Deal with natural emotions like stress, sadness, anger and denial before they lead to depression.
Featured book: Diabetes Burnout: What to Do When You Can't Take It Anymore is an interactive book that addresses the emotional issues that contribute to poor glycemic control and provides guidance to overcoming the barriers to good self-care.
Types-1
Anger
Diabetes is the perfect breeding ground for anger. Anger can start at diagnosis with the question, "Why me?" You may dwell on how unfair diabetes is: "I'm so angry at this disease! I don't want to treat it. I don't want to control it. I hate it!"
One reason diabetes and anger so often go hand in hand is that diabetes can make you feel threatened. Life with diabetes can seem full of dangers - insulin reactions or complications. When you fear these threats, anger often surges to your defense.
While it's true that out-of-control anger can cause more harm than good, that's only part of the story. Anger can also help you assert and protect yourself. You can learn to use your anger. You can even put it to work for better diabetes care.
Anger and Self-Care
Anger worked against Mary H., a woman in her mid-fifties who was diagnosed with diabetes six months ago. She was furious. She saw diabetes as not just a threat to her health, but also to her whole way of life. A very proud woman, active in community and social affairs, she found it impossible to be open about her "weakness." She didn't want her friends to prepare special foods for her. She even felt her husband now saw her as an "invalid" and that she was "less of a woman" to him. Denial fueled Mary's anger at diabetes.
The Anger Circle
Mary was stuck in an anger circle. She was angry at diabetes for changing her life. She refused to face her health care needs because she refused to change her life. Her diabetes went uncared for and her blood sugar levels stayed high. As the disease went on poorly controlled, Mary felt worse. Her anger at diabetes grew.
If you find yourself in an anger circle, like Mary, you don't have to stay stuck. One way to break the circle comes from Dr. Weisinger's Anger Work Out Book by Hendrie Weisinger, PhD. He suggests you do three things:
Figure out what's making you angry. How is that anger affecting your life? Keep track of when you feel angry. Each evening, think back over the day. When were you angry? What time was it? Who were you angry at? What did you do about it?
After several weeks, read over your notes. See any patterns? When Mary read her anger diary, she learned that social situations made her angry. She did not like talking about her diabetes in public. She felt angry if friends asked her what she could eat or made special food. When she and her husband tried to go out with friends, she felt her diabetes was the center of attention.
Change the thoughts, physical responses, and actions that fuel your anger. Look for warning signs that your anger is building. Do you feel tense? Are you talking louder and faster? When you feel anger taking over, calm yourself by:
talking slowly
slowing your breathing
getting a drink of water
sitting down
leaning back
quieting yourself. Silence is golden in these situations.
These steps don't mean you stop feeling angry. Instead, they mean you are taking charge of your anger.
Find ways to make your anger work for you. Your anger diary can help. Read your notes again. Look at each situation. Ask yourself - How was my anger helping me cope? Mary decided her anger was helping her avoid talking about her diabetes with others. She decided to try answering questions in a matter-of-fact way. But she found that talking about diabetes in public still made her furious.
Mary's anger told her something very important. She still hadn't accepted having diabetes. To get more support, she joined her local American Diabetes Association. Meeting other people with diabetes helped her feel less alone. She also realized that having diabetes did not make her less of a person.
Slowly, she was able to enjoy her friends again. She was able to talk openly about her disease and also tell her friends that she didn't want special treatment.
Let Anger Be Your Ally
The goal is not to get anger out of your life. You may go on feeling angry about the same things. When you feel threatened, afraid, or frustrated, anger is a normal response. But you can put your anger to work for you. Your anger may be a signal that you need to take action. A few sessions with a skilled counselor might help.
Anger can be a force for action, change, and growth. The better you understand your anger, the better you will be able to use it for good self-care.
Types-2
Denial
Denial is that voice inside repeating: "Not me." Most people go through denial when they are first diagnosed with diabetes. "I don't believe it. There must be some mistake," they say.
That first reaction is not the real problem. In fact, it's so common that some doctors think it's part of the process of accepting the diagnosis.
