RESEARCH ARTICLES
Emotional impact before the diagnosis of type 2 Diabetes Mellitus
Enéas Rangel TeixeiraI, Ilze José RochaII, Dayanna Santos de Paula FerreiraIII, Donizete Vago DaherIV
INurse, Psychologist, Postdoctoral, Full Professor at the Fluminense Federal University, Aurora de Afonso Costa Nursing School, Department of Medical-Surgical Nursing. Academic Coordinator of the Master of Science in Health Care, Leader of the Research Group Health Care, Nursing and Subjectivities in Trans-disciplinary Perspectives, Niteroi, Rio de Janeiro, Brazil. E-mail: eneaspsi@hotmail.com
IINurse, Psychology Student, Maria Thereza Integrated School Specialist in the Moulds of Residence, Nursing in Collective Health, Fluminense Federal University, Aurora de Afonso Costa Nursing School, Niteroi, Rio de Janeiro, Brazil. E-mail: ilze1909@yahoo.com.br
IIINurse, Specialist in the Moulds of Residence, Fernandes Figueira Neonatal Nursing Institute. Nursing Master's Student, Academic Master of Science in Health Care, Fluminense Federal University, Aurora de Afonso Costa Nursing School Niterói, Rio de Janeiro, Brazil. E-mail: dayannadepaula@ymail.com.
IVNurse. Phd in Nursing, Associate Professor at the Fluminense Federal University, Aurora de Afonso Costa Nursing School, Department of Medical-Surgical Nursing. Vice-leader of the Research Group Health Care, Nursing and subjectivities in Trans-disciplinary Perspectives. Niteroi, Rio de Janeiro, Brazil. E-mail: donizete@predialnet.com.br
ABSTRACT
The focusof this studyis theemotionalimpactof the type 2 Diabetes Mellitus diagnosis in the lives ofindividuals investigatedbylistening totheir life histories. This study aimed toidentify the perceptionof the person who receivesthe diagnosisand to discuss theemotionalimpactof the diagnosison the subject’s life history. This is a qualitative and descriptive studyconductedin Niterói, Rio de Janeiro, Brazil through the narrative oflife historyof 10patientswithdiabetes, in whichtwo themesemerged: Emotional responsesin addressing theimpact ofdiagnosis and repercussion of DiabetesMellitusdiagnosis in subject’s daily life. The diabetes diagnosisreflectedin the patients’ livesproducingsorrow, desolation andinsecurity, which culminates in alimitedacceptance of the diseaseandthetherapeutic itinerary. Therefore, health professionalsshouldrecognize theemotionalimpactof Diabetes Mellitus diagnosis in the patients’ lives and their influenceon health care.
Keywords: Emotional impact; type 2 Diabetes Mellitus; constitutional diagnosis; nursing.
INTRODUCTION
The focus of this study is the emotional repercussions of the patient faced with the diagnosis of type 2 Diabetes Mellitus through listening to the history of the subject's life.The purpose of this study pervades the scope of the disease; it is something intrinsic to the context of the perceptions of their emotions.
It is frequently observed, that the disease is diagnosed and does not consider the subject as a speaking psychological being, which expresses them and has feelings. Therefore, one works on the focus that the diabetic individual accepts their disease, through the bonding production with health professionals, in order to expose their feelings and difficulties. This is essential, because it is a chronic disease that will result in a series of changes in the subject's life, that need to be understood and managed by both health professionals and by the diabetic individual themselves.
Often, upon the diagnosis of a chronic disease by the physician, the individual starts to be referenced by this morbid classification, and not as a person, a being who has just received an impact generator diagnosis and that will influence or transform their life1. For this reason the patient is often devastated and with difficulties in accepting the disease and the care needed for its control.
