INTRODUCTION

This article seeks to add psychological data to the medical data, in a clinical case of a type 1 diabetic adolescent. The patient is being treated at the Diabetes and Metabolism outpatient clinics and the Center for Adolescent Health Studies (NESA), both at the Pedro Ernesto University Hospital (HUPE). The comments of clinical psychologist Miriam Burd, invited to the event, were based on her knowledge of medical psychology. The medical data were provided by the resident physician, Dr. André LM Teixeira, who treats the patient and his family. These data were supplemented and integrated to better understand what had happened up to that date. The meeting was moderated and led by Professor Evelyn Eisenstein and by members of the NESA outpatient clinic present. The authors sought to show how this event occurred.

DEVELOPMENT

CASE REPORT

ID: CML, 14 years and 11 months, male, student and locksmith, brown, born in Rio de Janeiro and resident in Belford Roxo.

QP: diabetes.

HDA: At the age of 5, he developed diabetes with diabetic ketoacidosis (DKA), and was hospitalized at the Instituto de Puericultura e Pediatria Martagão Gesteira (IPPMG) for a month, where he was in a coma for four days. After discharge, he remained in regular outpatient follow-up for three years.

As we have seen, the onset of type 1 diabetes mellitus (DM1) was sudden, acute and severe, requiring the child to be hospitalized for several days, and what happened was marked by the family as a disease that could have led to the child’s death. This type of opening could have been minimized if the disease had been diagnosed quickly and insulin therapy started immediately.

DM1, when diagnosed early, has a milder initial stage and generally does not require hospitalization. In any case, it is a disease for which several medical explanations must be given to the family, but with the certainty that they have learned the basic nursing procedures – such as administering insulin injections, performing urine or blood glucose tests and/or following the recommended diet for the child, etc. – to deal with the disease. In general, this information will be assimilated gradually and some of it will have to be repeated every time there is a consultation with the team. Often the family itself will learn to eat better, thus contributing to a healthier diet for everyone.

This is a psychosomatic disease that has the emotional aspect as its trigger., leading to difficulty in controlling it, which results in worsening of the condition. Therefore, the patient requires an interdisciplinary team for treatment, as in this case, in which the medical/team care should have been chronic, constant and close. This could have provided a good opportunity to establish the doctor-patient relationship. The presence of a team member should always be a staff member . This means that he/she will be the intermediary between the patient and his/her family and in any changes of team members that may occur.

For financial reasons, the patient began to receive DM1 monitoring at a municipal health center near his/her home. The doctor who was treating him resigned and, for two years, the child remained without any clinical and/or laboratory control. During this period, the family maintained a regimen of regular insulin and neutral protamine hagedorn (NPH) in the morning, with doses of 10 IU of each. During this period, the patient had about five quick hospitalizations in emergency rooms due to decompensated blood glucose levels, which the family attributed to an uncontrolled diet.

In the treatment of DM, since it is a chronic disease that accompanies the patient throughout his life, the team may also change during the course of the disease. In working-class families, or due to some type of socioeconomic change and/or change in the family’s residence, the follow-up may also need to be transferred to another medical institution.

In the present case, after two changes in five years of illness, this was one of the reasons that hindered a good doctor-patient relationship and, mainly, the patient-family-institution relationship. When there are numerous changes in health professionals, patients and their families begin to interact directly with the institution that treats them, thus creating a transfer (a term used in psychoanalysis) with this institution.

One of the reasons that leads the family to discontinue medical treatment may also be the feeling that if DM is not evident, except when there are complications, it can be treated at home with the resources that the family has available. Another reason may be one of the defense mechanisms in relation to the illness, that is, the denial that the child is sick or has a chronic disease.

For some time, the family had the illusion that it was a disease that started out serious, but over the years it became treatable and did not require chronic medical care. Therefore, this same denial mechanism often caused the patient and his/her family to forget the recommendations given at the beginning of the treatment of the disease.

On 05/24/05, as a teenager (14 years old), CML was admitted by his family to the Saracuruna Hospital, presenting with polyuria, polyphagia, polydipsia, dyspnea, abdominal distension, edema of the lower limbs (LL), jaundice and reduced level of consciousness. He was discharged from the hospital after one week with a diagnosis of hepatitis A and corrected DKA. The family then went to the NESA outpatient clinic on 07/11/05, which referred the patient to the Diabetes and Metabolism Outpatient Clinic at HUPE, and on 07/13/05, he was asked to be admitted to the ward to compensate for the diabetes.

Almost ten years had passed since the onset of DM1 and, once again, the teenager was admitted in serious condition, as on the previous occasion. The same situation occurred and even more serious, with the diagnosis of hepatitis A. Once again, there was a rapid change of medical institutions, when it was possible to confirm the difficulty of the first institution to fully assist and continue treating the patient.