The trouble comes when you keep on denying your diabetes. Long-term denial stops you from learning what you need to know to keep yourself healthy.
Why Deny?
Sometimes denial serves a purpose. It is a way of coping with bad news. It can keep you from getting overwhelmed and depressed. It lets you accept news little by little, when you are ready.
But denial can return later on because it seems easier. Denying that your diabetes is serious lets you avoid self-care. It shields you from the fact that diabetes is a lifelong, chronic illness, which, if left untreated, can result in complications. Denial also lets your family and friends pretend that "nothing is wrong."
Doctors who do not specialize in diabetes care may fuel your denial. They may talk about a "mild" case of diabetes or say there is "just a touch of sugar" in your blood. Though well-meaning, these terms send the wrong message. What you hear is "Don't worry. Your diabetes is not serious enough to hurt you."
Spotting Denial
Denial has a few catch phrases. If you hear yourself thinking or saying them, you are avoiding some part of your diabetes care.
One bite won't hurt.
This sore will heal by itself.
I'll go to the doctor later.
I don't have time to do it.
My diabetes isn't serious. I only have to take a pill, not shots.
Hidden Danger
Because denial can creep into any aspect of diabetes self-care, it can be dangerous. Any denial sabotages your health care.
Not Testing
It can be a bother to check your blood glucose regularly. You may decide you "know" what your blood glucose is by how you feel. But a meter is a much better measure of blood glucose than feelings are.
Ignoring Your Meal Plan
Changing eating habits and food choices is tough. When your doctor told you to see a dietitian, follow a meal plan, and change your eating habits, maybe you thought to yourself:
It's too expensive to see a registered dietitian.
I can't ask my family to change what they eat. I don't want to eat alone or fix two meals.
There's no place to buy healthy food where I work.
It's too hard to bring my lunch.
Eating right may not be as difficult as you think. A dietitian can help you put together a plan that meets your personal needs.
Forgetting Your Feet
You know you should check your feet each day, but it takes too much time. Or you forget. Or you have limited mobility and it's too hard. Washing and checking your feet for signs of trouble every day is essential to avoid serious injury. This is true no matter what type of diabetes you have.
Smoking
You might tell yourself, "I only take a few puffs." You may say smoking keeps you from eating too much. "If I quit, I'll gain weight." Smoking and diabetes are a deadly duo. Smoking increases your risk for complications. Quitting is one of the best things you can do for your health.
Confronting Denial
Denial is human. It's bound to crop up from time to time. When it does, you can recognize what's going on and fight back.
Make a plan — Write down your diabetes care plan and your health care goals. Understand why each item in your plan is important. Accept that it will take time to reach your goals.
Ask for help — If you find you are denying some parts of your diabetes care, ask your diabetes educator for help. If you have trouble with your food plan, talk to a registered dietitian. Together you can come up with solutions.
Enlist friends and family — Tell your friends and family how they can help. Let them know that encouraging you to go off your plan is not a kindness. Inform them about how you take care of your diabetes — they might want to adopt some of your healthy habits.
Types-3
,
Feeling down once in a while is normal. But some people feel a sadness that just won't go away. Life seems hopeless. Feeling this way most of the day for two weeks or more is a sign of serious depression.
Does Diabetes Cause Depression?
At any given time, most people with diabetes do not have depression. But studies show that people with diabetes have a greater risk of depression than people without diabetes. There are no easy answers about why this is true.
The stress of daily diabetes management can build. You may feel alone or set apart from your friends and family because of all this extra work.
If you face diabetes complications such as nerve damage, or if you are having trouble keeping your blood sugar levels where you'd like, you may feel like you're losing control of your diabetes. Even tension between you and your doctor may make you feel frustrated and sad.
Just like denial, depression can get you into a vicious cycle. It can block good diabetes self-care. If you are depressed and have no energy, chances are you will find such tasks as regular blood sugar testing too much. If you feel so anxious that you can't think straight, it will be hard to keep up with a good diet. You may not feel like eating at all. Of course, this will affect your blood sugar levels.
