Insulin-treated diabetes patients with fear of self-injecting or fear of self-testing: Psychological comorbidity and general well-being

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Abstract

Objective: To examine psychological functioning and self-management behaviours of Dutch adult patients with insulin-requiring diabetes mellitus suffering from extreme fear of self-injecting (FSI) and/or fear of self-testing (FST). Methods: A cross-sectional survey was performed in a sample of insulin-treated diabetes patients (n=1275; 51.1% male; age 49.7±15.8 years; 58.0% Type 1 diabetes), assessing FSI and FST. Patients completed the questionnaires concerning trait/state anxiety, depression, fear of hypoglycemia, diabetes-related distress, diabetes self-care activities, and general well-being. Comparisons were made on these measures between patients with extremely high scores on FSI and/or FST (≥95th percentile) and the other patients. Patients with extreme scores on FSI and/or FST were invited to take part in a second survey to assess the prevalence of major depression, common fears/phobias, and psychoneuroticism. Results: People with extreme FSI/ FST scores, as compared to the other patients, reported higher levels of trait/state anxiety and depression. This group also reported more fear of hypoglycaemia and diabetes-related distress, had lower levels of general well-being, and reported less frequent self-monitoring of blood glucose. The second survey showed 11.1% of patients with extreme FSI/FST reporting scores indicating major depression. Prevalence of scores greater than or equal to the high scores on phobias (38.0–63.3%) and psychoneuroticism (27.8%) were consistently higher than norm group prevalences. Discussion: Extreme levels of FSI and/or FST are associated with high diabetes-related distress, poor general well-being, and psychological comorbidity, as well as poorer adherence to the diabetes treatment regimen. It is concluded that patients with extreme FSI/FST are often burdened with more than this specific phobia.

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.

Section snippets

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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