The nurse's position towards the situation of the diagnosis of Diabetes Mellitus, will in addition to disseminating information about the disease, remove any doubts or emphasize lifestyle changes. It is necessary to offer support to this patient and their family, building possibilities for which they reveal their feelings and concerns towards the diagnosis. Because it has been proven that people's difficulty alter the habits that they have acquired during their existence in a sudden manner. Therefore, it is essential to listen to the difficulties that this patient is experiencing in addressing the diagnosis and, from that outline together the goals to achieve quality of life even with the presence of a chronic disease2.
From this perspective, the following guiding questions were raised: what are the emotional responses of the person who receives the disease diagnosis? And what is the impact of the diagnosis of type 2 Diabetes Mellitus in the person's life?
Given the issues face the following objectives: to identify the perception of the person receiving the diagnosis of type 2 Diabetes Mellitus and discuss the emotional impact of this diagnosis in the history of the subject's life.
THEORETIC REFERENTIAL
The person upon being diagnosed with a chronic disease and becoming aware of the confrontation that they will have from thereon, can present emotional changes such as anxiety, fear and insecurity for the unknown future and how they will experience the adaptation process to new life habits.The subjects who receive a diagnosis of Diabetes Mellitus have "common reactions such as: rage, anger and depression, which shows the disease a condition that, regardless of their etiology and age, cause profound bio-psychosocial changes"3:127. These diabetic individuals, they are in a complex choice between maintaining the previous habits and modifying them in order to obtain a better quality of life.
Patients with diabetes have considerable difficulty in accepting the diagnosis and tend to underestimate their condition and treatment until the first aggravated signs and symptoms the disease appears4.This fact is entailed by a tangle of feelings and behaviors, which hinder the acceptance of their chronic health condition, and, in addition, has the demands of health professionals, family members and friends in relation to changes in life habits5.
With time, however, when the complications exacerbate and intensify the treatment, diabetic patients typically report more distress and feel more vulnerable6,7. Complex treatments that involve both changes in life style, the introduction of many medicines can be very demanding, confronting the patient with the disease8,9.
The guidelines of the Brazilian Society of Diabetes emphasize that the social problems caused by Diabetes Mellitus is not restricted to economic issue.This is because, there are other intangible costs , such as: pain, anxiety, inconvenience, loss of quality of life, a great impact on the lives of people with diabetes and their families10; hence, these aspects are difficult to quantify.
The health professional when dealing with the diabetic patient should avoid the focus on the disease, but rather focus on the person, because, this diagnosis can be a generator of various emotions that make it difficult to adapt to the lifestyle that is presented after the diagnosis. Thus, it is important that the feelings and emotions produced after confirmation of the diagnosis are heard and valued, so that the patient can accept the disease and adhere to treatment in a participative mannner11.
It is important that the nursing professionals, due to their proximity and interaction with the users of health services, establish sensitive listening to the patient who received the diagnosis and from that moment on is replaced by the awareness of the process of living with a chronic disease and who will have to redirect their life habits. Therefore one can understand the subjectivity of the patient in order to understand their feelings, fears and anxieties12.
Added to this is the ability to engage the nurse, whereas the majority of diabetic patients have difficulties in accepting the disease and the therapeutic itinerary. The importance of the real meaning of the dialogue is present and it can be understood as "the meeting in which the reflecting and acting in solidarity of their subjects addressed to the world to be transformed and humanized, cannot be reduced to an act of depositing ideas of an individual in another"13:45.
Therefore, the chronic or incurable diabetes entails, for patients a significant impact on several aspects in their lies, such as work, interpersonal relations, social interaction and the physical and emotional well-being. The patient will in addition to the treatment and the disease's permanence in their life, they live in expectation of the possibilities of complications of the disease, determining an emotional impact, affecting their quality of life14.
METHODOLOGY
The approach is qualitative, since it allows the recognition of subjective aspects, these are impossible to be analyzed through statistical data15.The type of study adherent to this work was the life history, which uses an individual narrative, and is part of a socio-cultural context. The stories of life are self-revelation narratives about life experiences. With this method, the researcher asks participants to provide, in a chronological sequence, their ideas and experiences regarding any issue, either verbally or in writing16.
