectively is illustrated by my experience at a recent lecture. When I asked the audience of over 2000 people with diabetes to raise a hand if they felt they did everything they should do to manage their disease, two hands were raised. One of these individuals had been diagnosed with diabetes for 1 week and the other for 2 weeks!
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