INTRODUCTION

Adolescence is a very important phenomenon in the life of a human being. According to Arminda Aberastury et al.(1), it is a decisive stage in a process of detachment that begins at birth.

The psychological changes that occur during adolescence, which are the correlation of bodily changes, lead adolescents to a new relationship with their parents and the world. This is only possible through mourning the loss of their child’s body, their childhood identity, and the relationship with their parents during childhood.

In this process, adolescents deal with changes in the image they have of their body, with their new identity, and face the entry into adulthood, which will later allow them to be independent within a limit of necessary dependence.

Not only do adolescents suffer during this moment, but their parents also have difficulty accepting their growth, their struggle for independence, their entry into genitals , and the attitudes that arise from this process. It can also fluctuate between incomprehension and rejection, which can be masked by granting excessive freedom, which the adolescent interprets as abandonment (which is actually what it is); or between very rigid limits or exaggerated protection, which hinders the process of detachment that absolutely characterizes this period.

When the adolescent has illnesses during this period, losses and mourning will be much more difficult, and, along with them, the experience of the pathology will be more forceful. If this illness is acute and rapid, it will soon pass and the effects of the illness will also occur quickly. If the illness is chronic and here to stay, it is an aggravating factor and a complication in the process that is common to this phase.

In order to approach sick adolescents, knowledge is needed not only related to the illness itself, but also to the singularities of the period of life, encompassed in what has been conventionally called the syndrome of normal adolescence , whose components are the search for identity, independence from parents, challenging current standards, acquisition of conceptual thinking, bonding with peers, risk behaviors, sexual identity with sexuality exercised close to adult standards, and unique temporal experience.

Chronic childhood and adolescent illnesses, such as diabetes, reveal issues of extreme importance for patients, their families, the health team that is willing to accompany them, and society in general, which needs to welcome adolescents, both those who are considered normal and those who already have, or will have, an illness.

The treatment of diabetic adolescents requires strict medical supervision, which must involve an interdisciplinary team whose scope of action is broadened, ensuring a greater chance of success for the proposed treatment.

The objective of the proposed treatment approach will only be achieved when the adolescent no longer feels that controlling the disease is just another ordeal resulting from the disease, but rather as a tool that he or she can use to improve his or her quality of life now and in the long term, in the future.

It is extremely important that health teams understand the patient’s developmental stage, as well as the psychological reactions resulting from the illness and the defense mechanisms used by the patient (his or her family/team).

DISCUSSION

NARCISSISM AND THE EXPERIENCE OF ILLNESS: A BRIEF SUMMARY

According to Sigmund Freud, the term narcissism , already used in his previous texts, is emphasized for a special study(6), considering particularly the libidinal investments, in which the child (or every living creature), as a form of self-preservation, invests all its libido in itself. He called this early state primary narcissism . He called the return to the ego of the libido withdrawn from its object investments secondary narcissism

. When evaluating the influence of organic disease on the distribution of libido, Freud accepted as a natural thing that people who suffer, those who become ill, those who feel pain, those who are tormented by an organic malaise, cease to be interested in the things of the external world to the extent that these do not concern their suffering. As they suffer, these individuals withdraw their libidinal interest from their love objects and cease to love.

For Freud(6), “…The sick man withdraws his libidinal cathexes back into his own ego and puts them out again when he recovers”.

All of this is amplified in the adolescent phase. The adolescent, even healthy, is having to put his narcissism to the test all the time, when he is experiencing the mourning of the phase, the great bodily changes and the process of separation and distancing from his parents and the world of childhood. When the illness occurs, acute and/or chronic, he suffers very great losses, directly related to his wounded and fragile narcissism.

ACUTE ILLNESS

Lúcia Spitz(10) says that, upon discovering that he is ill, and suddenly, something causes anxiety, which is the individual’s response to the perception of danger. What is happening still has no name, it is unknown. These sensations that something is not right, the feelings of distress, fear and apprehension remain diffuse to prevent anxiety from overflowing and having destructive effects. The patient uses several defense mechanisms to deal with the unexpected, protect his narcissism and to be able to be cared for.

We can divide it into two moments:

• The diagnostic phase, of uncertainty, doubts and waiting, depends on how the disease set in: whether it was rapid, acute, unexpected or insidious. It is at this stage that the following questions should be asked:

– Did the disease develop gradually, and was it possible to diagnose it with enough time to prevent it from becoming worse or more serious?

– Was there a need for hospitalizations? What were they like?