The research was conducted with 10 diabetic patients, identified by words that mirror the sentiments which circulate among the subjects, who were registered in the Program Hiperdia of a Health Care Polyclinic in Niterói, State of Rio de Janeiro, during the year 2010 In this scenario they develop educational and health care activities, coordinated with activities of undergraduate education, postgraduate and extension. The data collection technique was a narrative type semi-structured interview which enables an interaction between the interviewer and interviewee, allowing a deepening of the communication.
To delimit the sufficiency, data the saturation criterion was used. The thematic content analysis technique was used and followed three steps: Pre-analysis, in which through careful reading, there were content approximations, systematizing the material, material exploration that occurred in the construction of the core themes; interpretation of data. Two core themes were generated: emotional responses in addressing the impact of diagnosis and the repercussion of Diabetes Mellitus diagnoses in the daily life of the subject.
Ethical aspects involving research with human beings were respected, which according to Resolution No. 196/96 of the CNS provides: informed consent; confidentiality of interviewees; guarantee that preventable damage would be avoided. This research was approved by the Research Ethics Committee of the Fluminense Federal University, with protocol No. 0502.0.000.258 -08.
RESULTS AND DISCUSSION
In order to meet the objectives of the study are presented and analyzed the results through two core themes.
Emotional responses in coping with the diagnosis
The Diabetes Mellitus is, generally, diagnosed through routine examinations or through the suspicion of the symptoms.The diagnosis confirmation generates various emotions and feelings, since it is a chronic disease that requires permanent treatment which also involves a change in lifestyle.Soon after knowing the diagnosis, the individual starts to receive information in relation to the disease, the treatment and control. Through this, the diabetic patient is treated as an individual free of emotions that may compromise their care. This is because it may not have the opportunity to expose their feelings, and this fact may hinder the acceptance of the disease and, consequently, the proposed treatment.
There is relationship between emotion and diabetes, one influencing the other. Often the emotional impact exerts a strong influence to the triggering of the complications in the Diabetes Mellitus.Thus, "the repression or flee from emotion can be the cause of multiple psychosomatic illnesses"17:30.In the majority of the narratives the diagnosis is related to the development of symptoms after hard times on the life of the individuals, confirming the existence of a close relationship between diabetes and emotion, the example of a participant:
I discovered it by having a blood test. Now, after I got sick, I did several tests, then gave me this diabetes. And I got sick after my sister was hospitalized. [...]. When I got home I started to feel sick, I was very nervous. I had a strong feeling of suffering, you know? And it hurts, and it hurts us. (Joy)
The diabetic patients are often already weakened by living the difficult moments of life. The arrival of the diagnosis may trigger emotional reactions that determine changes in the person's daily activities and this causes many feelings “such as regression, reduction of self-esteem, insecurity, anxiety, denial of the situation presented and depression. In accordance with the psychic structure of the person and their internal resources, they will handle it, better or worse, with the new disease situation"18:205. Many interviewees recount that this diagnosis generated emotions such as emotional shock, sadness, feeling of limitation, anger, concern, in addition to fear of complications and even death. One of the participants explained their sadness in the statement below:
Ahh! It was very sad, I was sorry. I was with a very young child. ugh! I thought that I would die [...] It was horrible and I was disgusted did not want to take care of myself, I isolated myself. If they made me take insulin I think I would kill myself. Greater despair! Do you believe that I became a very sad person after discovering that i was diabetic? (Hope)
Emotional reactions, when not managed by health professionals, may complicate the acceptance of the disease and the therapeutic itinerary. These reactions can lead to "social isolation; breakdown of the family unit and, consequently, non-compliance with the self-care actions, requiring the nurse to search for intervention strategies to facilitate and promote the actions of the self-care roles” 3:128.The narratives showed that it is essential to create a link between the professional and the diabetic patient, with the purpose of them feeling free to express their emotions and feelings, which will contribute to the understanding and acceptance of the disease. Upon receiving the diagnosis, respondents reported that they reacted with apprehension, worry, nervousness, anger, sadness and crying.
