Anxiety in People with Type 1 and Type 2 Diabetes

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While it is often expressed that daily management of type 1 and type 2 diabetes is intense, its potential to create or worsen existing anxiety isn’t often discussed in your routine check-ups.

“The potential impact of anxiety disorders on people with diabetes hasn’t gotten nearly as much attention as other concerns that people with diabetes face,” explained Tina Drossos, Ph.D. at this year’s American Diabetes Association Scientific Sessions.

“Patients cannot do this alone,” added Drossos. “This is definitely a collaborative process—caring and managing diabetes.”

Here are highlights from Drossos’ findings in recent research on anxiety in people with type 1 and type 2 diabetes.

How Common is Anxiety in People with Diabetes?

Anxiety is not only very common in people with diabetes, it also likely goes undiagnosed and untreated.

• One in six people with type 1 diabetes (T1D) is affected by moderate-to-severe anxiety symptoms.
• One in five people with type 2 diabetes (T2D) who use insulin is affected by moderate-to-severe anxiety symptoms.
• One in six people with T2D who do not use insulin is affected by moderate-to-severe anxiety symptoms.

Approximately only 36 percent of people with diabetes struggling with anxiety will ever receive treatment and support.

Types of Anxiety Disorders

Types of anxiety disorders that can affect people with diabetes include:

• Generalized Anxiety Disorder (GAD)
• Body Dysmorphic Disorder (BDD)
• Obsessive-Compulsive Disorder (OCD)
• Panic Disorder
• Specific phobias: Blood, injections, etc.
• Post-traumatic Stress Disorder (PTSD)
• Fear of Hypoglycemia (FOH)

How Diabetes Might Cause or Contribute to Anxiety

The burden of managing and living with T1D or T2D on a daily basis is the perfect recipe for anxiety. Drossos shared these four common expressions of anxiety in people with diabetes:

• “When I feel anxious and I have no one to turn to.”
• “I am constantly afraid of my disease getting worse.”
• “I feel that diabetes is preventing me from doing what I want.”
• “I am worried about not being able to carry out my family responsibilities in the future.”

A few of the specific aspects of these diseases that can contribute to anxiety include:

• Constant pressure to maintain healthy habits around food and exercise
• Constant pressure to achieve target blood sugar levels and other health measurements
• Daily tracking of calories, carbohydrates, fat, etc.
• Daily juggling of multiple medications and their side-effects
• Stress or shame related to body weight
• Fear of hypoglycemia (FOH) and its threat to one’s safety
• Fear of injections, finger pokes, setting up a new infusion site, etc.
• Constant juggling of technology (insulin pumps, CGMs, etc.)
• Constant threat of diabetes-related complications (neuropathy, retinopathy, etc.)
• Constant worry about affording numerous medications required to manage diabetes
• Constant worry about affording numerous types of technology to manage diabetes
• Enduring criticism and shame from others, including family, doctors, friends and strangers
• Stress-related to side-effects of daily management: scarring, bruising, bleeding, etc.
• Worry or embarrassment managing diabetes in public, at work, etc.
• Missing out on or getting behind in work, school, etc. because of high/low blood sugars
• Feeling isolated and alone while enduring the daily burden of diabetes

“We have seen a rise of anxiety and fear of hypoglycemia in people with continuous glucose monitors (CGM),” added Drossos, “despite the many benefits of using CGMs.”

While many people find CGM technology helpful, using a CGM can also fuel anxiety because of constant alarms, increased attention to blood sugar levels and the tendency it can create to hyperfocus on creating a perfect graph each day.

Living with any type of diabetes can impact every single hour of a person’s day. Achieving blood sugar targets doesn’t actually relieve this pressure, it can actually fuel it and reward it because achieving those targets requires daily persistence in many habits.

Common symptoms of anxiety in people with diabetes

Symptoms of anxiety specific to people with diabetes include:

• Nervousness, restlessness, or feeling tense
• Feelings of danger, panic, or dread
• Rapid heart rate
• Rapid breathing/hyperventilation
• Increased or heavy sweating
• Trembling or muscle twitching
• Weakness or lethargy
• Difficulty focusing or thinking clearly
• Insomnia
• Strong desire to avoid things that trigger anxiety
• Obsessions
• Compulsions (performing certain behaviors over and over again)
• Anxiety surrounding an event that has occurred in the past

Anxiety or Hypoglycemia?

