Personality and self-esteem in emerging adults with Type 1 diabetes
Introduction
Type 1 diabetes is a metabolic condition which requires a complex regimen of diet, exercise, blood glucose monitoring, and daily insulin administrations [1]. Emerging adults with Type 1 diabetes are generally seen as a high-risk group partially because they experience many stressful changes in their lives, such as searching for a job, establishing romantic relationships, and leaving the parental home [2], [3], [4]. Such developmental demands could interfere and even detract from focused diabetes management [3]. Hence, the accumulation of normative and illness-specific stressors makes this developmental period ideally suited to investigate patients' psychosocial functioning.
Developing a strong sense of self is a key developmental task during emerging adulthood [5]. According to a recent model of personality development, an individual's self-concept has to be assessed at different levels [5]. Personality traits are seen as the basic level of analysis and describe the most fundamental personality differences between individuals. Nowadays, most researchers agree that personality can be subsumed under five broad traits: Extraversion (energy, sociability, and experiencing frequent positive moods), Agreeableness (kindness, empathy, and cooperativeness), Conscientiousness (self-discipline, organization, and responsibility), Emotional Stability (the ability to deal with negative emotions), and Openness to Experience (the way that an individual seeks and deals with new information) [6]. However, people do more than act in more-or-less consistent ways as determined by these traits; they also make life choices and build a self-concept from which they derive a sense of self-worth [5], [7]. Hence, studies should focus on both personality traits and self-esteem, representing important core and surface characteristics of one's self-concept.
Several models within the chronic illness literature have emphasized the importance of patients' sense of self for their physical and psychosocial functioning [8], [9], [10]. According to the transactional stress and coping model [11], [12], adjusting to chronic illness results from a complex interplay of demographic (e.g., sex and age) and clinical parameters (e.g., illness type and severity), coping strategies, and perceptions of the self. A modified version of this model was adopted in the present study (see Fig. 1). In this model, personality and self-esteem play a key role in understanding how patients adjust to their illness. This pathway is in line with the vulnerability or predisposition model which states that a weak sense of self may put youngsters at risk for maladjustment, whereas youngsters with a mature sense of self are better equipped to cope with stressors (including diabetes-related challenges) [13]. Recent studies have indeed demonstrated the importance of personality traits and self-esteem for glycemic control, treatment adherence, quality of life, and coping in Type 1 diabetes [14], [15], [16], [17], [18], [19], [20], [21]. However, according to the scar or complication model of personality [13], the experience of psychosocial difficulties can also shape one's self. This view fits with the model of person–environment transactions which emphasizes the malleability of the self [22], [23], [24]. The latter model assumes that changes in the self can be triggered by changing roles, life events, and daily challenges. As chronic illness is viewed as a biographical disruption [25], [26], it may also shape youngsters' sense of self. Unfortunately, few studies to date have compared patients' sense of self with that of healthy controls.
Although studies have investigated whether individuals with diabetes have lowered self-esteem as compared to healthy controls, no consensus has yet been reached [27], [28], [29], [30], [31], [32], [33]. Such inconsistencies are mainly due to small sample sizes and a lack of matching on socio-demographic variables [27]. With regard to personality, a recent study found adolescents with congenital heart disease to display similar Big Five levels as compared to controls, except for a lower score on extraversion [34]. Because diabetes generally has a greater impact on daily life as compared to congenital heart disease, more pronounced differences might emerge when comparing patients to controls. Specifically, emerging adults with diabetes could show higher levels of conscientiousness, given the importance of treatment adherence for avoiding future health complications [35]. Because such a strict treatment regimen might hinder patients in their social activities [8], patients may also report lowered extraversion [34]. Finally, patients might show lower levels of emotional stability, given the elevated depression rates observed in this population [36].
However, differences in personality traits and self-esteem between patients and controls may differ according to sex and illness duration. Stahl and colleagues [19] reported improved self-esteem especially in boys with Type 1 diabetes. Indeed, female patients have been found to cope less well with their illness, as evidenced by higher rates of depression and diabetes-related worries [37], [38], [39]. Hence, one might expect more pronounced differences in self-esteem, extraversion, and emotional stability between female patients and controls. Further, individuals diagnosed with diabetes for a longer time could feel less engulfed because they might have developed coping mechanisms earlier in life [40]. Hence, one might hypothesize that patients with longer illness duration would have integrated their illness more strongly into their self-concept, resulting in self-esteem and Big Five scores that are similar or even higher (in the case of personal growth [41]) as compared to healthy controls. However, the role of illness duration remains unclear as a longitudinal study in Type 1 diabetes found illness duration to be unrelated to adolescents' coping strategies and symptomatology [8].
In sum, the present study investigated whether emerging adults with Type 1 diabetes have an increased risk for developing a weak sense of self. Given that patients' sense of self has been proven a substantial predictor of their physical and psychosocial functioning, it is important to identify the factors that optimize or, conversely, reduce these patients' opportunities to attain a strong sense of self.
According to the transactional stress and coping model [11], [12], both sex and illness duration can be expected to shape patients' sense of self [19], [37], [38], [39], [40]. Associations with age might also emerge, given that cognitive maturation gradually allows adolescents to arrive at balanced self-views [42]. Furthermore, there are some indications that insulin pump therapy positively impacts on glycemic control, diabetes self-efficacy, and quality of life [43], [44]. Hence, patients using an insulin pump can be expected to report higher self-esteem as compared to patients using injections. However, having an insulin pump could evoke body image concerns and, hence, might be associated with lower self-esteem among certain patients [43]. With regard to the Big Five, the increased flexibility in daily life which generally accompanies insulin pump therapy might allow patients to engage in more social activities, resulting in higher extraversion scores [44].
Besides looking at demographic and clinical correlates, the present study also focuses on psychological correlates, that is, the level of diabetes-related distress. Although patients with a strong sense of self are typically assumed to be better equipped to cope with diabetes [17], the transactional stress and coping model also states that elevated diabetes-related distress might negatively impact on patients' self-concept [11], [12]. Specifically, patients experiencing elevated diabetes-related distress can be expected to report lowered self-esteem as well as lower levels of extraversion, emotional stability, and agreeableness as compared to patients not experiencing such distress [14], [34].
Section snippets
Participants and procedure
Patients were recruited from the Belgian Diabetes Registry [45]. They were eligible for inclusion if they met the following criteria: Dutch speaking, presence of Type 1 diabetes, age 18–35 years, and the availability of contact details. In April 2012, the database included 8957 patients, of which 997 patients met the inclusion criteria. All eligible patients were sent a questionnaire, information letter, informed consent form, and pre-stamped return envelope by surface mail. Control participants
Participant characteristics
Of the 997 eligible patients, a total of 478 patients (48%) returned completed questionnaires. Of these 478 patients, a total of 341 (71%) could be matched (1:1) with a healthy control participant based on sex and age. Matched patients did not differ on any of the study variables from non-matched patients, except for lower scores on conscientiousness (F(1,470) = 13.16, p < .001, η2 = .03) and openness (F(1,470) = 5.90, p < .05, η2 = .01). Further, matched patients were significantly younger as compared to
Discussion
Previous research has demonstrated the importance of self-esteem and Big Five personality traits for glycemic control, treatment adherence, and quality of life in Type 1 diabetes [14], [15], [16], [17], [18], [19], [20]. The present study adds to this body of knowledge by examining mean-level differences in self-esteem and Big Five between emerging adults with Type 1 diabetes and healthy individuals matched on sex and age. Mean-level differences between patients and controls were found to
Conflict of interest
The authors have no conflicts of interest to state.
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