Ahh! I cried a lot, I was sad? But then I started to accept it? What I will do. I have to take care of myself? (Happiness)
Good! At the beginning then I became very disturbed [...] What else can I do? If I am diabetic, I will continue diabetic, because diabetes has no cure. Patience. What can I do? (Laughter). (Affective)
The majority of respondents referred negative reactions to receiving the diagnosis. "Receiving the diagnosis of a chronic disease, such as diabetes, awakens various feelings, emotional reactions and fantasies that need to be known and understood by health professionals"19:5.To have this knowledge the professional cannot grasp the difficulties that the patient may be experiencing and with these data outline effective care strategies.
Impact of the Diabetes Mellitus diagnosis in the subject's daily life
The impact of the diagnosis usually entails a variety of emotional responses, which transit between the acceptance and the resistance. The speeches showed this double sense: most of them accept with great tranquility the decision to change their habits (testimony of Love), others resist the necessary changes (testimony of Courage). Therefore, it is essential to worked on the dialog for treatment adherence procedures, with views to re-dimension preconceived conceptions.
I try to obey and really think it has helped me a lot to come this far. (Love)
Helping people is the same, the doctor says and whoever wants follows? Sometimes I follow, sometimes not. (Courage)
Diabetic patients know that the effectiveness of treatment depends in part on them, but they experience difficulties in adapting to the new lifestyle habits, especially when it comes to food. "The limitations and prohibitions imposed by the disease and its treatment take their freedom away from doing what they want, this is what causes a sad life"19:314 .The dietary restrictions are the main difficulty encountered by diabetics, because, they are present at every moment in the life of the subjects and represent a broad value in the society in which we live. This is due to the fact that food has a symbolic value and linked to the feeling of pleasure, satisfaction and camaraderie. The "Happiness" participant is exemplified in the statement by the difficulty to resist the sweets, one of the main reluctances of diabetics.
I started to not eat a lot of sweets and looked at dieting, but even so I still eat them just like before, yesterday I ate sweets, I could not resist (laughs). (Happiness)
In addition to the change in eating habits, there is a need for adaptation to other factors involving the treatment and control of diabetes, such as the use of insulin and the daily checking of capillary glucose. The emotional reactions arise from the need for care [...] and as an expression of individual emotional perception, causing greater difficulty for the performance of the actions contained in the roles of self-care and, consequently, to the adherence to treatment" 3:126. The diabetic patients often feel discouraged by having to perform daily control, treatment and prevention of complications, and at the same time knowing that all this effort is not a cure. Such circumstances are outlined below:
I had to buy a device that checks blood glucose for me, but I already had one to know how it was, but I then gave it to a lady who also had diabetes. I gave it, you know why? Ahh! Because all day measuring, and then check the time I'll stick where I am because I'm already nervous. Of course! I have to have nervous. It does not hurt I know, but I couldn't do it. (Courage)
For many, the fact of being diabetic represents living with limitations, which hinder their daily life. In addition, in their daily routine, the treatment and control of the disease will present, which will accompany them throughout their life. For example, "follow the prescribed food for a prolonged period of time is an extremely painful task"19:314, as well as having to take the medication and check the capillary glucose.
There are narratives that suggest the diagnosis as a determinant of reduced life enjoyment. The compromising of pleasure is directly related because diabetics generally have no opportunity to express their feelings. "Emotions also affects control of the disease, since diabetes control requires an intense control in order to avoid complications"20:76.