Spotting Depression
Spotting depression is the first step. Getting help is the second.
If you have been feeling really sad, blue, or down in the dumps, check for these symptoms:
Loss of pleasure — You no longer take interest in doing things you used to enjoy.
Change in sleep patterns — You have trouble falling asleep, you wake often during the night, or you want to sleep more than usual, including during the day.
Early to rise — You wake up earlier than usual and cannot to get back to sleep.
Change in appetite — You eat more or less than you used to, resulting in a quick weight gain or weight loss.
Trouble concentrating — You can't watch a TV program or read an article because other thoughts or feelings get in the way.
Loss of energy — You feel tired all the time.
Nervousness — You always feel so anxious you can't sit still.
Guilt — You feel you "never do anything right" and worry that you are a burden to others.
Morning sadness — You feel worse in the morning than you do the rest of the day.
Suicidal thoughts — You feel you want to die or are thinking about ways to hurt yourself.
If you have three or more of these symptoms, or if you have just one or two but have been feeling bad for two weeks or more, it's time to get help.
Getting Help
If you are feeling symptoms of depression, don't keep them to yourself. First, talk them over with your doctor. There may a physical cause for your depression.
Poor control of diabetes can cause symptoms that look like depression. During the day, high or low blood sugar may make you feel tired or anxious. Low blood sugar levels can also lead to hunger and eating too much. If you have low blood sugar at night, it could disturb your sleep. If you have high blood sugar at night, you may get up often to urinate and then feel tired during the day.
Other physical causes of depression can include the following:
Alcohol or drug abuse
Thyroid problems
Side effects from some medications
Do not stop taking a medication without telling your doctor. Your doctor will be able to help you discover if a physical problem is at the root of your sad feelings.
Mental Health Treatment
If you and your doctor rule out physical causes, your doctor will most likely refer you to a specialist. You might talk with a psychiatrist, psychologist, psychiatric nurse, licensed clinical social worker, or professional counselor. In fact, your doctor may already work with mental health professionals on a diabetes treatment team.
All of these mental health professionals can guide you through the rough waters of depression. In general, there are two types of treatment:
Psychotherapy, or counseling
Antidepressant medication
Psychotherapy
Psychotherapy with a well-trained therapist can help you look at the problems that bring on depression. It can also help you find ways to relieve the problem. Therapy can be short term or long term. You should be sure you feel at ease with the therapist you choose.
Medication
If medication is advised, you will need to consult with a psychiatrist (a medical doctor with special training in diagnosing and treating mental or emotional disorders). Psychiatrists are the only mental health professionals who can prescribe medication and treat physical causes of depression.
If you opt for trying an antidepressant drug, talk to the psychiatrist and your primary care provider about side effects, including how it might affect your blood sugar levels. Make sure that the doctors will consult about your care when needed. Many people do well with a combination of medication and psychotherapy.
If you have symptoms of depression, don't wait too long to get help. If your health care provider cannot refer you to a mental health professional, contact your local psychiatric society or psychiatry department of a medical school, or the local branch of organizations for psychiatric social workers, psychologists, or mental health counselors. Your local American Diabetes Association may also be a good resource for counselors who have worked with people with diabetes.
Types-4
Stress
Stress results when something causes your body to behave as if it were under attack. Sources of stress can be physical, like injury or illness. Or they can be mental, like problems in your marriage, job, health, or finances.
When stress occurs, the body prepares to take action. This preparation is called the fight-or-flight response. In the fight-or-flight response, levels of many hormones shoot up. Their net effect is to make a lot of stored energy — glucose and fat — available to cells. These cells are then primed to help the body get away from danger.
In people who have diabetes, the fight-or-flight response does not work well. Insulin is not always able to let the extra energy into the cells, so glucose piles up in the blood.
How Stress Affects Diabetes
Many sources of stress are long-term threats. For example, it can take many months to recover from surgery. Stress hormones that are designed to deal with short-term danger stay turned on for a long time. As a result, long-term stress can cause long-term high blood glucose levels.