Drossos shared that a significant number of people confuse symptoms of low blood sugar with symptoms of anxiety. This is likely more common in those who are not wearing a CGM or checking their blood sugar regularly with a meter.

For people with T2D, diabetes education around low blood sugars and insulin dose adjustment is largely inadequate. If a person isn’t given a thorough education on the signs and symptoms of hypoglycemia, they may be experiencing low blood sugars daily but labeling them as panic attacks.

This highlights the increased need for better diabetes education for the T2D population, especially those taking insulin or other medications that can cause low blood sugars.

How Anxiety Can Affect Your Diabetes Health

Left untreated, the impact anxiety can have on a person’s diabetes health includes:

• More difficulty managing blood sugar levels
• More difficulty with healthy eating habits
• Poorer self-care overall
• Increased burden of symptoms (blood sugar fluctuations, etc.)
• Increased physical complications (neuropathy, retinopathy, etc.)
• Decreased physical activity levels
• Increased likelihood of being a smoker
• Difficulty maintaining or reaching a healthy body weight
• Decreased overall quality of life

When People with Diabetes Should Be Screened for Anxiety

Any of the following behaviors can indicate a person with diabetes may be struggling with anxiety and should be screened further:

• At diagnosis and during regularly scheduled visits
• Changes in medical status
• During hospitalizations
• When new-onset complications occur
• Whenever problems are identified related to:
  • Overall blood sugar levels
  • Self-management
  • Quality of life
• Exhibit anxiety or worries that interfere with diabetes management behaviors, including:
  • complications
  • Insulin injections
  • Infusion and CGM sites
  • Taking medications
  • Hypoglycemia
• Express fear, dread, or irrational thoughts
• Show anxiety symptoms including:
  • Avoidance behaviors (including medical care)
  • Excessive repetitive behaviors
  • Social withdrawal
• Preoccupation with an imagined defect in appearance that interferences with social, occupational, or other areas of function, including body dysmorphic disorder
• Exhibits excessive diabetes self-management behaviors to achieve glycemic targets
• Reports repetitive negative thoughts about the inability to prevent poor health outcomes
• Has related thoughts and behaviors that interfere with daily living (likely OCD)
• Experiences severe hypoglycemia

How to screen for anxiety in people with diabetes

There are a number of processes used to screen for anxiety, but Drossos reports that the GAD-7 questionnaire is the most widely used.

• Beck Anxiety Inventory (BAI)
• Hospital Anxiety and Depression Scale (HADS)
• Generalized Anxiety Disorder (GAD-7)
• Panic Disorder Severity Scale (PDSS)
• State-Trait Anxiety Inventory (STAI)
• Hypoglycemia Fear Scale (HFS or HFS-II or FH-15)

Treatment Options for Anxiety in People with Diabetes

“It’s important to talk to a patient about their anxiety and create a plan to support them,” said Drossos, who suggests referring patients to specialists if they test positive for anxiety in any screening process.

Peer-led diabetes self-management interventions

While there are a number of types of therapy and medications to help a person with any type of anxiety, Drossos says peer support treatment programs have proven to be the most effective.

Therapy

• Cognitive Behavior Therapy (CBT) teaches patients to recognize anxious thoughts and behaviors and change them.
• Exposure Therapy gradually exposes a patient to the stimulus that makes them anxious to help them learn how to manage your feelings and decrease anxiety
• Exposure and Response Prevention (ERP) involves exposing the patient to the thoughts, images, objects and situations that make the patient anxious and then make a choice not to engage in associated compulsive behavior
• Group therapy: support groups or skills-based groups

Medications

• Antidepressants
• Anxiolytics

Again, only 36 percent of those struggling with anxiety and diabetes receive treatment, which means we need improved screening and more open discussion on how common it is.

For more coverage of the American Diabetes Association’s 81st Scientific sessions, CLICK HERE.