– At what point in the individual’s life cycle did the disease appear?

– How was the illness experienced by the patient and/or his/her family?

– What fantasies about the disease do the patient and/or his/her family have?

– How was the diagnosis communicated to the patient (and his/her family)?

– Did they show signs of having understood it? – How was the doctor/patient/family relationship during this phase?

• Prognosis phase:

– Was it possible to cure it? Did it leave any after-effects?

– Was it characterized as a chronic disease, is there treatment, control, is it for the rest of the patient’s life?

– Is it a disabling disease? Is it subject to relapses?

– Is it potentially fatal? Non-fatal? Will it reduce the patient’s life prospects? Will it harm his or her quality of life?

– Does it require major changes in lifestyle habits to control it?

– Is the treatment painful, invasive, time-consuming, expensive? Is it non-existent, experimental, partial, complex?

– How was the prognosis communicated to the patient (and his or her family) by the health team? Did the patient show signs of having understood it? And his or her family?

CHRONIC DISEASE

Chronic diseases, by definition, have no cure and are lifelong. There is treatment and control for them; they may or may not have asymptomatic periods; be potentially fatal, fatal or non-fatal; progressive or not. They may require drastic changes in lifestyle habits and may or may not be disabling. It represents a wound in the narcissism of the patient and his/her family. There will also be chronic monitoring with the medical team, the patient and his/her family.

For Spitz(10), from the point of view of the doctor/health team that monitors the patient, chronic illness can trigger feelings of impotence, hopelessness and devaluation, especially during periods of exacerbation of symptoms.

PSYCHOLOGICAL REACTIONS TO ILLNESS AND BECOMING ILL

The transition of the individual from a healthy to an ill state, whatever this transition may be, modifies his/her relationship with the world and with himself/herself, and, according to Spitz(10), “…It always implies psychological repercussions both in him/herself and in his/her family and social circle”. The way in which they react to the outbreak of the illness, whatever it may be, is generally experienced as a threat from fate , due to numerous factors of the pathology itself, the personality of the individual and his/her characteristics linked to his/her resources and deficits.

We can divide such reactions according to the point of view:

• of the patient:

– regression: this is a defense mechanism and adaptation to the disease, as it allows the patient to allow themselves to be cared for by the health team, temporarily give up their routine activities and accept the need for hospitalization, surgeries and/or treatments to be performed. At first, this regression is welcome, but if it continues, it infantilizes the patient’s way of reacting. Sometimes the team or the family encourages regression and its longer duration, and it is up to the team to allow the healthier and more adult aspects of the patient to take hold and recover the diminished initiative of the disease, instead of making regressive behaviors chronic;

– denial: this is a defense against becoming aware of the disease, which consists of the partial and/or total refusal to acknowledge the fact of being ill. This refusal can lead to negligence in treatment, acceptance of the nature, effects and diagnosis/prognosis of the disease;

– depression: this is an almost inevitable psychological consequence of becoming ill. It is important not to confuse feelings of sadness, hopelessness and worry associated with illness and hospitalization with mild, moderate and severe cases of depression. If severe or moderate, it involves the need for referral to a psychiatrist, who may prescribe antidepressant medication and/or psychotherapy;

– primary gains: these are those that play a significant role in triggering the illness or in its very structuring;

– secondary gains: these are those that result from the consequences of the illness, favoring accommodation in the illness and its chronicity. Conscious gains are linked to the social compensation of the illness. Regressive desires of dependence and passivity are unconscious gains, since the patient becomes the target of special care;

– adaptation and acceptance of the illness: this does not mean passive acceptance or submission to the illness. It is a dynamic and ongoing process of trying to find a reasonable coexistence with the illness through emotional work to work through the narcissistic wound that being ill represents. There is a process of working through the mourning for the losses suffered in terms of autonomy, health, the body’s capacity, etc.;

• The patient’s family: there are those who, faced with the disease, give in to it, are overcome by pain, despair and the situation experienced as traumatic. Others fight for the restructuring and possibility of homeostasis of the organism and the home atmosphere, mobilizing positive defenses to adapt and accept the disease.

– according to Burd and Graça(4), this reveals “…classic attitudes found in all patients, especially chronic patients and their families: anxious hyperprotection, rejection, omnipotent denial, realistic acceptance of the disease”;

• of the medical team: Michel Balint(3) emphasizes the relationship established between the doctor/health team and the patient/family, the first medicine in the treatment of the disease and the patient. If this relationship is positive, it helps those involved in following the treatment and controlling the disease. If it is not so good, it can help to perpetuate defense mechanisms against the disease that hinder the good progress of the therapy. It can chronically perpetuate regression, denial or any more negative mechanism of the patient/family when faced with the illness.