There are several possible reasons for this: NESA is one of the best units for treating adolescents, and HUPE is one of the references for treating DM1, therefore it would have more resources to treat a disease that was serious, with complications and complications, thus requiring increasingly specialized resources. The other would be the fact that, from the beginning, the patient and his family demonstrated difficulties in maintaining lasting bonds with the medical teams that treated them. A good doctor-team-patient relationship is the first form of treatment, especially when dealing with a juvenile and chronic disease.

HGPPN: Mother G2P2A0; prenatal care without complications performed at a health center; denies gestational diabetes mellitus (GDM); cesarean delivery (macrosomic) at term; neonatal jaundice with phototherapy.

BW = 4,800 g, EN =?

HPP: Goiter at three years of age, circumcision at four years of age and common childhood viruses (CVCI).

Dietary history: Breastfeeding (exclusively until 6 months) until 5 years of age; low-carb diet since 5 years of age, irregularly.

The patient’s dietary history shows that, as a baby, he was breastfed by his mother until 5 years of age, which makes us think that the weaning situation was very difficult for the mother/baby pair (here the term was used to emphasize the circumstance). There were attempts to introduce other foods besides breast milk from 6 months of age, but the emotional deficiencies of both were responsible for dragging out the weaning attempts for five long years.

The patient was weaned during the period that psychoanalysis called Oedipal., that is, between 3 and 5 years of age, a period that can be considered critical and of intense and significant psychological changes. In addition, at this time – and we can assume – this also contributed to an excessive increase in stress factors, which acted as triggers for the onset of the disease. Diabetes arrives for this pair as a way of undoing this symbiosis (mother/baby) that had been established.

Developmental history: Normal, except for short stature and delayed puberty. Absent semenarche and sexarche.

Vaccination history: Complete.

Family history: Healthy father, 1.81m; healthy mother, 1.58m; 23-year-old brother, 1.80m; maternal grandmother and aunt with type 2 diabetes mellitus (DM2).

The family tendency for diabetes is found in the presence of DM2 in the maternal grandmother and aunt. Despite being type 2, diabetes presents itself as a hereditary trait.

It is not known whether the paternal family has a history of DM carriers, but if this was not confirmed, this fact may have contributed to the mother’s feeling of guilt for having given birth to a sick, diabetic son eight years after her oldest, healthy son. This situation probably also fostered a close bond between the mother and the premature son who became ill.

Social history: The patient lives with his father and mother in a brick house with piped sewage, artesian well water and electric light. His father is a bricklayer and his mother is a housewife. He studies at night (5th ^grade of elementary school) and works as a locksmith with his brother during the day, but does not contribute to the family income. He denies smoking, drinking or using illicit drugs.

The house has two bedrooms and four people live there. He reports being afraid of sleeping alone in his room, because the window looks out onto a haunted house .

Regarding living conditions, it is observed that this family, from a working-class and structured family, has a stable and regular situation, with the father, mother and children living together. The patient studies and works productively, despite his illness, using what he earns probably to cover his own expenses. Thus, since it is enough for him alone, the family does not need help from his salary with common expenses. CML is a little behind in his school situation, which is probably due to the illness that required him to be hospitalized frequently.

It is noteworthy to note that, in this period of early puberty, he is experiencing the Oedipal period like all other adolescents, with discomfort linked to frequent insomnia that the patient attributes to the fact that his window faces a haunted house.. Although puberty is delayed, sexual development must have already begun, as well as some sensations related to your genitals and/or feelings related to these facts, which must cause you difficulty in falling asleep.

It is not difficult to associate the beginning of this critical period, like adolescence, with the difficulties of having uncontrolled DM. This caused your last two hospitalizations, as if the beginning of adolescence was also a reason for the lack of control of your hypocaloric intake and the sharp increase in your blood sugar.

The good doctor-patient relationship – which is now being established – has allowed a positive identification of the patient with his young and healthy doctor, who is also open to clarifying the issues of diabetes and your physical/psychological development.

PHYSICAL EXAM

• Atypical fascia, lucid and oriented in time and space, flushed, hydrated, anicteric and acyanotic.
• HR=90bpm;RR=20rpm;BP=100x70mmHg.
• Head/neck: no adenomegaly; oropharynx without abnormalities; palpable thyroid; of overall volume, irregular and without nodules on palpation.
• ACV: RCR2T s/SS, BNF, quiet precordium, normal pulse.

AR = MBVUA s/RA symmetrical chest s/gynecomastia.

• ABD: flat, peristalsis ⁺ , flaccid, painless on palpation without masses or VMG; liver palpable in RCD without changes in consistency, with smooth edge, hepatimetry 6cm, Traube tympanic.
• Limbs: no edema, good pcp.
• Genitalia: ♂, testes topic, prepubertal, Tanner stage G1P1.
• FO: transparent media, papilla with clear edges, excavation 0.3×0.3 OD and 0.4×0.4 OS; vessels of normal caliber and tortuosity with sparse microaneurysms, applied retina and normal macular region.