I was so happy with life, and more joyful, when I was not diabetic. I've used to be good-humored, joking a lot. But that is over, I am not like that anymore [...] I stopped being like that. I miss it . I'm not able to be the same person. (Hope)
While, some of the subjects have difficulty in adapting to the diabetes and seek new perspectives in relation to their own lives, others are looking for ways to adapt to the new lifestyle. This way, the diabetic individual can reward their desires through, for example, the family environment and the stimulus of other senses such as smell.
I'm living life with diabetes. Because I have my distractions, my children. We have a very good life and distracted. (Passion)
Sometimes I don't want to eat the sweets, but I feel like I smell of them. (Courage)
Therefore, diabetic individuals will be helping themselves, when they implement new strategies to stay on the diet, but many of them are finding it difficult to take care of their health. These highlight the need for a multidisciplinary approach to provide support and look for and perform sensitive listening, seeking adjustments to the therapeutic itinerary. Therefore, the care requires an interdisciplinary dialog, emphasizing the integration of knowledge, which are designed to empower them to live with the adverse situation to their health and encourages them to transform this situation21.This highlights the importance of an integrated health care system and the deviation of the biomedical approach.
And I know that I need to do better, for example, walking is so important to everyone that reaches of 40 and 50 years of age, the muscles get softer, so you need to move. And I am kind of lazy about it, even now the doctor told me to walk 40 minutes, I can't even do it for a half hour (laughter), a half an hour for me is already too much. I do my time, and not their time. (Hope)
Living with diabetes is complex because it is necessary for the subject to be able to reconcile their daily lives (work, living in society, nutrition, body rhythm) with the routine of the therapeutic proposition. "Living with the disease is a suffering process, permeated by mood swings and frequent exposure to negative feelings, such as discouragement, sadness, conflicts and guilt"22:206.
Living with diabetes [...] difficult! If you go to somewhere you have to take everything. I think that it would be easier if I had insulin that did not need be on ice. (Happiness)
It is very common that diabetic individuals resist using insulin, an injectable drug which represents for many to live with painful and constant invasive procedures. The fact of having to perform daily applications can limit one's activities generating "difficulties related to the medication transport and increased visibility of the disease which it causes, leading to public recognition that they are a person who has diabetes"22:207.The narratives remind us on the living restrictions generated by the diabetes diagnosis.
CONCLUSION
It was found that the diagnosis of type 2 Diabetes Mellitus was received by an impact with repercussions on the patient's life, highlighting the emotional aspect.This confirms that there is a close relationship between diabetes and emotional aspects, either before, during or after the diagnosis, with its respective characteristics. And that the diabetic patient's emotions and feelings can influence acceptance of the disease as well as in their care.
The emotional repercussions after the diagnosis were evidenced, through reactions, perceptions and negative emotions, which contributed to the difficulty in accepting the disease and living with it.
It was also clear that the greater difficulty of the patients in relation to the therapeutic itinerary and the food issue, that is, also, closely related to social life. Many of them have sensations of limitations or prohibitions, and this causes that they deviate from their social life.
Another difficulty of the diabetic patient is related to the use of insulin, because many of them do not accept the compulsory daily use of insulin. For diabetic individuals, insulin treatment represents a form of nuisance, with a restrictive character.
Given the evidence that this study addressed in relation to emotional aspects and its repercussions on daily life of the subject, one can realize the importance of identifying the emotions, perceptions, and difficulties of the diabetic individual in caring for themselves. The health professional needs to be aware that the emotional aspects can influence or determine the effectiveness of care.
Accordingly, given the difficulties faced after diagnosis and living with diabetes, it is essential to work in partnership with the family, so that these individuals can feel safe and empowered in dealing with the disease.
In fact, health professionals, especially nurses, need to build bonds with patients, looking to heal them and allowing their self-expression, because they have much to contribute in the direction of care actions. Thus, the narrative is a research resource that allows us to understand the subjectivity related to health and disease.
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Received: 15.05.2012
Approved: 15.01.2013