Stress, distress & burn out

Diabetes can affect you physically, emotionally, socially & psychologically. This is also relevant for family members and caregivers who can experience the same emotions and reactions to diabetes as the person who has been diagnosed.

Diabetes requires self management on a daily basis. This means you need to be in the driver’s seat and you should be at the centre of your diabetes management team. Diabetes is often an unpredictable and tricky disease to manage. It can be frustrating and feel pointless. Diabetes can be difficult to control no matter what sometimes and it can complicate life in general!

Diabetes tests and targets can raise stress

Targets in diabetes are important, such as blood glucose levels (BGL), HbA1c or A1c (the average BGL over the past 8 – 12 weeks), blood pressure and so on. However this can make you feel like you are “sitting an exam” every day.

The results of BGL checks, managing your weight, choosing healthy foods, managing insulin ratios and exercise, etc etc can lead to guilt, worry and stress. If you start to feel you are “not doing the right thing” and/or you are “not getting the right results”, it can lead to diabetes distress and you may end up blaming yourself. As a parent this can help your child as you model to them, these are more helpful and empowering ways to talk about their diabetes.

Talking about “high and low” blood glucose and not “good and bad” can be a healthy place to start.

It is important to remember that these targets are guides to your health and diabetes management. The results on your home blood glucose monitor are a tool to helping you and your health care team to make adjustments and work towards a healthy you.

These numbers are not ends in themselves. How you choose to use them will depend on the type of diabetes you have, how long you have had it and your personal needs and choices.

Diabetes Distress

Diabetes may lead to specific problems and increased stress, which we often call “diabetes distress”.

Daily life and general stress levels can affect your diabetes control. How well your diabetes is going can in turn affect your general stress levels – so it is a bit of a chicken and egg. It is very important to get the general stress in your life under control, as this will assist with your diabetes management. Likewise, feeling settled with your diabetes management will decrease your overall stress.

If you are struggling with stress at work, or in your personal life, it can be harder to manage diabetes and it suffers. We all experience stress and life would be boring without some stress! People say they would rather not have stress in their lives, but in fact we need a balance between just enough stress and not too much, to keep us alive and active. Not all stress is bad believe it or not.

Some of the things that can lead to diabetes distress are:

Worry about food changes
Management of blood glucose levels
Weight management
Going onto insulin/medication
Hypos (low BGL)
Depression & mood swings – have been shown to be higher in people with diabetes
Relationship & sexual problems
Work stress, discrimination in relation to your diabetes
Disclosure – wondering if you should tell people about your diabetes
Lack of understanding or support from family/friends
Guilt, fear, worry, panic & anxiety about diabetes and your future
Risk of Complications
Feeling alone and isolated
Seeing or hearing about all the things that can go wrong
Feeling out of control
Other mental health problems such as an eating disorder
Feeling overhwelmed and exhausted
Lack of information

Minding Diabetes

Here is a great tool from the NDSS which we had some input into. You can check your emotional health and hop back across here for some support – http://mindingdiabetes.com.au/

It is not all doom and gloom!

It is not inevitable that you will have all or any, of these problems. You may or may not experience some ups and downs with your diabetes and this might lead to increased stress.

We are all different.

What is important is to understand that diabetes is in itself a full time job and managing it can bring increased stress. This can make it easier to be gentle on yourself when things get tough and to seek support in managing.

What is stress?

In basic terms if what you are being asked to do at this point in time is too much for you, you will experience stress. What you can handle will vary from day to day and even within a day and will vary from person to person. This means your ability to cope with stress will also vary.

Stress is made up of many things: the experiences we have, pathways within our body and brain, the responses we have to stressful situations and events and outcomes of this stress.

Stress is caused by a range of different events or circumstances.

Different people experience different aspects and identify with different definitions.

Stress and worrying

Even imagined change can be a stress. This is what we tend to call “worrying”. If you worry that you will not have enough money to pay your rent, or that you might suffer the complications of diabetes, that can lead to increased negative stress. This kind of stress is in your control to manage – you can tune into the way you are thinking about things and stop this worry in its tracks, thus minimising the impact on your body and your life.

Regular relaxation and time out can help you to minimise worry. Talking to other people about your worries, rather than keeping them to yourself, can also help.

