Insulin-treated diabetes patients with fear of self-injecting or fear of self-testing: Psychological comorbidity and general well-being
Introduction
Patients with Type 1 diabetes (onset often <20 years) have an absolute deficiency of insulin, necessitating injections of insulin on a daily basis. Adherence to the regimen of insulin therapy and self-testing has been shown to be difficult for a number of diabetic patients [1], [2], [3]. It is unknown as to what extent difficulties in coping with the diabetes regimen are due to fear of self-injecting (FSI) and/or fear of self-testing (FST).
FSI and/or FST are likely to adversely affect glycaemic control, through postponing or skipping injections and/or avoiding self-testing of blood glucose. FSI and/or FST may, thus, be regarded as risk factors for the early development of diabetes-related complications [4]. Research suggests that fear of injecting insulin in diabetes patients is associated with general anxiety, concern about having to inject more frequently, and previous avoidance of injections. No significant correlation has been demonstrated between injection anxiety and glycated hemoglobin values (HbA1c) [5]. A small number of case studies have been published on FSI in diabetes patients [4], [6], [7], [8], which illustrate the negative impact of FSI on quality of life and self-care.
Blood–injury phobia, which may be related to FSI/FST, was shown to be associated with less frequently performed self-monitoring of blood glucose [9] and poorer glycaemic control [10]. An epidemiological study concerning blood–injury–illness (BII) phobia [11] showed that BII phobics with diabetes had significantly higher rates of macrovascular complications compared to diabetes patients who did not suffer from BII phobia.
To our knowledge, no population-based research has been performed on the psychological comorbidity and well-being of patients who suffer from FSI/FST. Here we report on a large survey among diabetes patients, examining the differences in patient characteristics, psychological functioning, and diabetes self-care of adult diabetes patients with and without extreme FSI/FST. We hypothesized that: Hypothesis 1 Patients with long-standing diabetes and extreme FSI/FST would report relatively high levels of depression, as well as more difficulties in psychological functioning (psychoneuroticism, trait anxiety) [12]. Hypothesis 2 Given the daily confrontation with an anxiety-provoking task, fearful patients would report high levels of diabetes-related distress and poor general well-being.
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Participants and procedure
A composite questionnaire (described below), two letters in which the goals and procedure of the study were described, and a prestamped response envelope were mailed to a sample of 3000 patients with Type 1 or 2 diabetes. The subjects were randomly drawn from the approximately 40,000 patient members of the Dutch Diabetes Association (DVN, Diabetes Vereniging Nederland). Inclusion criteria for our study were: (1) age >16 years, and (2) being on insulin therapy for a minimum of 6 months. The
Results
In total, 1484 questionnaires were returned (49.5%). No information could be obtained on the nonresponders. Twelve questionnaires were excluded from data analyses due to incompleteness and 197 subjects were excluded since they did not use insulin. A total of 1275 patients participated in the current study (51.1% male; age 49.7±15.8 years; 58.0% Type 1 diabetes; diabetes duration 17.5±12.0 years; duration of insulin use 15.1±12.2 years). Response rate for the second questionnaire, which was
Discussion
In line with our expectations, we found that patients who suffer from extreme FSI/FST report significantly worse psychological functioning, higher levels of diabetes-related emotional distress, and poorer general well-being.
Given the cross-sectional design, we cannot infer a causal relationship between psychological comorbidity and FSI/FST. Longitudinal research is warranted, following up on newly diagnosed insulin-requiring diabetes patients in their adaptation to their new self-care
Acknowledgements
This study was financially supported by the Dutch Diabetes Research Foundation (Diabetes Fonds Nederland, DFN) (grant no. 96.105). Our thanks are also due to the board and members of the Dutch Diabetes Association (Diabetes Vereniging Nederland, DVN) for their kind cooperation in this study.
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