In relation to chronic, incapacitating, relapsing and potentially fatal diseases, the team may encounter obstacles in accepting the great difficulties of the patients and their serious prognosis or death. They tend to withdraw prematurely and prematurely from the patients and their families, when they most need frequent and close care.

DIABETES MELLITUS

Type 1 diabetes mellitus (DM1), due to its frequency, constitutes, in the pediatric age group, the most important endocrine-metabolic disease, and can bring about a range of alterations in practically all sectors of the body. Its onset can be acute, sudden, severe, and lead to hospitalization for ketoacidosis. If diagnosed in time, its onset can be less dramatic, starting treatment of the patient and avoiding serious complications. It is a chronic disease that requires continuous and strict treatment, with major changes in lifestyle habits, such as diet, use of injectable medications, tests to measure glucose and the need for physical exercise. Type 2

diabetes mellitus (DM2) is also beginning to affect adolescents in Brazil, and even earlier in children in the United States. It is also a chronic disease and requires systematic control, changes in lifestyle habits that led to obesity (and its complications) and the onset of the condition.

As a disease that can start in an acute and severe form and become chronic, since there is still no cure, it has repercussions on the patient’s psyche and his/her family. Often referred to as emotional by patients, its treatment, as well as its control, can be compromised by psychological reactions.

The exuberant characteristics of the phase called normal adolescence syndrome are added to the psychological difficulties of diabetic adolescents. It is necessary for the health professional to know how to identify when the emotional side is impaired (and causing harm), leading to exacerbated and destructive reactions.

WHAT IS THE EMOTIONAL SIDE OF A DIABETIC ADOLESCENT?

From the moment a chronic illness is diagnosed, the patient’s future plans, whether they are a child or an adolescent, will be completely changed in all family members in a more or less important way, and will determine that the patient himself will rebuild his narcissistic economy, that is, reshape his projection of a perfect body, which worked very well and was a source of pleasure.

It is not without stress that chronic illness affects the family and the patient. Stress to which the protagonists adapt better or worse, with sometimes problematic consequences on the psychic or somatic plane, such as, for example, sabotage or abandonment of diabetes control and the treatment itself.

With the onset of diabetes, attacks on the narcissism of those involved occur, as well as the issue of diagnosis and prognosis, and complications that lead families and patients to guilt and resentment, with an increase in ambivalence towards the sick adolescent.

On the part of the patient, there may be a fixation on a situation of passive dependence, rebellion with a commitment to following medical guidelines and prescriptions or realistic acceptance. Healing and having a normal life will need to be worked on by those involved and will become goals of the interdisciplinary team.

On the part of the parents, the wound of narcissism, with all its vicissitudes, will be maintained and stitched together by a failure : not having healthy children, which, on the one hand, can generate overprotection, preventing the child from becoming independent, and, on the other hand, silent or explicit neglect may arise. In the first case, it can lead the diabetic adolescent to not become independent and not move towards adulthood; in the second, to risky behavior or even to real attempts at filicide and suicide that can lead, in extreme cases, to death.

For the health team, the attack on narcissism reaches the performance of its practice, in its essence, in the pursuit of a cure for the disease.

The possibility of enduring this failure and being able to move around in times of great difficulty makes possible the relationship and connection between all these characters involved: the patient, the family and the health team.

CONCLUSION

This article briefly describes some important aspects related to the experience of becoming ill and its main psychological reactions that also occur in adolescent patients.

Chronic diseases in children and adolescents, such as diabetes, reveal issues of extreme importance for patients, their families and the health team that is willing to accompany them. Diabetes is a psychosomatic disease, in which emotions can help trigger its onset, exacerbate symptoms, and impair treatment and control.

In the experience of becoming ill, adolescence, considered a normal syndrome, has added its characteristics, amplified the psychological reactions to the disease and the related defense mechanisms so that the patient can face the changes in the way of living this phase of detachment.

For Burd(5), “…the empathetic understanding of the health team that cares for the diabetic adolescent (and his/her family) will facilitate adherence to treatment and his/her integration into the society in which he/she lives, when controlling the disease is no longer felt as a trial, but rather as an instrument that he/she can use to improve his/her quality of life”.