“Catastrophising” when something goes wrong also increases your stress – this is the “it’s the end of the world”; “everything happens to me” kind of thinking. If one small thing goes wrong it is easy to start linking it to all the other things that have happened and then see this as “the end of the world”. Learning how to keep this thinking in check can really help minimise stress.

A major source of stress is overdoing things. If you push yourself too much you have less rest time. Eventually you will “hit the wall. If ongoing, permanent damage may be done.

What happens to our body when under stress?

Fight or flight response

When faced with a threat an automatic response is set off in our body – the fight or flight response.

This was an essential tool for human survival, developed over many thousands of years living in wild and dangerous places. To us, living in today’s world, it is often an ineffective response, which can actively prevent us from responding usefully to a problem situation – just think about road rage!!

Fight or flight is a response to anything which is perceived as a threat, or a potential threat by our body – it is not something we necessarily think about – it just happens.

This begins when certain primitive parts of the brain send a message to the adrenal glands which release a number of hormones including adrenaline, whose purpose is to prepare the body for vigorous emergency action.

The main changes that follow are below:

Non-essential processes are immediately switched off by our body. Things we don’t need right now are turned off.In particular, if the body is digesting food, that is stopped immediately, and people can notice a feeling of churning or ‘butterflies’ in the stomach, or feeling nauseous or sick.

A number of other changes follow, to make the muscles as strong as possible
- The liver releases stored glucose into the bloodstream.
- Fats are released into the bloodstream from the fat stores in the body. These are fuel for the muscles, so oxygen is needed to burn them – and so the breathing increases. Those under stress may notice feeling breathless.
- The body needs to get fuel to the muscles – (remember, the body thinks this is a life or death emergency) – so the heart begins beating far faster – some people notice palpitations.
- Blood pressure rises, some people notice feeling hot or cold – breaking into a sweat, as the body seeks to spread out the heat that will be generated by vigorous muscular activity, for which body is preparing.
- Becoming ready for instant action, muscle tension increases, and a person may notice shaking, or becoming restless and fidgeting.

Some people feel like this often and if this pattern is continued for long enough, chronic headaches, backache and other physical complaints may result i.e. chronic stress.

At the same time as all this muscle action is happening, blood supply to the front parts of the brain, responsible for higher levels of reasoning is reduced, while the blood supply to the more primitive parts, near the brain stem, is increased.

These parts of the brain are responsible for automatic, or instinctive, or impulsive decision making & behaviour.

A person undergoing a stress response may be prone to impulsive thinking and behaviour – which they may thoroughly regret later – this means we can say and do things without thinking clearly.

There are a number of ways in which chronic stress can impact on your body and general health:

Brain -fatigue, aches & pains, crying spells, depression, anxiety/panic attacks, sleep disturbance
Gastrointestinal Tract – Ulcer, cramps & diarrhoea, colitis, irritable bowel
Glandular System – Thyroid gland malfunction
Cardiovascular (important for diabetes) – High blood pressure, heart attack, abnormal heart beat, stroke
Skin – Itchy skin rashes
Immune System – Decreased resistance to infections

How does stress affect diabetes?

Stress can cause BGL’s to rise.

Feelings of distress, especially when intense and long lasting, can show an increase in HbA1c (or A1C) with this typically higher in those struggling with difficult conditions at work, home or problems such as depression. Yet laboratory studies have not shown that stress consistently raises BGL – some studies show that it does and some show that it does not!

Many people report that stress does raise their BGL and we know that when life becomes busy, stressful and overwhelming, diabetes can take a back seat. In this case the stress raises BGL as the situation causing the stress interferes with diabetes management, rather than a direct effect on blood glucose levels.

The best answer to how stress affects diabetes is taken from Dr William Polonsky – “Diabetes Burnout” book :

Stress can have a negative effect on diabetes self management, but only for certain people at certain times
Stress can have a direct and immediate effect on BGL but only for certain people at certain times

If you are significantly distressed over a long period of time it is likely that you will begin to have problems managing your diabetes. Stress might affect your ability to exercise or follow a meal plan for example. In this case it is how you understand and respond to stressful events that is the key to managing diabetes when under stress. Interestingly not all types of stress appear to make BGL rise.