Many long-term sources of stress are mental. Your mind sometimes reacts to a harmless event as if it were a real threat. Like physical stress, mental stress can be short term: from taking a test to getting stuck in a traffic jam. It can also be long term: from working for a demanding boss to taking care of an aging parent. With mental stress, the body pumps out hormones to no avail. Neither fighting nor fleeing is any help when the "enemy" is your own mind.
In people with diabetes, stress can alter blood glucose levels in two ways:
People under stress may not take good care of themselves. They may drink more alcohol or exercise less. They may forget, or not have time, to check their glucose levels or plan good meals.
Stress hormones may also alter blood glucose levels directly.
Scientists have studied the effects of stress on glucose levels in animals and people. Diabetic mice under physical or mental stress have elevated glucose levels. The effects in people with type 1 diabetes are more mixed. While most people's glucose levels go up with mental stress, others' glucose levels can go down. In people with type 2 diabetes, mental stress often raises blood glucose levels. Physical stress, such as illness or injury, causes higher blood glucose levels in people with either type of diabetes.
It's easy to find out whether mental stress affects your glucose control. Before checking your glucose levels, write down a number rating your mental stress level on a scale of 1 to 10. Then write down your glucose level next to it. After a week or two, look for a pattern. Drawing a graph may help you see trends better. Do high stress levels often occur with high glucose levels, and low stress levels with low glucose levels? If so, stress may affect your glucose control.
Reducing Mental Stress
Making Changes
You may be able to get rid of some stresses of life. If traffic upsets you, for example, maybe you can find a new route to work or leave home early enough to miss the traffic jams. If your job drives you crazy, apply for a transfer if you can, or possibly discuss with your boss how to improve things. As a last resort, you can look for another job. If you are at odds with a friend or relative, you can make the first move to patch things up. For such problems, stress may be a sign that something needs to change.
There are other ways to fight stress as well:
Start an exercise program or join a sports team.
Take dance lessons or join a dancing club.
Start a new hobby or learn a new craft.
Volunteer at a hospital or charity.
Coping Style
Something else that affects people's responses to stress is coping style. Coping style is how a person deals with stress. For example, some people have a problem-solving attitude. They say to themselves, "What can I do about this problem?" They try to change their situation to get rid of the stress.
Other people talk themselves into accepting the problem as okay. They say to themselves, "This problem really isn't so bad after all."
These two methods of coping are usually helpful. People who use them tend to have less blood glucose elevation in response to mental stress.
Learning to Relax
For some people with diabetes, controlling stress with relaxation therapy seems to help, though it is more likely to help people with type 2 diabetes than people with type 1 diabetes. This difference makes sense. Stress blocks the body from releasing insulin in people with type 2 diabetes, so cutting stress may be more helpful for these people. People with type 1 diabetes don't make insulin, so stress reduction doesn't have this effect. Some people with type 2 diabetes may also be more sensitive to some of the stress hormones. Relaxing can help by blunting this sensitivity.
There are many ways to help yourself relax:
Breathing exercises
Sit or lie down and uncross your legs and arms. Take in a deep breath. Then push out as much air as you can. Breathe in and out again, this time relaxing your muscles on purpose while breathing out. Keep breathing and relaxing for 5 to 20 minutes at a time. Do the breathing exercises at least once a day.
Progressive relaxation therapy
In this technique, which you can learn in a clinic or from an audio tape, you tense muscles, then relax them.
Exercise
Another way to relax your body is by moving it through a wide range of motion. Three ways to loosen up through movement are circling, stretching, and shaking parts of your body. To make this exercise more fun, move with music.
Replace bad thoughts with good ones
Each time you notice a bad thought, purposefully think of something that makes you happy or proud. Or memorize a poem, prayer, or quote and use it to replace a bad thought.
Whatever method you choose to relax, practice it. Just as it takes weeks or months of practice to learn a new sport, it takes practice to learn relaxation.