COMPLEMENTARY EXAMS

• Blood count: Hem=4.51; Hb=12.5; Hto=36.8%; MCV=81.5; HCM=27.6; MCHC=33.9; RDW=16.9; PQT=466000 Leuco=7.6 (0/1/0/0/2/50/39/8).
• Na=137; K=4.4; U=34; Cr=0.6; T ₄ L=0.8; TSH=0.67.
• Cholesterol: 180; trigerides: 189; HDL=35.
• Gly. hospitalization = 427; Gly. discharge = 85.
• EAS: pH=6; ptn=3 ⁺ ; G=3 ⁺ ; cet=clue; Hb=2 ⁺ ; Nit=neg; Pio=4-6; Hem=8-10.
• 24h Ptnuria: 1.36g/24h.
• Renal ultrasound (US): no abnormalities.
• Thyroid US: diffuse goiter, no nodules.
• Genetic target: 1.76m.
• Bone age: 10 years.

FOLLOW-UP

The patient was discharged from the ward seven days after his blood glucose levels returned to normal and after receiving guidance on diet, pathology, prognosis and complications.

He is being monitored at the HUPE diabetes outpatient clinic and the NESA clinic, maintaining adequate blood glucose levels and following nutritional guidance. CML uses 24 IU of NPH insulin before breakfast and 10 IU before dinner. This clinical case is ongoing.

During the clinical session, some considerations were presented from both sides, the doctor and the psychologist. In a knowledge that becomes psychosomatic, DM is considered autoimmune and chronic, that is, there is still no cure, and finds the low-calorie diet to be followed as one of its greatest difficulties, both for adolescents and for diabetic adults. Today’s adolescents have been bombarded by incessant appeals from the media to eat their meals at fast-food

chains . In addition, plentiful food has always been a source of joy for a poor family like the one mentioned in this case report. It is very difficult for a mother to tell her child not to eat sugary treats. The ultimate perfection for a good mother is to deny nothing to her beloved child, not even the breast. Weaning a child can be as negative an attitude for the mother as not having anything to feed him. For parents, food means showing love and taking good care of their children. It is a sign in our Western society that when children are treated with love, sweets should not be denied , which would represent affection . Our ideal of plenitude, freedom and well-being is to be able to eat all the tasty things. CONCLUSIONS This article was based on the conclusions reached at the end of the Scientific Meeting, in light of the clinical case supervised and commented on by those present. We can summarize them as follows.

• DM1 is a psychosomatic illness; therefore, all members of the interdisciplinary team that cares for the patient (and their family) need to be aware of the clinical and psychological characteristics that affect it.
• The onset of the disease may be sudden, acute and/or severe, as in this clinical case, or, on the contrary, with rapid diagnosis and treatment, it may be milder. Differences in the form of onset affect the prognosis and future treatment.
• A good doctor-team-patient-family relationship is the first possible form of treatment; professionals working in institutions that treat these patients must keep in mind that this good relationship is essential for good and continuous treatment, especially when it comes to juvenile and chronic diseases.
• In this case, we were able to identify a defense mechanism on the part of the patient and, more so, on the part of the family. This reaction to the illness was denial , which prevents awareness of the illness and consists of the partial or total refusal to acknowledge the fact of being ill. This is one of many reactions that can occur.
• Adolescence is a critical phase of human development with many characteristics. Those who work with adolescents should equip themselves with material on this phase to understand both the physical and psychological aspects. In this case, the onset of DM did not occur in adolescence (a period of crisis), but at another critical time, that of the Oedipal complex . Research indicates that, during certain critical times, due to an excessive increase in stress factors and in certain people, DM can have its onset triggered, linked to the autoimmune and hereditary factors of the disease.
• As in this clinical case, the difficulty of following a low-calorie diet, mainly leaving out common sugar, has also been highlighted by research on DM, both type 1 and type 2. For the baby, feeding (after breathing) is the first major moment of entry into life outside the womb.
• As a result of the previous item, difficult and late weaning is also linked to the difficulties of the patient and their family in complying with and enforcing the diet, one of the constant reasons for the large increase in blood glucose, the acute complication (such as ketoacidosis) that led to numerous and successive hospitalizations to treat the aggravated condition.
• Pubertal development in the present case is delayed, attention to the stage of development of the gonads and the entry into genitality close to that of an adult result in psychotherapeutic help for the patient or, if this is not possible, a good relationship between the doctor and the adolescent, who, through identification with the young and healthy male figure, can help a lot in this regard.
• The team’s ongoing support to the patient’s family is also part of the differentiated treatment that can be offered to diabetic adolescents. Especially in childhood and adolescence, the family is the one who brings the patient to treatment and helps him/her to comply with it. Thus, they can help with their resources or hinder if they have deficiencies.
• The patient, despite the chronic disease, with complications and intercurrences that occur constantly, is still productive: he studies and works. Helping him avoid such complications (acute and chronic) linked to DM1 will give him the possibility of a healthier youth, maturity and old age, with all the possible developments of his life cycle, such as graduating, getting married and having children (without wanting to), as well as working and living with a good quality of life, which, despite diabetes, is perfectly possible.