Situations where you feel trapped (in that you can not make changes) or where you feel things are out of your personal control appear to be most likely to influence BGL directly.

How sensitive are you to Stress?

Some of us are more sensitive to stress than others. Scientists believe that there are 3 types of people:

Stress insensitive – BGL not directly affected by stress
BGL rises under conditions of stress
BGL drops when stressed

Some people might experience elements of all of these at different times. You can experiment to see what happens to your BGL when under stress. This might be by tracking your BGL when under a particular stress to see what happens and/or checking BGL prior to and following a relaxation session over a week or so, to see if your BGL decreases.

Diabetes Burn Out

Diabetes Burn Out is a common problem. If you are under too much stress in particular, this is a potential risk. Diabetes is like a “job” and the day to day effort to manage can become overwhelming. This is especially true when the results are not what you would like them to be and you know you have done all you can and worked hard.

Burn out is much more than feeling a little down. It is an overwhelming feeling of helplessness and hopelessness that you can not go on with your diabetes management – people often give up at this point and depression can also occur.

If you think Diabetes Burn Out has or may happen to you these tips may help:

Think about what particular areas of diabetes are causing you problems. Sometimes people say it is “just diabetes” that is the problem, but often there are specific areas that are causing problems and you are actually doing ok with other areas. It can be helpful and very positive to see that it is not everything about your diabetes that is difficult. For example you may be ok with checking your blood glucose and exercising, but not so happy with the way you are managing your food intake. Seeing the things you are doing well with gives you something to build on and gives perspective.

Consider what’s happening in your life that might be conflicting with diabetes care? What is making it harder at the moment for you to manage diabetes? What blocks and barriers are there and how might you deal with these other parts of your life? Sorting these things out will in turn make diabetes management easier.

Work out what your expectations are for your diabetes management at the moment? What are your targets? What do you want?
And are your goals realistic right now? Sometimes we expect too much, or too little of ourselves. You may need to work harder, or ease off on your diabetes management depending on what else is happening in your life and with your health.

Look at whether there difficult emotions you need to deal with? Emotions such as sadness, anger and grief may be present due to diabetes diagnosis, depression or another event in your life. These emotions can be uncomfortable but very important. Acknowledging and accepting these feelings, then working through them so you can move on with your life can help.

Finally do not suffer in silence. Always seek support if needed. This may be from your usual doctor, diabetes educator of other team member. A friend, family member or someone else you trust. A counsellor or psychologist. Or a service such as ours where you can access counselling, support and understanding in one place.

Stress and Relaxation

Too much “fight/flight” activity or in other words too much stress, without corresponding rest and relaxation leads to distress. Importantly you can “bank” your rest and relaxation times. By practicing regular relaxation and rest times, no matter what the stress levels are in your life, you allow your body to heal itself and stay strong in the face of the inevitable stresses of our lives.

This may be listening to quiet music, getting out in the garden, walking in the sunshine, playing a game with your child, or using guided relaxation practices. We highly recommend learning and practicing guided relaxation. It gives a much deeper relaxed state for the body and mind than many other things and can make a large difference to depression and anxiety.

We have a number of relaxation practices here on our relaxation pages. We use and recommend Dr Gillian Ross’s relaxation CDs. You can listen to some of these on our relaxation pages.

Stress Management and Exercise

Exercise is critical to overall health. The current recommendation for adults is 30 minutes moderate every day if you can and at least 4 – 5 times week (60 minutes a day for children). We now have so many convenience machines and often sedentary lifestyles, that structured exercise is even more important. This does not need to be at the gym!

Walking is one of the best forms of exercise and it is free! Swimming and water based exercise are great for people with mobility problems. If you need help to work out the best exercise for you, an exercise physiologist can be great. You can access one via a diabetes care plan – just ask your GP to refer you to someone as part of your 5 allied health care visits. They can then set this up and work out an exercise plan that will work for you and your abilities. Hop across and have a look at our Diabetes and Exercise page.

If you have type 1 diabetes this is a fantastic resource Allan Bolton.

Apart from the obvious physical health benefits exercise is also vital to stress management as it encourages that parasympathetic (rest and relaxation) response, calms body and mind and uses excess energy and muscular tension.

Go to our Relaxation and Meditation pages for information about these practices