Dealing with Diabetes-Related Stress
Some sources of stress are never going to go away, no matter what you do. Having diabetes is one of those. Still, there are ways to reduce the stresses of living with diabetes. Support groups can help. Knowing other people in the same situation helps you feel less alone. You can also learn other people's hints for coping with problems. Making friends in a support group can lighten the burden of diabetes-related stresses.
Dealing directly with diabetes care issues can also help. Think about the aspects of life with diabetes that are the most stressful for you. It might be taking your medication, or checking your blood glucose levels regularly, or exercising, or eating as you should.
If you need help with any of these issues, ask a member of your diabetes team for a referral. Sometimes stress can be so severe that you feel overwhelmed. Then, counseling or psychotherapy might help. Talking with a therapist may help you come to grips with your problems. You may learn new ways of coping or new ways of changing your behavior.
Types-5
Diabetes Distress
Checking blood glucose, taking medications, hitting the gym, counting carbs, and cooking up healthful meals: At times, your laundry list of responsibilities may feel overwhelming.
The understandable sense of burden or defeat that may occasionally punctuate your life with diabetes has a name: diabetes distress. Doctors are just beginning to understand this condition and how it affects your health and well-being. What is clear, though, is that diabetes distress is a drag—and that's why researchers are seeking ways of overcoming these negative emotions.
More Than Worry
Diabetes distress is hard to nail down because it overlaps with several related conditions, including depression, anxiety, and stress. "It's messy," says Lawrence Fisher, PhD, professor at the Diabetes Center of the University of California–San Francisco. "It's hard to define and hard to distinguish from the other states."
It was from seeing patients that Fisher first got the hint that this diabetes-specific emotional state exists. "We were really struck by the number of folks reporting high levels of stress and depressive symptoms who weren't even close to reaching major depressive disorder," he says. So if they weren't clinically depressed, he wondered, what were they dealing with? The answer was that they were experiencing unique emotional issues directly related to the burdens and worries of living with a chronic disease. They had diabetes distress.
The condition is characterized by "worry, frustration, concern, and maybe a bit of burnout," says Stephanie Fonda, PhD, a researcher at the Diabetes Institute of the Walter Reed National Military Medical Center. She says these emotions can be related, for example, to concerns about getting proper treatment or communicating effectively with a health care provider. Fonda says a person with diabetes distress may wonder if anyone understands how tough it is to have diabetes and think, "I'm tired of being sick all the time."
These feelings are not rare. Fisher's research suggests that, in any 18-month period, between a third and a half of people with diabetes will experience diabetes distress. That's a problem for both emotional and physical well-being because diabetes distress is linked to poor health outcomes. A 2010 study in Diabetes Care reported that people with higher distress levels were more likely to develop high blood glucose than those with less distress. Someone who is burned out on diabetes might be less likely to take medications to lower blood glucose, says Fisher, who led the study. He also found that higher blood glucose levels seemed to raise the risk of distress. "If I saw my A1C go up, I might get more distress," explains Fisher.
When trying to determine if diabetes distress is likely to cause health problems or prevent people from taking their medication, Fonda looks for signs of burnout. "They say things like 'Nothing I do works' or 'I'm taking these pills, but they aren't doing anything for me,'?" she says. "If they believe that, then they aren't going to take them."
Distress Test
Because distinguishing diabetes distress from related conditions can be challenging, Fisher and colleagues developed a special test that aims to identify people burdened by distress. The test, which health care providers give to patients, covers four general areas.
The first is "regimen distress," says Fisher, which he calls "the distress of having to do the diet, manage the exercise, take the medications, etc."
The second test section focuses on concerns about a future with diabetes and the possibility of developing complications.
The third part looks at whether a person is worried about the quality of care he or she is getting from doctors and the cost of that care.
Finally, Fisher's test checks for "social burden." Some people mistakenly believe, for example, that people with diabetes are to blame for developing their disease because they ate too many sweets. There's a "stigma associated with the disease," Fisher says, and that can take a toll.
The test is designed for people with type 2 diabetes, but Fisher is working on versions specifically for people with type 1 and for caregivers. Fisher says diabetes distress is at least as common among caregivers as with people who have the disease. Fears about low blood glucose (hypoglycemia) are mainly what distinguish distress in type 1 from that in type 2. "You don't hear a lot of adult type 2s worried about hypos," says Fisher. With type 1, hypoglycemia can be dramatic, frequent, and sudden. That leads to concerns about driving and other activities, which can blossom into diabetes distress.
Defusing Distress
Diabetes distress may not necessarily require a doctor's care, says Fisher. He considers occasional bouts of distress normal for people with diabetes. "Sometimes it gets out of hand, and it can have consequences, but for the majority, it's part of having diabetes," he says. For many people, simply taking things one step at a time can be helpful, Fisher says, rather than tackling a new exercise routine, meal plan, and blood glucose–monitoring regimen all at once. He also suggests making changes slowly, so as not to get discouraged when results don't come quickly. Fisher encourages people to speak up and talk about their diabetes, with a health care provider as well as family members and other people with diabetes.
Fisher is wrapping up a study that tests two ways of reducing diabetes distress. One is to "improve diabetes management so people will have less to worry about," he says. "The other way is to target the distress directly," with cognitive behavioral "talk" therapy. This structured approach trains people to become aware of negative thoughts and to address them in a productive manner.
Another way to reduce distress may be to set appropriate health-improvement goals. Fonda uses an old joke to explain this tactic: "How do you eat an elephant? One bite at a time." She encourages people with diabetes to focus on small, discrete goals. Vague or unachievable goals, such as trying to lose a large amount of weight in a short time, can cause frustration and pain, Fonda says. For peace of mind, it's important to redefine success, she says: "Any progress toward a goal is success."
Coping Strategies
We asked three members of the Diabetes Forecast Reader Panel whether they've experienced diabetes distress and how they coped. Here are their stories.
Accept that you can't control everything
Sherry Reynolds, RN, CSPI, was diagnosed with type 2 diabetes about two years ago and, as a nurse, she usually feels pretty on top of it. That changed last December, when Reynolds had a serious asthma attack that sent her to the doctor, who prescribed steroids. These medications tend to raise blood glucose levels. By the fourth day, Reynolds's blood glucose was over 300 mg/dl. "At that point I was, for the first time since I was diagnosed as a diabetic, quite fearful," she says. "I had done all of the right things and all of the tricks I know to do as a nurse to keep my blood sugar in check, including increase my medication, and nothing worked." Reynolds says that was her true moment of awakening—realizing that with diabetes she can't control everything. "This has been the only time that I have been distressed over my disease and how it can 'control' me rather than [my maintaining] it." Yet, Reynolds generally keeps things in perspective. "I'm not pleased with [diabetes]," she says, "but understand that as we age, bodies do tend to wear out and must be dealt with."
Look for support from people who can relate
Every night, Sarah Howard or her husband gets up to check the blood glucose of their 8-year-old son, who has type 1 diabetes. Each morning, they check to see if he is still breathing. They worry that he might not be because of "dead-in-bed" syndrome. In this unusual event, someone with type 1 who showed no sign of illness the evening before is found dead in the morning. Maybe checking their son frequently qualifies as diabetes distress, Howard says, although part of her thinks it's just prudent. In another instance of distress, "when I first met my son's teacher, I broke down in tears and had to leave the school," she says. "I just was not ready to let him go and hand him over to someone else all day." But she was able to deal with it. "I went online to see if others had dealt with this and got some support that way," Howard says. "It has worked out fine.
Tap into faith and family
"I don't worry about these diseases. I just get weary fighting them. And discouraged at times," says John Greller, who has lived with type 1 diabetes for about 40 years. "Did I ever experience frustration and disappointment about having and treating diabetes? Of course," he says. "As a consequence of diabetes, I've experienced end-stage renal disease, a failed kidney/pancreas transplant, a successful living-donor kidney transplant from one of our sons, and numerous other complications from this disease." For Greller, the people in his life and his religion have been a big comfort. "I am able to cope with it because of my faith, my dear caregiving wife, Jane, family, friends, and a wonderful medical team over all these years."